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GenitoGenito-Urinary Fistula
Definition: Definition:
Fistula means: means: Abnormal communication between two epithelial surfaces. GenitoGenito-urinary fistula means: means: Abnormal communication between the urinary and female genital tracts through which urine dribbles continuously.

GenitoGenito-Urinary Fistula
Anatomical classifications: classifications:
Ureteric fistula: fistula: 1. Uretro-vaginal 2. Uretro-cervical 3. Uretro-uterine Vesical fistula: fistula: 1. Vesico-vaginal 2. Vesico-cervical 3. Vesico-uterine Urethral fistula: fistula: 1. Urethro-vaginal

VesicoVesico-vaginal fistula
Definition: Definition:
Abnormal communication between the urinary bladder and vagina through which urine dribbles continuously

Etiology
A. Traumatic Fistula: Fistula:
1. Obstetric trauma: trauma: a. Necrotic obstetric fistula: fistula: Obstructed labor prolonged ischemia of tissues between the fetal head and maternal pelvis avascular necrosis and sloughing within 5-7 days. b. Traumatic obstetric fistula: By fistula: 1. During Lower Segment Cesarean Section. 2. Rupture bladder during forceps rotation and extraction. 3. Perforator or speckles of bones after craniotomy.

Etiology
A. Traumatic Fistula: Fistula:
2. Surgical trauma: trauma: Fistula may occur during or after the following surgical procedures: 1.Forcible passage of metal catheter. 2.Vaginal or abdominal hysterectomy. 3.Wertheim`s operation (Dissection of lymph nodes around the ureter). 4.Anterior colporaphy.

Etiology
A. Traumatic Fistula: Fistula:
3. Direct trauma: trauma: 1.Falling on sharp object. 2.Fracture pelvis. 3.Neglected foreign body or vaginal pessary ulceration and fistula formation.

Etiology
B. Inflammatory fistula: fistula:
Due to chronic granulomatous lesion of the urinary or genital systems e.g. syphilis, tuberculosis, or bilharziasis

C. Malignant fistula: fistula:


Only seen in advanced or neglected malignant diseases of the urinary or genital systems

D. Post-irradiation fistula: Postfistula:


Radium can cause sever damage to the bladder or ureter, these fistulas are almost inoperable, because they are surrounded by extensive scarring. Fistula usually occurs 3-9 months after radiotherapy.

Clinical picture
History: History:
The history gives an idea about 2 items: items: 1. Difference between types of incontinence e.g. true, partial, urgency ect. 2. The etiology of fistula, whether obstetric, surgical. ect.

Clinical picture
Symptoms: Symptoms:
1. Incontinence of urine: Total incontinence: Complete escape of incontinence: urine, i.e. no urine is retained inside bladder and pass voluntary. Partial incontinence: The patient can incontinence: retain some urine inside bladder and pass it voluntary, this can occur within these fistulas:
a. b. c. Small vesico-vaginal fistula. Fistula situated high in the bladder. Uretero-vaginal fistula.

Clinical picture
Symptoms: Symptoms:
2. Soreness and pruritis vulva: Due to continuous irritation with urine 3. Psychological troubles: E.g. Anxiety and depression even amenorrhea 4. Pain: Ascending infection causes: 5. Cystitis suprapubic pains. 6. Pyelitis and pyelonephritis loin pains

Clinical picture
Signs: Signs:
General examination: examination: For evidence of renal failure Abdominal examination: examination: The kidney is palpated for tenderness or enlargement Vaginal examination: examination: Inspection: Inspection: 1. Evidence of infection e.g. vulvitis or vaginitis 2. Phosphates crystals deposited on the vulva giving the skin a gritty sensation

Clinical picture
Digital palpation: palpation: 1. Large Fistula: the opening is felt by the examining finger 2. Small fistula: Known by its scarring 3. The site, size, number of fistulous opening and the extend of scarring should be determined

Clinical picture
Speculum examination: examination: i. Sim`s position:  The patient is examined by Sim`s speculum.  The patient lie on her left side near the edge of the table, with her left thigh and knee are extended the right thigh and knee is flexed.  The left arm behind the patient and the right arm at the edge of the table and the pelvis is raised to allow air to enter into the vagina to be distended after Sims speculum introduction as the intestine is displaced upwards.

Clinical picture
ii. Modified knee-elbow position: iii. Lithotomy position: Used if the fistula is low down in the vaginal wall. iv. Click test: A metal catheter may pass through the urethra to see its tip from vagina. A probe or sound passes into the fistula from vagina. A click sound is heard when the 2 metal catheters are touched.

Investigations
Methylene blue test: test:
Aim: Aim: Differentiate between small vesico-vaginal and uretero-vaginal fistula Procedure: Procedure:  3 pieces of gauze are placed in the vagina, one above the other.  The bladder is filled with 200 cc methylene blue through a rubber catheter.  Then the patient is allowed to walk for 5 minutes and inspect the inner 2 pieces of gauze, as the lowest piece is discarded because it is usually stained during filling.

Investigations
Methylene blue test: test:
Results: Results: 1.Stained gauze: vesicovaginal fistula. 2.Non-stained gauze and the upper one is socked with urine: Uretero-vaginal fistula.

Investigations
Cystoscopy: Cystoscopy:
Value: Value: 1.Diagnose small vesico-vaginal fistula. 2.Show the relation of fistula to ureteric opening. 3.Exclude multiple fistulous opening. 4.Diagnose uretero-vaginal fistula: By weak or absent reflux from affected side, and if ureteric catheter is passed, it will stop at the site of fistula and cannot reach the renal pelvis. 5.Injection of indigocarmine (colored dye) I.V, colored urine seen coming from healthy ureter

Investigations
IntraIntra-venous pyelography (IVP): (IVP):
Value: Value: 1.Assessment of renal function. 2.Diagnosis of hydroureter and hydronephrosis. 3.Visualization of the course of ureter. 4.Diagnose ureteric fistula, as the affected side is interrupted at the site of fistula and its lower end may not be seen

Preventive measures
1.The bladder should be kept empty during labor. 2.Early diagnosis of contracted pelvis and obstructed labor. 3.The patient should not be left more than. 2 hours in the second stage of labor 4.Evacuation of the bladder by sterile catheter before application of forceps. 5.Self-retaining catheter should be inserted into the bladder before caesarian hysterectomy. 6.Proper mobilization of the bladder during caesarian section by Doyen's retractor.

Preventive measures
7.If the bladder is injured, it should be repaired immediately and a self-retaining catheter should be inserted for 14 days. 8.Patient with successful repair of vesico-vaginal fistula should deliver by upper segment cesarean section. 9.Early diagnosis of invasive cervical cancer. 10.Proper radium insertion for treatment of gynecological malignancy.

Treatment
 If the bladder is injured during labor, it is useless to close the fistula immediately, because of the edema and friability of tissues.  A rubber catheter is fixed into the bladder for 3 weeks and gives urinary antiseptics.  The Fistula may heal completely or left a small size.  Operation is performed 3-6 months later to allow for involution of tissues, absorption of scar tissues and control any infections.

PrePre-operative preparation
Blood picture: picture:
For detection and correction of anemia

Kidney function test: test:


Serum creatinine, blood urea and IVP

Cystoscopy: Cystoscopy:
 The bladder is filled with sterile water and a finger or pack is placed into vagina to prevent fluid escape.  Cystoscopy may be introduced with the patient lying in the knee-elbow position, to allow the bladder distension by the negative intraabdominal pressure (indirect cystoscopy).

PrePre-operative preparation
Treatment of genital infection: infection:
Vulvitis: Vulvitis:  Treated by antiseptic wash, phosphate deposits are scrapped and the resultant ulcers painted by silver nitrate or Mercurochrome.  The skin of vulva and thighs are covered and painted by a layer of Vaseline or zinc oxide ointment to prevent maceration by continues urine flow. Vaginitis Antiseptic vaginal douches Cervicitis: Cervicitis: By cauterization

PrePre-operative preparation
Treatment of urinary infection: infection:
 Urine analysis, culture and sensitivity test are performed  Urine is collected by catheter, or put a sterile piece of cotton in the vagina, then removed and squeezed

Operative treatment
2 problems must be overcome: overcome:
a. The access of fistula: fistula: The patient must be in position, which provides the surgeon with most comfortable approach: Urologist: Prefers the abdominal approach Urologist: Gynecologist: Prefers the vaginal approach, Gynecologist: either by lithotomy position or modified kneeelbow position b. Avoidance of wound tension: tension: Sometimes an extended episiotomy may be needed

Vaginal Operations
Flap splitting (Dedoublement) operation: operation:
 A circular incision is made around the margin of fistula and from this incision 2 longitudinal cuts are made going through the vagina but not the bladder, resulting in 2 flaps.  The vagina is mobilized from the bladder.

Vaginal Operations
Flap splitting (Dedoublement) operation: operation:
 The bladder hole is closed in 2 layers by interrupted lambert (inverted) sutures with chromatized catgut number 1, including the muscle wall but not the mucosa, to avoid phosphate incrustations on the tissue line.  Methelyne blue is injected into the bladder to be sure that it is watertight.  The vaginal flaps are sutured by interrupted catgut suture number 0.  A rubber catheter is fixed through the urethra to avoid bladder distension.  A vaginal pack may be inserted for 24 hours to prevent bleeding

Vaginal Operations
Sim`s or saucerization operation: operation: The edge of the fistula is excised removing a wider part of the vagina than the muscle wall of the bladder. No removal of any bladder mucosa. The edges of both organs are simultaneously coapted together by non-absorbable silk or nylon sutures.

Vaginal Operations
Latzko operation: operation:
 It is usually done for inaccessible fistula as vault fistula.  Vaginal vault tissue is removed in 4 quadrants with piece meal dissection for about 3 cm.  The hole in the bladder is closed first, and then the vaginal wall is closed by interrupted chromatized sutures.

Abdominal operations
 The space of Retzius is opened and the bladder is mobilized.  2 Polyethylene ureteric catheters are inserted in ureters.  Vaginal pack is done before starting operation to push the bladder upwards.  The bladder wall is mobilized from the vagina.  The vaginal mucosa is closed then the bladder wall.

Interposition operations
Interposition operation: operation:
  1. 2. 3. 4. An adjacent tissue or structure is placed between bladder and vagina. This may be required when support is needed with fresh blood supply as in recurrent or postirradiation fistula. Interposition of Bulbospongiosus muscle Interposition of gracilis muscle Interposition of omental fat Interposition of retus abdominus muscle

PostPost-operative care
 Self-retaining catheter is left for 14 days.  Urine observation every 2 hours day and night. Examination is done for amount, color, reaction, and presence of blood or precipitate.  If no urine pass through the catheter, this indicated either blockage of the catheter by blood clot, phosphatic deposits or anurea.  A blocked catheter is known by full bladder and treated by gentile injection of saline; if there is resistance the catheter is changed.  If urine is bloody, the bladder is washed by 1 % silver nitrate solution.

PostPost-operative care
 Liberal amount of fluid intake, at least 3 liters per day.  Vaginal pack is removed after 24 hours, the nonabsorbable sutures are removed after 2 weeks.  Broad spectrum antibiotics.  After removal of the catheter, the patient is instructed to pass urine every 2 hours day and night to avoid over distension of the bladder.  No sexual intercourse for 3 months.  No pregnancy for 1 year.  Subsequent deliveries by upper segment cesarean section.

Causes of failure of operation


Causes before operation: operation:
1.Infection of the genital tract. E.g. vaginitis. 2.Infection of the urinary tract. E.g. cystitis.

Causes during operation: operation:


1.Incomplete closure. 2.Eversion of bladder mucosa. 3.Excessive trauma to tissues. 4.Unreliable catgut (Should resist absorption for 30 days). 5.Poor surgical technique. 6.Bad choice of operation.

Causes of failure of operation


Causes after operation: operation:
1.Obstruction of bladder catheter. 2.Hemorrhage inside the bladder. 3.Postoperative infection.

Causes
1. Usually traumatic and rarely congenital fistula. 2. The traumatic injury of ureter usually occurs during abdominal or vaginal operations or rarely may be injured by extension of cervical and lower segment laceration during labor. 3. Ureteric injury may be partially or completely, by a clamp, inclusion in a ligature, resection of a portion or avascular necrosis resulting from vigorous dissection (Wertheim`s operation).

Clinical picture
1.Partial incontinence 2.Small fistula situated in the lateral fornix.

Investigations
1.Methylene blue test: The vaginal is gauze with urine. 2.Cystoscopy: Absence of ureteric reflux from the affected side. 3.I.V.P: Is diagnostic.

Treatment
a) Borie's operation
Re-implantation of the ureter into the bladder if possible. This is done abdominally by using a bladder flap sutured around the ureter.

b) Re-implantation of the ureter into: Reinto:


1. Opposite renal pelvis or ureter Replacement by isolated length of ileum 2. Sigmoid colon: Urine is passed per rectum

c) Nephrectomy: Nephrectomy:
If the Kidney function is impaired

UrethroUrethro-Vaginal Fistula
 It is usually traumatic in origin.  The patient is continent because the fistula is usually below the level of internal urethral meatus.  During micturation, some urine passes through the fistulous opening into the vagina (Double stream).

UrethroUrethro-Vaginal Fistula
Treatment
The operation is difficult because the urethral wall is thin and adherent to the vaginal wall. 1. If the fistula is small: small: The edge should be repaired and the fistula is closed silk sutures. 2. Large fistula: 'Martius operation fistula: 1. U shaped is made in anterior vaginal wall 2. The vaginal flaps are mobilized. 3. The flaps are sutured over a catheter. 4. A new tube is formed which is supported to prevent or minimize stress incontinence

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