Fistula

Question 1

How do you diagnose a rectovaginal fistula?

Answer 1

1. Place water in the posterior vagina and add air into the rectum which would cause bubbling
2. Methylene blue admixed enema into rectum

Question 2

What determines a anovaginal fistula or low fistula?

Answer 2

If the fistula occurs below the dentate line

Question 3

What determines a high fistula?

Answer 3

If the fistula occurs above the dentate line

Question 4

How do you manage a rectovaginal fistula?

Answer 4

Preoperative considerations
1. Immediately at time of damage or wait 3-4 months for inflammation/infection to settle
2. Estrogen cream if postmenopausal
3. Antibiotics if infection present
4. Liquid diet 24-48hrs before surgery
5. Bowel prep
6. Antibiotics pre surgery Cefoxitin

Question 5

How does a urovaginal fistula present?

Answer 5

Vaginal fluid drainage after hysterectomy or pelvic floor procedure

Question 6

What is the differential for a urovaginal fistula?

Answer 6

1. Vesicovaginal fistula
2. Uretero-vaginal fistula
3. Urinoma drainage from ureteral injury
4. Incomplete closure of vaginal apex

Question 7

How do you diagnose a urovaginal fistula?

Answer 7

Dual tampon test

Question 8

What is the dual tampon test?

Answer 8

Instill dyed sterile fluid mixed with saline into the bladder. Place a tampon in the vagina. Give Pyridium.

If tampon turns blue= vesicovaginal fistula
If tampon turns orange= Ureterovaginal fistula

Question 9

How do you manage a vesicovaginal fistula?

Answer 9

Conservative management
Foley catheter decompression of bladder for 4-6 weeks. If this fails surgical management with foley for 12 weeks
Surgery= repair by 3 layer closure after excision of fistulous tract