Fistula Flashcards
Definition vesicovaginal fistula
Abnormal passageway between the bladder and vagina that causes urinary incontinence and leakage
Causes of vesicovaginal fistula
Obstetric:
- Obstructed Labour (leading cause in developing countries)
- Forceps/instrumental
- Injury at time of CS
- Uterine rupture
Surgical:
- Hysterectomy (leading cause in developed countries)
- Vaginal surgery
Radiation for malignancy
Malignancy
- Most common: cervical, vaginal and endometrial
Congenital:
- E.g. VATER/VACTERL
Other:
- Infection
- Inflammation
- Foreign body (retained pessary)
- Trauma/sexual assault
Presentation of vesicovaginal fistula
- Continuous leaking of urine day and night- may just be a watery discharge
- Incontinence
Diagnosing vesicovaginal fistula
- Examination- fistula often visible at speculum
- ‘Tampon test’ - fill bladder with methylene blue. Insert a tampon into the vagina. If tampon blue then = fistula
- Cystoscopy
- Intravenous pyelogram
- CT IVU
- MRI
Treating vesicovaginal fistula
Conservative (first-line):
- Vaginal Oestrogen
- Foley catheter and bladder rest
- Antibiotic cover
- Treat underlying causes
Surgical (second-line):
- Surgical repair with either transvaginal, abdominal or laparoscopic approach (usually delay by 3/12)
- most commonly transvaginal approach
- debridement and closure +/- flap surgery
- Minimally invasive for patients who are not surgical candidates: Occlusion with laser, electrocautery or glue
Definition rectovaginal fistula
Abnormal connection between rectum and vagina causing stool to leak from the rectum into the vagina
Can be ‘low’ - ie at entrance to vagina (e.g. OASIS) or high- ie in upper vagina near cervix (e.g. malignancy) can also be simple or complex
Causes of rectovaginal fistula
Obstetric:
- Obstructed Labour
- Forceps/instrumental
- 3rd or 4th degree tear
- Infected episiotomy
Crohn’s disease
Surgical:
- Hysterectomy
- Urogynae surgery or other surgery involving rectum, vagina, anus, perineum
Radiation for malignancy
Malignancy
- Most common: cervical, vaginal, endometrial, rectum, anus
Other:
- Infection
- Inflammation
- Foreign body
- Trauma/sexual assault
Symptoms of rectovaginal fistula
- Passage of gas, stool or pus from the vagina
- A foul-smelling vaginal discharge
- Recurrent vaginal or urinary tract infections
- Irritation or pain in the vulva, vagina and perineum
- Dyspareunia
Investigations for rectovaginal fistula
- Dye in the vagina, bladder or rectum to find all signs of leakage
- Urinalysis to check for infection
- Blood test to check for signs of infection
- CT or MRI
- Anorectal ultrasound to evaluate the structure of the anal sphincter and show defects caused by obstetric injury
Treatment for rectovaginal fistula
- Ensure any infection/inflammation clears
- Often try to wait 3-6/12 to allow for healing
- Seton drain for superficial tracts
Surgical:
- Endorectal advancement flap, with or without sphincteroplasty
- Episioproctotomy with reconstruction of the ano-rectalvaginal septum
- Martius flap
What are the types of urinary fistula?
Uretovaginal (more likely after hysteroecomy)
Vesicovaginal (more likely after obstructed labour)
Urethrovaginal (more likely after obstructed labour)
management of ureterovaginal fistula.
- first-line Rx is early surgical repair, otherwise potential complications for upper urinary tract
- Stenting
- End-to-end anastomosis
- Ureteric implantation
