Fistulas

Question 1

What is the dual tampon test

Answer 1

Bladder fistula vs ureter
1. Tampon placed in vagina, bladder is filled with methylene blue. Presence of dye on the tampon indicates a vesico-vaginal fistula. Leave foley in to decompress the bladder
2. If no dye, bladder is drained, second tampon placed, and IV indigo carmine is given. If dye on the tampon, ureterovaginal fistula
3. Confirm with cysto or CT urogram

Question 2

Management of vesico-vaginal fistula

Answer 2

1. Spontaneous healing may occur with small fistula or high fistula with long thin tract
2. Catheter drainage is left in for 4-6 weeks to allow for complete healing of surgical sites (obs to 12 weeks post op). If fistula is still present, surgery to repair

Repair:
1. Excise the fistula tract to fresh tissue margins
2. Reapproximation of bladder submucosa with 3-0 vicryl
3. Reapproximation of bladder muscularis with 2-0 or 3-0 suture
4. Closure of vaginal mucosa with similar suture

Question 3

Management of uretero-vaginal fistula

Answer 3

1. Cystoscopy (to exclude bladder involvement) and CT urogram to identify site of injury
2. Low ureteral injury–> ureteral stent
3. High ureteral injury–> percutaneous nephrostomy for renal decompression and ureteral surgery 12 weeks post op with urology

Question 4

Management of recto-vaginal fistula

Answer 4

Occur most commonly due to obstetrical trauma

Identify: saline instilled into vaginal vault, air is insufflated into the rectum and the appearance of bubbles indicates fistula. Or can do methylene blue lubricant rubbed into anterior rectal wall and look for blue staining in vagina.

Repair:
1. Allow inflammation to subside
2. Tissue cleanliness with sitz baths in interim
3. Bowel prep prior to repair
4. Complete excision of the tract with 2cm margins
5. Repair in layers. Do not overlap suture lines.