genital fistulae

GENITAL GENITAL FISTULAEFISTULAE

PRESENTED BY PRESENTED BY

DR. JAMES ENIMI OMIETIMIDR. JAMES ENIMI OMIETIMI

INTRODUCTIONINTRODUCTIONA fistula is an abnormal A fistula is an abnormal communication between two (2) or communication between two (2) or more epithelial surfaces.more epithelial surfaces.A genital fistula is an abnormal A genital fistula is an abnormal communication between the genital communication between the genital tract (vagina, cervix, uterus or tract (vagina, cervix, uterus or perineum, in decreasing order of perineum, in decreasing order of frequency) and either the urinary frequency) and either the urinary tract (urinary bladder, urethra or tract (urinary bladder, urethra or ureter) or the gastrointestinal tract ureter) or the gastrointestinal tract (rectum, colon, anal canal or small (rectum, colon, anal canal or small bowel). bowel).

INTRODUCTION INTRODUCTION Continued.Continued.

Multiple or complex genital fistulae Multiple or complex genital fistulae involving the urinary and intestinal involving the urinary and intestinal tract are regularlytract are regularly

seen: VVF with RVF.seen: VVF with RVF.Rarer forms of fistulae like Rarer forms of fistulae like salpingocolic fistula following salpingocolic fistula following infection with tuberculosis and infection with tuberculosis and actinomycosis which cause actinomycosis which cause diagnostic confusion and therapeutic diagnostic confusion and therapeutic difficulties have also been reported.difficulties have also been reported.

PREVALENCEPREVALENCEVaries from country to Varies from country to

country and continent to country and continent to continent as causative continent as causative

factors vary.factors vary.

UK; 120-350 per yearUK; 120-350 per year Third World; about 700 per yearThird World; about 700 per year UPTH; 9 out of 452 gynae admissions UPTH; 9 out of 452 gynae admissions

(annual report of 2001)(annual report of 2001) WHO estimate; 500 000 untreated WHO estimate; 500 000 untreated

cases worldwidecases worldwide

TYPES OF GENITAL TYPES OF GENITAL FISTULAEFISTULAE

Anterior vaginal wallAnterior vaginal wall;;

1.1. Vesicovaginal fistula (VVF)Vesicovaginal fistula (VVF)

2.2. Urethrovaginal fistula (UVF)Urethrovaginal fistula (UVF)

3.3. Sub-symphysial fistula Sub-symphysial fistula

4.4. Bladder neck fistula Bladder neck fistula

5.5. Mid-vaginal fistulaMid-vaginal fistula

6.6. Juxta-cervical fistulaJuxta-cervical fistula

TYPES OF G. FISTULAE TYPES OF G. FISTULAE contd.contd.

Posterior vaginal wallPosterior vaginal wall1.Rectovaginal fistula (RVF)1.Rectovaginal fistula (RVF)2. Anovaginal fistula (AVF)2. Anovaginal fistula (AVF)OTHERSOTHERS1.Vault fistula1.Vault fistula2.Uretero-vaginal fistula2.Uretero-vaginal fistula3.Vesico-cervical fistula3.Vesico-cervical fistula4Vesico-uterine fistula4Vesico-uterine fistula5.Colo-uterine fistula5.Colo-uterine fistula6.Salpingocolic fistula6.Salpingocolic fistula

AETIOLOGY OF GENITAL AETIOLOGY OF GENITAL FISTULAEFISTULAE

The aetiology of genital fistulae is varied The aetiology of genital fistulae is varied and may be broadly categorized into;and may be broadly categorized into;

Obstetric ( following prolonged neglected Obstetric ( following prolonged neglected obstructed labour) accounting for over obstructed labour) accounting for over 90% of cases in developing countries.90% of cases in developing countries.

Traditional Surgical Practices; FGM, Traditional Surgical Practices; FGM, Gishiri cutGishiri cut

Surgical (following pelvic surgery e.g. Surgical (following pelvic surgery e.g. TAH) accounting for over 70% of cases in TAH) accounting for over 70% of cases in developed countries.developed countries.

Radiation to the pelvis for various reasonsRadiation to the pelvis for various reasons Malignancy within the pelvisMalignancy within the pelvis

Aetiology of G. Fistulae Aetiology of G. Fistulae contd.contd.

Obstetric trauma following Obstetric trauma following operative vaginal deliveryoperative vaginal delivery

1.Forcible rotation of the fetal head with 1.Forcible rotation of the fetal head with kielland’s forceps may injure the kielland’s forceps may injure the urinary bladder urinary bladder

2.Simpson’s perforator may injure the 2.Simpson’s perforator may injure the bladder during craniotomybladder during craniotomy

3. Symphysiotomy may lead to injury to 3. Symphysiotomy may lead to injury to the neck of the urinary bladderthe neck of the urinary bladder


InfectionsInfections

1.Schistosomiasis1.Schistosomiasis

2.Tuberculosis2.Tuberculosis

3.Actinomycosis3.Actinomycosis

4.Lymphogranuloma venereum4.Lymphogranuloma venereum

5.Measles5.Measles

6.Noma vaginae6.Noma vaginae


Inflammation within the abdomen Inflammation within the abdomen and pelvisand pelvis

1.Crohn’s Disease > colo-uterine fistula1.Crohn’s Disease > colo-uterine fistula

2.Ulcerative Colitis > rectovaginal fistula2.Ulcerative Colitis > rectovaginal fistula

3.Diverticular Disease > colo-vaginal 3.Diverticular Disease > colo-vaginal fistulafistula

>colo-uterine fistula>colo-uterine fistula


MiscellaneousMiscellaneous

1.Coital Injury1.Coital Injury

2.Penetrating Trauma2.Penetrating Trauma

3.Neglected Pessary3.Neglected Pessary

4.Other Foreign Bodies 4.Other Foreign Bodies

5.Catheter Related Injuries5.Catheter Related Injuries

CLINICAL CLINICAL PRESENTATIONPRESENTATION

Patient may be depressed, malnourished, Patient may be depressed, malnourished, anaemicanaemic

May present with foot drop & smell of urineMay present with foot drop & smell of urine Hx. –leakage of urine & or faeces over a Hx. –leakage of urine & or faeces over a

period time following delivery, surgery etc. period time following delivery, surgery etc. Symptoms usually develop 5-14 days after Symptoms usually develop 5-14 days after

injuryinjury Continuous urinary incontinence Continuous urinary incontinence obstetric and radiation fistulaeobstetric and radiation fistulae Cyclical haematuria or menouria Cyclical haematuria or menouria vesico-uterine or vesico-cervical fistulae vesico-uterine or vesico-cervical fistulae

following caesarean section following caesarean section watery vaginal dischargewatery vaginal discharge

Clinical presentation Clinical presentation contd.contd.

Stress incontinenceStress incontinenceproximal urethrovaginal fistulaeproximal urethrovaginal fistulae Postoperative urinary leakage, Postoperative urinary leakage,

oliguria, abdominal distension, oliguria, abdominal distension, pyrexia or loin painpyrexia or loin pain

ureteric fistulaeureteric fistulae Offensive vaginal discharge, Offensive vaginal discharge,

incontinence of liquid stool and flatusincontinence of liquid stool and flatuscolo-vaginal and rectovaginal fistulae colo-vaginal and rectovaginal fistulae

FINDINGS ONFINDINGS ONCLINICAL CLINICAL

EXAMINATIONEXAMINATIONO\E -Ill looking, pale with evidence O\E -Ill looking, pale with evidence

of inter current infectionsof inter current infections

Abd. –kidneys may be enlarged & Abd. –kidneys may be enlarged & tendertender

Pelvic Exam. –vulva & thigh Pelvic Exam. –vulva & thigh excoriationsexcoriations

(ammoniacal (ammoniacal dermatitis) dermatitis)

Clinical Examination Clinical Examination contd.contd.

V/E –best performed in a lateral prone V/E –best performed in a lateral prone positionposition

-digital to precede speculum exam.-digital to precede speculum exam.

-insert speculum of appropriate size-insert speculum of appropriate size

-visualize ant. Vaginal wall & then -visualize ant. Vaginal wall & then

-post. Vaginal wall-post. Vaginal wall

-Do digital rectal exam. to R\O RVF-Do digital rectal exam. to R\O RVF

EXAMINATION UNDER EXAMINATION UNDER ANAESTHESIAANAESTHESIA

Digital vaginal examination and Digital vaginal examination and examination with a Sim’s speculum may examination with a Sim’s speculum may not confirm or exclude a fistula, thus not confirm or exclude a fistula, thus necessitating examination under necessitating examination under anaesthesia.anaesthesia.

A malleable silver probe is passed A malleable silver probe is passed through openings in the vaginal wall;through openings in the vaginal wall;

-For VVF and UVF, a metallic click against -For VVF and UVF, a metallic click against a silver catheter may be felt or seen via a a silver catheter may be felt or seen via a cystoscope.cystoscope.

-For RVF , the probe may be felt digitally -For RVF , the probe may be felt digitally in the rectum or seen via a proctoscopein the rectum or seen via a proctoscope..

EUA Continued.EUA Continued.

Available access and the mobility of Available access and the mobility of tissues for vaginal repair is tissues for vaginal repair is assessed.assessed.

The decision to repair vaginally or The decision to repair vaginally or an abdominal approach can also be an abdominal approach can also be taken then.taken then.

INVESTIGATIONSINVESTIGATIONS

GENERALGENERAL FBC + Malaria Parasite + Widal FBC + Malaria Parasite + Widal

TestTest Urine for urinalysis & m.c.s.Urine for urinalysis & m.c.s. Stool for Parasitic InfestationsStool for Parasitic Infestations CXRCXR Serum E/U/CrSerum E/U/Cr Intravenous UrographyIntravenous Urography

INVESTIGATIONS INVESTIGATIONS contd.contd.

Clinical examination and Examination Clinical examination and Examination Under Anaesthesia may not Under Anaesthesia may not conclusively confirm or exclude the conclusively confirm or exclude the presence or absence of a fistula. presence or absence of a fistula. Further investigations are thus Further investigations are thus necessary to confirm or exclude a necessary to confirm or exclude a fistula. Investigations are also fistula. Investigations are also necessary for full evaluation prior to necessary for full evaluation prior to deciding on treatment. Further deciding on treatment. Further specific investigations done include;specific investigations done include;

SPECIFIC SPECIFIC INVESTIGATIONSINVESTIGATIONS

DYES STUDIESDYES STUDIES Investigations of first choiceInvestigations of first choice Confirm if discharge is urinaryConfirm if discharge is urinary If leakage is extra-urethral rather than If leakage is extra-urethral rather than

urethralurethral To establish the site of leakageTo establish the site of leakage Phenazopyridine-200mg tds orallyPhenazopyridine-200mg tds orally Indigo carmine- intraveneouslyIndigo carmine- intraveneously Methylene blue instillationMethylene blue instillation

DYE STUDIES contd.DYE STUDIES contd.

Patient in lithotomy positionPatient in lithotomy position Examination best done under direct Examination best done under direct

visionvision ‘‘Three Swab Test’ has limitations and Three Swab Test’ has limitations and

is not recommended.is not recommended. Adequate distension of the urinary Adequate distension of the urinary

bladderbladder If clear fluid leaks after instillation of If clear fluid leaks after instillation of

dye, ureteric fistula is likely.dye, ureteric fistula is likely.

DYE STUDIES contd.DYE STUDIES contd. Confirmed by ‘two dye test’Confirmed by ‘two dye test’ Phenazopyridine to stain renal urine Phenazopyridine to stain renal urine

andand Methylene blue to stain the bladder Methylene blue to stain the bladder

urine.urine. Not very useful for intestinal fistulae; Not very useful for intestinal fistulae;

However, oral carmine marker may be However, oral carmine marker may be usefuluseful

Rectal air via a sigmoidoscope and Rectal air via a sigmoidoscope and vagina filled with salinevagina filled with saline

OTHER SPECIFIC OTHER SPECIFIC INVESTIGATIONSINVESTIGATIONS

Cystoscopy – small vvfCystoscopy – small vvf Cystography – vesico uterine fistulae (lat. Cystography – vesico uterine fistulae (lat.

view) view) Hysteroscopy/Hysteosalpingography-vesico Hysteroscopy/Hysteosalpingography-vesico

uterine fistulae ( lat. view)uterine fistulae ( lat. view)

Fistulography –small intestinal fistulaeFistulography –small intestinal fistulae Colpography –small fistulae involving vaginaColpography –small fistulae involving vagina

Endoanal Ultrasound, MRI –anorectal & Endoanal Ultrasound, MRI –anorectal & perineal perineal fistulaefistulae

Barium enema, Barium meal & follow through Barium enema, Barium meal & follow through -Intestinal fistulae above the anorectum -Intestinal fistulae above the anorectum

PREOPERATIVE PREOPERATIVE TREATMENTTREATMENT

Timing of definitive repairTiming of definitive repair Improve Patient’s General Health; Improve Patient’s General Health;

high protein diet, antimalarials, high protein diet, antimalarials, antihelmintics, haematinics & Rx antihelmintics, haematinics & Rx infectionsinfections

Rx vulval dermatitis with silicone Rx vulval dermatitis with silicone barrier creams, zinc & castor oilbarrier creams, zinc & castor oil

Bowel PreparationBowel Preparation Prophylactic Antibiotics Prophylactic Antibiotics

REPAIR OF VVFREPAIR OF VVF

Route of Repair; vaginal or abdominalRoute of Repair; vaginal or abdominal Position of Patient; lithotomy or reverse Position of Patient; lithotomy or reverse

lithotomy (knee-elbow position)lithotomy (knee-elbow position) Type of suture materials; absorbable -Type of suture materials; absorbable -

vicryl 2/0 or chromic catgut 2/0vicryl 2/0 or chromic catgut 2/0 Types of Repair;(1) Dissection & repair Types of Repair;(1) Dissection & repair

in in layers (2) layers (2) SaucerizationSaucerization

POST OPERATIVE POST OPERATIVE MANAGEMENTMANAGEMENT

Fluid Balance; intake 3-4 litres per dayFluid Balance; intake 3-4 litres per dayoutput 100-120mls/hroutput 100-120mls/hr

Bladder Drainage; check drainage & vol. of Bladder Drainage; check drainage & vol. of urine hrlyurine hrly

Post Operative antibioticsPost Operative antibiotics Prevention of Deep Vein ThrombosisPrevention of Deep Vein Thrombosis Care of the perineum with vulva padsCare of the perineum with vulva pads Duration of Drainage; 10-14 days on the Duration of Drainage; 10-14 days on the

averageaverage Retraining of urinary bladder before discharge Retraining of urinary bladder before discharge

Post Operative Mgt. Post Operative Mgt. Contd.Contd.

Instructions on DischargeInstructions on Discharge EUA & dye test on day 21 before EUA & dye test on day 21 before

dischargedischarge Refrain from sexual intercourse for Refrain from sexual intercourse for

3months3months Counsel for antenatal care & hospital Counsel for antenatal care & hospital

delivery in all subsequent pregnanciesdelivery in all subsequent pregnancies Elective Caesarean Section next Elective Caesarean Section next

pregnancy pregnancy

genital fistulae

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