Gynecology Gynecology

FISTULA

INTRODUCTIONINTRODUCTIONA fistula is an abnormal connection

between an organ, vessel, or intestine and another structure. Fistulas are usually the result of injury or surgery. It can also result from infection or inflammation.

Inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, is an example of a disease that leads to fistulas between one loop of intestine and another.

PART OF FISTULAEPART OF FISTULAEFistulas may occur in many parts of the body.

Arteriovenous (between an artery and vein)Biliary (created during gallbladder surgery,

connecting bile ducts to the surface of the skin)

Cervical (either an abnormal opening into the cervix or in the neck)

Craniosinus (between the space inside the skull and a nasal sinus)

Enterovaginal (between the bowel and vagina)

Cont….Cont….Fecal or anal (the feces is discharged through an

opening other than the anus)Gastric (from the stomach to the surface of the skin)Metroperitoneal (between the uterus and peritoneal

cavity)Pulmonary arteriovenous (in a lung, the pulmonary

artery and vein are connected, allowing the blood to bypass the oxygenation process in the lung (pulmonary arteriovenous fistula )

Umbilical (connection between the navel and gut)

The common is genito-urinary fistulae which is vesico vaginal fistulae, recto vaginal fistulae and uretero vaginal fistulae.

TYPES OF FISTULAETYPES OF FISTULAEBlind (open on one end only, but

connects to two structures)Complete (has both external and

internal openings)Horseshoe (connecting the anus to the

surface of the skin after going around the rectum)

Incomplete (a tube from the skin that is closed on the inside and does not connect to any internal structure)

ETIOLOGYETIOLOGY

◦Fistulas can develop from of variety of causes but usually the result of Surgery child-birth Trauma cancer and radiation therapy.

Predisposing conditions for fistula formation include previous surgery, diabetes, smoking, cancer, or steroid use.

VESICO-VAGINAL VESICO-VAGINAL FISTULAEFISTULAEDef : A vesicovaginal fistula is an

abnormal connection between the bladder (vesico) and the vagina.

Patients with vaginal fistulas usually present 1 to 3 weeks after a gynecologic surgery with complaints of continuous urinary incontinence, vaginal discharge, pain or an abnormal urinary stream.

The common sign and symptom is most likely have fluid leaking or flowing out of vagina.

RECTO VAGINAL FISTULAERECTO VAGINAL FISTULAEA rectovaginal fistula is an abnormal

connection between the lower portion of large intestine —rectum— and vagina.

Signs and symptoms of a rectovaginal fistula may include:

Passage of gas, stool or pus from your vagina A foul-smelling vaginal discharge Recurrent vaginal or urinary tract infections Irritation or pain in the vulva, vagina and the area

between your vagina and anus (perineum) Pain during sexual activity

URETERO VAGINAL URETERO VAGINAL FISTULAFISTULAIts between ureter and vagina.Cause by injury to ureter during a

gynaecological operation as hysterectomy may develop following a difficult labour.

It leads to incomplete incontinence which is urine from affected ureter escapes from vagina while bladder fills up & empties normally from other ureter.

SIGN AND SYMPTOMSSIGN AND SYMPTOMSPatient may be

depressed,malnourished, anaemicMay present with foot drop & smell

of urineleakage of urine & or faeces over a

period time following delivery, surgery etc.

Cyclical haematuria or menouria vesico-uterine or vesico-cervical fistulae

Cont….Cont….Postoperative urinary

leakage,oliguria, abdominal distension,pyrexia or loin pain ureteric fistulae

Offensive vaginal discharge,incontinence of liquid stool and flatus colo-vaginal and rectovaginal fistulae

TREATMENTTREATMENTTiming of definitive repairImprove Patient’s General

Health;high protein diet, antimalarials,antihelmintics, haematinics & Rx infections

Rx vulval dermatitis with siliconebarrier creams, zinc & castor oilBowel PreparationProphylactic AntibioticsSurgery

COMPLICATIONSCOMPLICATIONS

Post Operative FailureRecurrent Fistula FormationInjury to Ureter, Bowel, or IntestinesVaginal Shortening - is a potential

complication, this is minimized and a rarity when performing vesicovaginal fistula repair laparoscopically.

MANAGEMENTMANAGEMENTEncourage patient to make a

important of perineal hygiene. Perineum should cleanses every 4hours.

Encourage patient to take a warm bath in every 3times per day.

Change perineal pad frequently to avoid from infections.

Encourage patient to maintain on adequate fluid intake.

Encouragement and reassurance in helping patient cope with her problems.

Post OperationPost OperationGiving care on avoidance of stress on

repaired area and prevention of infections.Alert to give care so that the indwelling

catheter usually in place for 7 to 10 days is draining all times.

Oral fluids should be priorities to provide for internal catheter irrigation.

Minimal pressure and strict asepsis used if catheter irrigation becomes necessary.

Supportive nursing care for patient is important.

NURSING DIAGNOSISNURSING DIAGNOSISNursing diagnosisRisk for infection related to

deficits hygiene care at vagina and anus site.

Objectives.To prevent infection by make

sure that patient clean their perineum part and decrease the level of infections.

Interventions Interventions Assess patient vital sign and temperature that indicate

infections. Take the blood specimen and culture and sensivity to

define the infection with medication. Educate and teach patient about care of vagina and

perineum site to comfortable and prevent infection. Encourage patient to drink lot of plain water. Tell patient to make sure dried the anus and vaginal site

after using toilet to avoid the growth of bacteria. Advise patient to clean up and wash the perineal site with

warm water and avoid from use dry toilet paper. Administer antibiotics by doctor ordered by using 7’s

Right rules.

Evaluation The sign and symptoms of infection not develop and risk

for infections decreased.

Nursing DiagnosisNursing Diagnosis

Nursing diagnosisNutrition intake related to

improvement of healing process after surgery.

ObjectiveThere is no disturbance within

healing process and the time for healing process become short.

InterventionsInterventions Assess patient level of conditions to nursing care plan. Advise patient to increase the intake of protein to

promote the development of growth new tissue. Advise patient to take balance diet and refer to dietician

if needed. Encourage patient to not lift heavy things to prevent the

surgery part became worse. Advise patient to stop doing sexual intercourse activity

until the fistula closed. Educate patient about healthy diet. Perform and let patient do deep breathing exercise to

promote the oxygen and blood circulation due to lack of exercise can do.

Evaluation Wound healed in short time,less than three month.

Nursing DiagnosisNursing DiagnosisPain related to post-operation.

Objective to reduce pain from 6 to 4 by

using pain scale.

InterventionsInterventions

Lifestyle and Home Lifestyle and Home RemediesRemediesWash with water. Dry thoroughly.Avoid irritants.Use a cold compress. Apply a cream or powder. Wear cotton underwear and

loose clothing.

REFERENCESREFERENCESMedical surgical nursing (mosby)