GENITAL

FISTULAE

PRESENTED BY
DR. JAMES ENIMI OMIETIMI
 INTRODUCTION
A fistula is an abnormal
communication between two (2) or
more epithelial surfaces.
A genital fistula is an abnormal
communication between the genital
tract (vagina, cervix, uterus or
perineum, in decreasing order of
frequency) and either the urinary
tract (urinary bladder, urethra or
ureter) or the gastrointestinal tract
(rectum, colon, anal canal or small
 INTRODUCTION
Continued.
Multiple or complex genital fistulae
involving the urinary and intestinal
tract are regularly
seen: VVF with RVF.
Rarer forms of fistulae like
salpingocolic fistula following
infection with tuberculosis and
actinomycosis which cause diagnostic
confusion and therapeutic difficulties
have also been reported.
 Varies from country to
country and continent to
continent as causative
factors vary.

 UK; 120-350 per year

 Third World; about 700 per year
 UPTH; 9 out of 452 gynae admissions
(annual report of 2001)
 WHO estimate; 500 000 untreated cases
worldwide
 TYPES OF GENITAL
FISTULAE
 Anterior vaginal wall;
2. Vesicovaginal fistula (VVF)
3. Urethrovaginal fistula (UVF)
4. Sub-symphysial fistula
5. Bladder neck fistula
6. Mid-vaginal fistula
7. Juxta-cervical fistula
 TYPES OF G. FISTULAE
contd.
 Posterior vaginal wall
1.Rectovaginal fistula (RVF)
2. Anovaginal fistula (AVF)
OTHERS
1.Vault fistula
2.Uretero-vaginal fistula
3.Vesico-cervical fistula
4Vesico-uterine fistula
5.Colo-uterine fistula
6.Salpingocolic fistula
 AETIOLOGY OF GENITAL FISTULAE
The aetiology of genital fistulae is varied
and may be broadly categorized into;
 Obstetric ( following prolonged
neglected obstructed labour)
accounting for over 90% of cases in
developing countries.
 Traditional Surgical Practices; FGM,
Gishiri cut
 Surgical (following pelvic surgery e.g.
TAH) accounting for over 70% of cases
in developed countries.
 Radiation to the pelvis for various
reasons
Aetiology of G. Fistulae
contd.
 Obstetric trauma following
operative vaginal delivery
1.Forcible rotation of the fetal head with
kielland’s forceps may injure the urinary
bladder
2.Simpson’s perforator may injure the
bladder during craniotomy
3. Symphysiotomy may lead to injury to
the neck of the urinary bladder
 Aetiology of G. Fistulae
contd.
 Infections
1.Schistosomiasis
2.Tuberculosis
3.Actinomycosis
4.Lymphogranuloma venereum
5.Measles
6.Noma vaginae
 Aetiology of G. Fistulae
contd.
 Inflammation within the
abdomen and pelvis
1.Crohn’s Disease > colo-uterine
fistula
2.Ulcerative Colitis > rectovaginal
fistula
3.Diverticular Disease > colo-vaginal
fistula
>colo-uterine fistula
 Aetiology of G. Fistulae
contd.
 Miscellaneous
1.Coital Injury
2.Penetrating Trauma
3.Neglected Pessary
4.Other Foreign Bodies
5.Catheter Related Injuries
 CLINICAL
PRESENTATION
 Patient may be depressed,
malnourished, anaemic
 May present with foot drop & smell of
urine
 Hx. –leakage of urine & or faeces over a
period time following delivery, surgery
etc.
 Symptoms usually develop 5-14 days
after injury
 Continuous urinary incontinence

obstetric and radiation fistulae

 Cyclical haematuria or menouria
 Clinical presentation
contd.
 Stress incontinence
proximal urethrovaginal fistulae
 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
 FINDINGS ON
CLINICAL
EXAMINATION
O\E -Ill looking, pale with evidence of
inter current infections
Abd. –kidneys may be enlarged &
tender
Pelvic Exam. –vulva & thigh
excoriations
(ammoniacal
dermatitis)
 Clinical Examination
contd.
 V/E –best performed in a lateral
prone position
-digital to precede speculum
exam.
-insert speculum of appropriate
size
-visualize ant. Vaginal wall & then
-post. Vaginal wall
-Do digital rectal exam. to R\O RVF
 EXAMINATION UNDER
ANAESTHESIA
 Digital vaginal examination and
examination with a Sim’s speculum
may not confirm or exclude a
fistula, thus necessitating
examination under anaesthesia.
 A malleable silver probe is passed
through openings in the vaginal
wall;
-For VVF and UVF, a metallic click
against a silver catheter may be
felt or seen via a cystoscope.
-For RVF , the probe may be felt
 EUA Continued.
 Available access and the mobility of
tissues for vaginal repair is assessed.
 The decision to repair vaginally or an
abdominal approach can also be
taken then.
 INVESTIGATIONS
 GENERAL
 FBC + Malaria Parasite + Widal Test
 Urine for urinalysis & m.c.s.
 Stool for Parasitic Infestations
 CXR
 Serum E/U/Cr
 Intravenous Urography
INVESTIGATIONS contd.
Clinical examination and
Examination Under Anaesthesia
may not conclusively confirm or
exclude the presence or absence
of a fistula. Further investigations
are thus necessary to confirm or
exclude a fistula. Investigations
are also necessary for full
evaluation prior to deciding on
treatment. Further specific
investigations done include;
 SPECIFIC
INVESTIGATIONS
 DYES STUDIES
 Investigations of first choice
 Confirm if discharge is urinary
 If leakage is extra-urethral rather than
urethral
 To establish the site of leakage
 Phenazopyridine-200mg tds orally
 Indigo carmine- intraveneously
 Methylene blue instillation
 DYE STUDIES contd.
 Patient in lithotomy position
 Examination best done under direct
vision
 ‘Three Swab Test’ has limitations and
is not recommended.
 Adequate distension of the urinary
bladder
 If clear fluid leaks after instillation of
dye, ureteric fistula is likely.
 DYE STUDIES contd.
 Confirmed by ‘two dye test’
 Phenazopyridine to stain renal
urine and
 Methylene blue to stain the
bladder urine.
 Not very useful for intestinal
fistulae; However, oral carmine
marker may be useful
 Rectal air via a sigmoidoscope and
vagina filled with saline
 OTHER SPECIFIC
INVESTIGATIONS
 Cystoscopy – small vvf
 Cystography – vesico uterine fistulae
(lat. view)
 Hysteroscopy/Hysteosalpingography-
vesico uterine fistulae (
lat. view)
 Fistulography –small intestinal fistulae
 Colpography –small fistulae involving
vagina

 Endoanal Ultrasound, MRI –anorectal &

perineal
fistulae
 PREOPERATIVE
TREATMENT
 Timing of definitive repair
 Improve Patient’s General Health;
high protein diet, antimalarials,
antihelmintics, haematinics & Rx
infections
 Rx vulval dermatitis with silicone
barrier creams, zinc & castor oil
 Bowel Preparation
 Prophylactic Antibiotics
 REPAIR OF VVF

 Route of Repair; vaginal or

abdominal
 Position of Patient; lithotomy or
reverse lithotomy (knee-elbow
position)
 Type of suture materials; absorbable
-vicryl 2/0 or chromic catgut 2/0
 Types of Repair;(1) Dissection &
repair in layers (2)
Saucerization
 POST OPERATIVE
MANAGEMENT
 Fluid Balance; intake 3-4 litres per day
output 100-120mls/hr
 Bladder Drainage; check drainage & vol. of
urine hrly
 Post Operative antibiotics
 Prevention of Deep Vein Thrombosis
 Care of the perineum with vulva pads
 Duration of Drainage; 10-14 days on the
average
 Retraining of urinary bladder before
discharge
 Post Operative Mgt.
Contd.
Instructions on Discharge
 EUA & dye test on day 21 before
discharge
 Refrain from sexual intercourse for
3months
 Counsel for antenatal care & hospital
delivery in all subsequent
pregnancies
 Elective Caesarean Section next
pregnancy