Genitourinary fistula
Genitourinary fistuladefinition:
Abnormal epithelialized tract communicating between urinary & genital tracts.
Genitourinary fistulaclassification:
( according to anatomical situation)
A. Ureteric:
1. Uretro-uterine fistula.
2. Uretro-cervical fistula.
3. Uretro-vaginal fistula.
B. Vesical:
1. Vesico-uterine fistula.
2. Vesico-cervical fistula.
3. Vesicovaginal fistula.
C. Urethral: urethro-vaginal fistula.
D. Combined: e.g. cervico-vesico-vaginal fistula.
Genitourinary fistula (Ureteric injuries & uretro-vaginal fistula)
Uretro-vaginal fistula definition:
abnormal communication between ureter and vagina usually in the lateral vaginal fornix.
Uretro-vaginal fistulaaetiology:
1) Congenital: very rare.
2) Traumatic: * surgical trauma: common.
* Obstetric trauma: rare.
Types of ureteric injuries:
1) Transection complete or partial.
2) Inclusion of a ligature.
3) Crushing during clamping of a structure.
4) Resection of a segment.
5) Excessive dissection of ureter causing
avascular necrosis.
Uretro-vaginal fistuladiagnosis:
♦ During operation (suspected by a senior surgeon)
1) Urine appears in the field with the urinefrous odour.
2) Ureter distends in the field after a tying suture.
3) If indigocarmine injected, appearance of violet dye in the field.
♦ After operation
C/P:
1) History: of operation or a trauma.
2) Symptoms: *usually: partial incontinence.
*Rarely: complete incontinence.
3) Signs:
General: as vesico-vaginal fistula.
Abdominal: as vesico-vaginal fistula.
Local: *fistula is felt or seen at the anterior vaginal wall.
*Usually small and situated near the lateral vaginal fornix.
4) Complications:
♦ Urinoma: may collect i.e. pelvic abscess or escape i.e. fistula formation.
♦ Stormy picture: peritonism manifestations appear.
Investigations:
1) Methylene blue test: upper gauze is soaked with urine.
2) Cystoscopy: *intact bladder.
*Absent ureteric reflux on the affected side.
*Ureteric catheter stops on the affected site.
3) IVP: to detect site & side of fistula.
Uretro-vaginal fistulatreatment:
A. Preventive:
1) Preoperative:
♦Preoperative IVP to visualize the course of ureter.
♦Preoperative ureteric catheterization via cystoscopy.
2)Intra-operative:
♦ Ureteric identification during operation & any clamping is done under vision.
♦ Proper surgical technique & applying the artery forceps to bleeding point exactly.
B. Active treatment:
Treatment of fistula:
1. Segmental resection and end to end anastomosis.
2. Pulling the ureter into urinary bladder (reimplantation).
3. Boari’s flap operation.
– Indication: high ureteric injury.
– Method: a tube-like connection between the lower end of the ureter &UB is created by bladder flap excised and remodeled.
Treatment of complication:
1. Immediate evacuation of urinoma.
2. Nephrostomy for stormy picture.
Urethro-vaginal fistula
Urethro- vaginal fistulaaetiology:
Trauma is usually the incriminated cause.
Urethro- vaginal fistulaC/P:
1. The patient is continent (As fistula level below the sphincter).
2. Double stream of urine on micturition or vaginal drippling from vagina.
Urethro- vaginal fistulatreatment:
vaginal repair resolve the condition.
Vesico-uterine fistula
Vesico-uterine fistulaaetiology: Surgical e.g. abdominal operations as CS ….. (rare)
Vesico-uterine fistulaC/P:
If lies above the isthmus leads to menouria.
(Cyclic hematuria occurs due to escape of blood from uterus to urinary bladder
during menses).
Vesico-uterine fistulatreatment:
1. Preventive: Proper separation of bladder during operations e.g. CS.
2. Active: abdominal repair is sufficient.