Vesicovaginal fistula definition:
Abnormal epithelialized tract connecting between urinary bladder cavity & vaginal lumen.
Vesicovaginal fistula incidence:
the commonest type of genitourinary fistulae.
Vesicovaginal fistula aetiology:
A. Congenital: very rare.
B. Traumatic : the commonest
I. Surgical trauma (the commonest):
Mechanism: bladder is injured during: * abdominal operation e.g. TAH.
* Vaginal operation e.g. vaginal hysterectomy.
Timing: incontinence develops immediately post operative.
II. Obstetric trauma:
1. Necrotic obstetric fistula:
Mechanism: during labour, the bladder base & anterior vaginal wall are compressed
for a long time between pubic bone& fetal head ischemia
sloughing separation of the compressed tissues leaving a tract.
Timing: incontinence develops around week after labour.
2. Instrumental obstetric fistula:
Mechanism: direct injury of vagina & bladder e.g. forceps application before full
Timing: incontinence develops immediately postpartum.
III. Accidental trauma: Rough trauma to soft tissues e.g. defloration & stab wound.
C. Inflammatory: very rare.
Specific: e.g. TB caseation process destructing tissues.
Non specific: e.g. pelvic abscess may get access to bladder & vagina.
D. Neoplastic: advanced cases of cancer cervix –commonest- may invade tissues.
E. Radiotherapy: *Mechanism: ischemic necrosis caused by end arteritis obliterans.
*Timing: incontinence develops months or years after radiotherapy.
Vesicovaginal fistula diagnosis:
give an idea about the possible cause
1. Start since birth: congenital fistula.
2. If following * labour:
Immediately: instrumental fistula.
One week after: necrotic fistula.
* Gynecological operation: surgical fistula.
3. Past history of:
♦ Pelvic infection: points to inflammatory fistula.
♦ Pelvic malignancy: points to malignant fistula.
♦ Radiotherapy: points to radiation fistula.
Symptoms of the disease itself:
1. Incontinence of urine: *Usually complete (no desire to micturate).
*Rarely partially (small, high or valvular): there is desire to micturate.
2. Symptoms of 2ry vulvitis: vulval soreness & pruritus due to continuous soiling of
the vulva by urine.
Symptoms of complications:
1. Urinary tract infection:
♦ Suprapubic pain (cystitis).
♦ Loin pain (pyelonephritis).
2. Amenorrhea due to:
♦ Psychological cause: the commonest cause.
♦ Operative cause of fistula is the same cause of amenorrhea i.e. hysterectomy.
♦ Severe infection destroying endometrium and causing fistula.
Symptoms of the cause & any previous repair:
♦ Essential (affect the choice and type of treatment operation).
♦ Anemia: affects healing of the fistula.
♦ Uremia: as a complication.
♦ Loin mass and palpable kidney: hydronephrosis.
♦ Loin tenderness: pyelonephritis.
♦ Scar of previous operation (surgical fistula).
♦ Inspection of the vulva: 2ry vulvitis & phosphatic encrustation.
♦ Palpation of anterior vaginal wall: * Site, size number of fistula.
* Capacity of the vagina.
N.B.: If the fistula is small, it can be identified by the surrounding fibrosis.
♦ Inspection of anterior vaginal wall:
Method: by Sim’s speculum with the patient in Sim’s position.
1) The patient lies on her left side near the edge of the table.
2) Her left arm behind her body.
3) Her right arm holds the edge of the table fixing her body.
4) Her left thigh & knee are kept semi-flexed or straight.
5) Her right thigh & knee are fully flexed.
Why? : This position creates negative pressure in the pelvis -displaces
the intestine upwards- leading to vaginal inflation.
1) Detect site, size & number of fistulae.
2) If small or high: detected by methylene blue test.
3) Metal catheter in the urethra and urinary bladder & uterine
sound in the vagina: clicking sound can be heard.
1) To confirm the diagnosis: (must be done in each case to detect other fistulae)
1. Methylene blue test:
a) 3 pieces of gauze are placed into the vagina.
b) 200 ml sterile MB injected into urinary bladder using proper catheterization.
c) The catheter is then removed & the patient is asked to walk for 10 minutes.
d) The lowest gauze is discarded as it is usually stained during dye injection.
Interpretation (results): inspect both middle & lower gauzes:
a) If both gauzes are stained blue: vesico-vaginal fistula.
b) If both gauzes are stained yellow: uretro-vaginal fistula.
c) If both are dry & unstained: – exclude fistulae,
– search for other causes of incontinence.
a) Confirm the diagnosis of vesico-vaginal fistula & determine site, size,
number & relation of fistula to the ureteric opening.
b) Exclude uretro-vaginal fistula by:
♦ No ureteric reflux on the affected side.
♦ If a ureteric catheter is passed, it stopped short at the site of injury.
Idea: IV injection of 4 cc of 4 % solution of indigocarmine, normally the
dye will appear in urine 4 minutes after injection.
i. Confirm the diagnosis of vesico-vaginal fistula.
ii. Assessment of kidney function.
Give an idea about kidney functions.
Diagnosis of hydronephrosis.
Outline the course of the ureter (Normal or aberrant).
Diagnosis of hydroureter.
2) To prepare the patient for operation:
1. Very important especially KFT & urine analysis.
2. CBC: Hb & WBCs.
E. Differential diagnosis: other causes of urinary incontinence (as before).
Vesicovaginal fistula treatment:
A. Prophylactic treatment: (the most important part of management)
♦♦♦ Avoid the possible cause e.g.* Evacuation of the bladder before labour & operations.
* Early management of bladder injury during operation.
B. Active treatment:
♦♦♦ If the fistula is discovered immediately:
Immediate repair+ catheter is fixed for 15 days+ antibiotics are given.
♦♦♦ If the fistula is discovered lately> 24 hours:
Timing of the operation
1) Post menstrual: decrease pelvic congestion and decrease intraoperative blood loss.
2) 3 – 6 months after delivery or abortion: to allow maximum involution of tissues.
3) 3 – 6 months after previous repair: to allow maximal fibrosis.
1) Improve the general condition:
Correction of anemia if present.
Proper control of DM & hypertension if uncontrolled.
2) Improve local condition:
Treatment of vulvitis by:
– Covering the area by vaseline or zinc oxide to avoid maceration.
– Scrapping of phosphatic encrustations & painting the resulting ulcer by
Treatment of UTI by: antibiotics.
3) Pre-operative investigations:
Blood picture & blood sugar.
LFT & KFT.
ECG & urine analysis.
A. Vaginal repair (better):
1) Dedoublement (flap splitting operation). The most suitable.
♦♦♦ Indication: mobile fistula.
1. The vagina is dissected from the urinary bladder after one circular
incision around the fistula & 2 extended vertical incisions & then
the fistula is excised.
2. Closure of the urinary bladder in 2 layers excluding the mucosa to avoid
3. Vaginal pack & urinary catheter are applied.
2) Saucerization (Sim’s operation):
♦♦♦ Indication: fixed fistula.
1. A wider part of vaginal mucosa is removed including the fistula.
2. The part removed from vaginal mucosa wider than that from bladder.
3. The edges of the bladder & vaginal opening are sutured together.
3) Interposition operation (Martius operation):
♦♦♦ Indication: post-irradiation fistula.
♦♦♦ Technique: interposition of bulbocavernosus flap with its blood supply
between vagina &UB.
4) Latzko operation (partial colpocleisis):
♦♦♦ Indication: vault fistula after hysterectomy.
1. The upper part of the vagina is removed.
2. Firstly close hole in the urinary bladder.
3. Then close hole in the vagina.
B. Abdominal repair:
1. Failure of previous vaginal repair.
2. High fistula that difficult to be accessed vaginally.
3. Narrow vagina (extensive fibrosis).
1. Intra-peritoneal: trans-vesical & extra-vesical routs.
2. Extra-peritoneal: trans-vesical & extra-vesical routs.
Post- operative care
A. Vaginal pack for 24 hours.
B. Catheter is fixed till healing of the urinary bladder (14 days).
Care of the catheter
1. Urine output:
Checked every 2 hours.
If no urine for 2 hours: indicates catheter blockage or anuria (dehydration).
Dehydration: IV fluids.
Blockage: * Gentle injection of sterile saline.
* Replacement of catheter.
2. Urine culture & sensitivity.
3. Antibiotics: according to culture & sensitivity.
4. IV fluids: at least 3 liters / day.
5. Bloody urine: injection of silver nitrate 1 % is through the catheter.
6. Alkaline urine: acidification of urine by ammonium chloride.
7. Passive training: intermittent clamping of the catheter is tried before its removal.
8. Active training: *done after removal of the catheter to inhibit UB overdistension.
*The patient is asked to micturate every: 2 hours by day & 4 hours
A. No sexual intercourse: for 6 months.
B. No pregnancy: for 12 months.
C. Subsequent deliveries: by elective USCS.
1. Complications of anesthesia.
3. Intraoperative 1ry hemorrhage.
4. Injury of important structures e.g. bladder, ureter & rectum.
B. Post operative:
1. Reactionary hemorrhage & 2ry hemorrhage.
2. Infection affecting wound & urinary tract infection.
3. Pulmonary complications: due to DVT.
Delayed: recurrent fistula.
Recurrent Vesicovaginal fistula
Def.: Recurrence of fistula 6 months following successful surgery.
A. Pre-operative causes:
Bad general conditions Bad local condition Bad time of operation
♦♦♦ Anemia not resolved.
♦♦♦ Uremia not resolved.
♦♦♦ Vaginitis & UTI
♦♦♦ Immediate postoperative or postpartum
B. Operative causes:
A. Bad diagnosis of other fistulae.
B. Bad choice of operation.
C. Bad technique of operation: bad hemostasis, sutures were under tension.
C. Postoperative causes:
a) Bad early management:
♦ Early distension of the bladder affecting sutures.
♦ Complications as infections or hematoma affecting sutures.
b) Bad late management:
♦ Early intercourse and early pregnancy.
♦ Badly managed subsequent labour (unsuitable circumstances).
1) Another chance is tried 3 – 6 months after the first repair.
2) Failure of vaginal repair making abdominal repair a reasonable way.
3) You have to try one of the following if repeated operations fail to close the fistula,
Closure of the vaginal cavity (Colpocleisis).
Complications are: obstruction, ascending infection & hyperchloraemic acidosis.
Vesicovaginal fistula power point presentations:
UROGENITAL FISTULAS Prof.M.C.Bansal. MBBS., MS. MICOG.FICOG. Founder Principal & Controller ; Jhalawar Medical College And Hospital , Jhalawar. Ex. Principal & Controller; Mahatma Gandhi Medical College And Hospital,Sitapura , Jaipur Dr Jaya Patel (PG Student,NIMS Medical College Jaipur
Obstetric Fistula Dr. A. P. Soibi-Harry Dept. of Obstetrics & Gyneacology Lagos University Teaching Hospital