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Classification – Urinary Fistula

 

Vesicovaginal Fistula

Uretero Vaginal Fistula

Urethro Vaginal Fistula

M/C

VVF is the m/c urinary fistula

 

 

Etiology

In developing countries - Obstructed

Labor

It is due to ischemic necrosis, so develops 3-5days after delivery.

In Developed countries - hysterectomy

Hysterectomy

Maximum risk is with

Wertheims hysterectomy

No continuous leakage but

when patient urinates, urine leaks from urethra and vagina.

Chief Complaint

Continuous dribbling of urine from vagina + no normal urge for urination

Continous dribbling of urine from vagina + normal urge

for urination

Lower most cotton plug is

wet with dye, other two are

dry.

Methylene blue 3 swab test (M oirs test)

Middle cotton plug is wet with dye and urine (blue in colour)

Uppermost cotton plug is wet with urine but not with dye.

Other 2 cotton swabs are dry

 

Investigation of choice

Cystoscopy

Dye test with indigo carmine demonstrates urinary extravasation and identifies the location of injury + Cystoscopy

 

Mgt of Choice-Surgery

Technique: Layer technique/ Latzko repair (for post hysterectomy VVF repair)

chassar moir technique

Time of surgery: If it is due to obstructed labor repair should be done after 3 months. (so that infection and

inflammation subside)

If it is due to surgery and is recognised within 24 hours-

Immediate repair. If recognised later-repair after 10-12 weeks Radiation fistulas are repaired after 12 months

Boari Flap technique

 

 

 

As early as possible

 

 

Vesicovaginal Fistula

  • Prolonged and obstructed labor is the MC cause of vesicovaginal fistula (VVF) in India.
  • It is due to ischemic necrosis, so it develops 3-5 days following delivery.
  • In developed countries, the MC cause is postsurgery.
  • Patients with VVF present with continuous incontinence with no urge to pass urine. Patients with ureterovaginal fistula also present with continuous incontinence, but there is an urge to pass urine.
  • Patients with urinary fistula may also have secondary amenorrhea (hypothalamic origin), which gets corrected following successful repair of fistula.

MOIR's Three Tampon (Swab) Test

  • Patient is placed in dorsal lithotomy or knee chest position
  • Three cotton tampons are placed in the vagina
  • Methylene blue is instilled into the bladder
  • Patient made to walk for 10-15 min
  • Tampons removed and examined

Interpretation

 

Observation

Inference

Upper most swab is soaked with urine (not with dye), lower two are dry

Ureterovaginal fistula

Middle swab is wet with dye (blue in color); other two are dry

Vesicovaginal fistula

Lowest swab is wet with dye (blue); other two are dry

Urethrovaginal fistula

  • Surgery for closure of VVF is layer technique.
  • The ideal time to do the surgery is 3-6 months following delivery.
  • Fistula formed during surgery is to be closed immediately if detected during the operation.
  • If the fistula is detected in the postoperative period, it is to be closed after 3-6 months.
  • Surgery for closure of posthysterectomy VVF= Latzko technique (layer technique + partial colpocleisis).

Youssef’s Syndrome

 

Menuria (menses in urine / cyclical hematuria) is seen in uterovesical fistula. Menuria is also seen in vesical endometriosis.





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