VESICO-VAGINAL FISTULAE

Dr. Awoyesuku
A fistula is defined as an abnormal communication between 2 or more epithelial surfaces.

Vesico-vaginal fistula (VVF) therefore is an abnormal communication between the

genital tract (vagina, cervix, uterus) and the urinary tract (bladder, urethra and ureter).

VVF is of public health importance because the social implications are far reaching. Due
to the constant dribbling of urine and its pungent smell, they are usually ostracized and
considered as outcast.

EPIDERMIOLOGY
The exact prevalence and incidence of VVF in Nigeria is not known. Harrison in 1985
gave a value of 0.35 of all births in Zaria.
- It affects all ages but more in teenagers
- It affects all parities but more in primips
- Other factors include low social groups, illiteracy, low socio-economic groups
especially rural dwellers
Following a not too recent workshop by experts in Nigera, it was estimated that there are
about 200,000 unrepaired fistulae in Nigeria and about 2 million worldwide.
Estimated third world incidence is 1-2 per 1000 deliveries with about 50,000-100,000
new cases each year.

AETIOLOGY/PATHOLOGY
It may be congenital or acquired.
(A) Congenital eg. Cases of ectopic ureter may discharge into the vagina. It is very rarely
seen and therefore often overlooked.

(B) Acquired
1. Obstetric: 90% 0f fistulae in the third world.
(i). Negleted Obstructed Labour: Most common cause resulting from pressure
necrosis which follows impaction of the fetal skull in the pelvis = trapping of soft
tissues between fetal skull bones and maternal pelvis.
Immediate effect = Dusty. By 2nd day = dark marking. 3-4th day = sloughing.
Healing phase takes 10-12 weeks. Sepsis makes healing longer.

(ii). Operative deliveries

o Accidental trauma
o Cesarean section esp. with lower segment repeat c/section
o Forceps delivery eg. Forcible rotation with Kiellands
o Breech extraction
o Symphisiotomy = bladder injury
o Traditional practices play a role in the aetiology of obstetric fistulae eg.
Gishiri cut on the anterior vaginal wall, cicumcision esp. extreme forms
can lead to tears (ant. vag. wall) or obstructed labour.
2. Surgical: > 70% in UK & developed world. It may result from compromise of blood
supply = necrosis, or direct injury to the lower urinary tract.
i. Hysterectomy
ii. Colporrhaphy
iii. Colposuspension. Cytoplasty, sling
iv. Cervical stumpectomy
3. Radiation
i. Pre-operative pelvic irradiation increases the risk of post-operative fistula
development.
ii. Irradiation itself may be a cause of fistula. Oblitirative endarteritis =
Ischaemia. This also makes ordinary surgical repair have a high failure
rate.
4. Malignancy
i. Surgery or radiotherapy for pelvic malignancy has risk of fistula
development
ii. Tissue loss from malignant disease itself may result in genital tract fistular.
5. Miscellaneous
i. Infections e.g. LGV, Schistosomiasis, TB, Actinomycosis, etc.
ii. Catheter associated
iii. Trauma (penetrating trauma)
iv. Infection
v. Coital Injury
vi. Neglected pessary
vii. Foreign body

CLASSIFICATION
First classification was by Benion Thomas (1945)
- Juxta urethral
- Midvaginal
- Juxtacervical

Krishner (1949) added – Combined

Chasser Moir - Circumferential
Lawson (1968)
- Juxtaurethral
- Midvaginal
- Juxtacervical
- Very large vault
- Combined
Hamilton/Nicholson
Simple (healthy tissues, good access) – VVF, RVF, UrVF
Difficult (tissue loss/scarring, impaired access) – High RVF, Vut. F
N/B
Over 60% of fistulae in 3rd world are mid-vaginal, juxtacervical or massive (reflecting
obstetric aetiology) while 50% of fistulae in UK are in vaginal vault (reflecting surgical
aetiology).
PRESENTATION
1. Continuous involuntary (total) urinary incontinence
2. Dysuria, if there is associated UTI
3. Excoriations
4. Loin pains
5. Cyclical haematuria

Obstructed Labour Injury Complex

An attempt to appreciate the total problems of the patient following obstructed labour, so
that treatment will be geared towards the complete individual.
1. Urologic injury- VVF, Uvf, UrVF, UtVF, Complete Urethral loss, secondary
hydronephrosis, stress incontinence, renal failure.
2. Gynaecologic- Amenorrhoea (psychologic, chemical), gynaetresia, cervical injury
= incompetence/stenosis, PID with adhesions, secondary infertility.
3. Gastrointestinal tract- RVF, 3rd degree perineal tear, anal sphincter incompetence
4. Musculoskeletal system- Osteitis pubis, pressure sores
5. Central Nervous System- Foot drop (common peroneal nerve, L4,5 S1,2), Bladder
dysfunction
6. Skin- Chronic ulceration
7. Social- Isolation, divorce, worsening poverty, malnutrition, suicide.

INVESTIGATIONS
1. FBC: Reduced Hb, increased WBC
2. URINE M/C/S: UTI is uncommon in VVF patients but should be sought
after and treated before repair is undertaken. Pipette
specimen is taken from the intraversical space.
3. SERUM E/U/Cr: Renal Function Test
4. IVU: To outline urinary tract and connections
5. HSG: To evaluate any amenorrhoea and exclude any Ut.VF
6. CYSTOSCOPY: To examine bladder mucosa, rule out calculi, see exact
opening and its relationship to the ureteric orifices and
bladder neck.
7. EUA & DYE TEST When the diagnosis is in doubt, this will help to confirm
actual leackage being extraurethral and not urethral and the
site of the leakage.
In confirmed cases, EUA is done to determine
o the number, site and size of the fistulae
o the presence of scarring (fibrosis)
o the best approach/position for repair and
o the patency of the bladder.
- Dye test is necessary to identify very small fistula and there location (triple dye
test)
 - A uretero-vaginal fistula produces a constant trickle of urine, but the bladder is
still intact and will continue to function. The usual test is to instill a solution of
suitable dye into the bladder. Cotton-wool in the vagina will not be stained if the
fistula is ureteric.
MANAGEMENT
This is divided into initial management and definitive management.
Initial Management
Surgical fistula recognized within 24Hrs of the operation should be repaired immediately.
Majority are recognized 5-14 days post-op and should be treated with continuous bladder
drainage for 6-8weeks for spontaneous closure to occur.
Obstetric fistulae after obstructed labour should be treated by continuous bladder
drainage, combined with antibiotics to limit tissue damage from infection.
Palliation/Skin care
During the waiting period, the patient should use pads to soakurine and improve her
social life. Due to the risk of developing ammoniacal dermatitis, a silicone barrier cream
or Zinc oxide in castor oil should be used liberally.
Nutrition
They are often malnourished and anaemic and therefore improved nutrition is advocated.
Haematinics should also be useful.
Physiotherapy
Management of a physiotherapist of foot drop/limb contracture for rehabilitation of the
patients is essential.
Surgery
Options
– Vaginal repair (route of choice)
- Abdominal (Transvesical/transperitoneal) repair
- Combined
- Ureteric transplantation/ ileal conduit
- Colpocleisis
Principles of Vaginal Repair
1. Allow time for wound healing = 3 months for obstructed labour VVF
= 6 months for radiation VVF
= (? Recent advocates for earliar repair)
2. Pre-operatively
- Time away from menses
- Avoid OCP/steroids = impair healing
- PCV, group & crossmatch blood if necessary
3. Anaesthesia
- Local anaesthesia
- Regional (spinal) – now being favoured
- General anaesthesia – most people, to allow for adequate positioning
4. Exposure/lighting
i. Position
o Knee-chest position (genu-pectoral)
o Trendelenburg
o Exaggerated lithotomy
 ii. Vaginal access
o Labial stitch/Schuchardts incision
o Specula
iii. Good lighting source – direct vision

5. Dissection/Mobilization
- Catheterize urethra
- Steady fistula, infilterate – adrenaline 1:200,000 sol
 Define tissue plane
 Reduce blood loss

- Excision of margin not necessary

- Make plans for possible graft
- Closure can be continuous or interrupted but should not be under tension
- Invert bladder margins, use 3/0 or 2/0 chromic catgut. Vicryl and Dexon are the
best. It is better to use UR6 needles.
- Take wide bites – muscle and submucosa but avoid mucosa.
- Closure can be transversely or longitudinally
- Bladder is preferably closed in 2 layers but one may be okay
- Remember to do dye test at the end to ascertain adequate closure
- Pack the vagina with acriflavin dye or Vaseline gauze

POST-OPERATIVE MANAGEMENT
1. Good nursing care
2. High fluid intake - not less than 3-4L in 24Hrs
3. Monitor urine output – not less than 100-150mls per hour
4. Continuous bladder drainage x 14 days
5. Antibiotics administration is controversial. Give prophylactically if
uncertain of sterile procedure
6. Analgesics
7. Vaginal pack can be removed in 24-48Hrs
8. Perineal toileting is essential
9. Ambulation Vs Restriction – if elderly, early ambulation will reduce the
risk of DVT.
10. Discharge procedure
 Bladder retraining/test of cure
 No coitus for 6 months (3 months might be enough)
 With subsequent pregnancy, mandatory ANC & C/S
 Counselling on cause of injury and prevention.
N/B
What Is Cure:
Closure of VVF, continence and re-integration into the society

Combined VVF & RVF:

You repair the VVF first then repair the RVF in 3 weeks.
For a high RVF, you may need to do a colostomy.
COMPLICATIONS
EARLY
o Bleeding
o Ureteric obstruction
o Catheter not draining = use bladder syringe
o Wound breakdown
o Anaesthetic complication
LATE
o Stress incontinence
o Gynaetresia
o Mis-direction of menses

PREVENTION
It is absolutely preventable, especially with safe motherhood
- Social equity for women
- Antenatal care for all
- Essential obstetrics for those at risk
- Family planning for both couple
- Effective child survival strategies

CONCLUSION
It is one social calamity too many.
The cause is obstruction at all levels
The pathology is misery and social alienation
The cure is surgery
The problem is enormous
Prevention is the will.