Urinary Fistulae by Dr. Bilqis Afridi

URINARY FISTULAE
By: Prof. Bilqis Afridi
INTRODUCTION
nDefinition : A fistula may be defined as an abnormal communication two or more epithelial surfaces.
As Gynaecologists our primary concern is fistulae between genital tract and urinary tract

GENITAL TRACT URINARY TRACT
- Vagina - Bladder
- Cervix - Urethra
- Uterus - Ureter
- Perineum
ATEIOLOGY AND EPIDEMIOLOGY
A. Congenital
B. Acquired
o Obstetrical
o Surgical
o Radiation
o Malignant
o Miscellaneous
In most third world countries over 90% are of Obstetrical aetiology, whereas in U.K over 70% pervic surgery.
OBSTETRIC
Underlying factors responsible for obstetric fistulae
1. Physical
2. Biology
3. Cultural
4. Geographical


PHYSICAL FACTORS responsible for obstructed fistulae

a) Obstructed labour
b) Accidental injury at the time of C section
c) Forceps delivery
d) Craniotomy / Symphysiotomy


Obstructed labour
Ø is most often due to contracted pelvis, which is due to
Ø Stunting of growth by malnutrition
Ø Untreated infection in childhood /adolescence
Ø Women retain a subservient role in society
Ø Standard of education is limited
Ø Early marriage and absence of family planning
Ø Early start to child bearing
Ø First pregnancies occur soon after menarche before growth of pelvis is complete.

Following factors have lower incidence in our set-up.

Surgical
Radiation
Malignancy

PREVALANCE
Recent data in England and Wales.
Seven fistulae repairs per health region per year over the last 5 years, a national incidence of 120 per year. (Hilton – 1995)
nEstimated III-rd world war prevalence is 1 – 2/1000 deliveries with 50,000 – 100,000 new cases each year.
nEstimated 500,000 untreated cases world wide.

nClassification of Urogenital Fistulae
ü Urethral
ü Bladder neck
ü Sub – symphysial
ü Mid – vaginal
ü Juxta – cervical
ü Vault fistulae
ü Vesico – uterine
ü Vesico – cervical
ü Massive fistulae


PRESENTATION
Incontinence viz variable and may be affected by position


INVESTIGATION
nHistory
nClinical examination with Sim’s speculum


Further Investigation

nUrinary Micro-biology
nDye studies – Excretory Urography
nCystography
nFistulography
nCystoscopy


Examination Under Anaesthesia

nAssessment of fistulae
Type , Size , Site , Number

nDecision between vaginal and abdominal approach


IMMEDIATE MANAGMENT
Surgical fistulae
Early recognition followed by early repair
at the time of injury
Obstetric fistulae
Prophylactic catherization in cases of obstructed labour
Persistent bladder drainage
Antibiotics
Palliation / Skin Care
Nutrition / Correction of anaemia
Counseling

GENERAL PRINCIPAL OF SURGICAL TREATMENT
1. An EUA is important before the actual repair for assessment of the case, timing of repair and route of surgery.
2. Timing of repair
§ Obstetric cases - - 3 months
§ Radiation fistulae - - 12 months
3. Route of repair
§ Vaginal
§ Abdominal
4. Dissention should be precise
5. Suture material – polyglactin vicry 1 2/0 sutures for both bladder and vagina.
VAGINAL PROCEDURE

Dissection and closure in layers

Meticulous suturing of bladder wall,

no penetration of mucosa which should be
inverted as far as possible,

interrupted sutures closure in layers.

Tension free sutures

ABDOMINAL PROCEDURES

nTrans – vesical
nTrans – peritoneal
nGrafting – flaps
nTesting the repair

POST-OP MANAGEMENT
nFluid balance
nBladder drainage 1-hrly catheter check.
nCatheter for 12 – 21 days depending on the case
nPrevent kinking / drag on the catheter
nBed rest followed by full mobilization of patient in few days
nThrombo- prophylaxis
nAntibiotics after 48 hrly C/s.
n
PREVENTION
nObstetrical fistulae and MMR are closely related
nSage motherhood initiative
nAntenatal and intrapartum
nEarly transfer of high – risk patients
nIndentification of high risk areas.
nA major social change
nIncreased education
nDeferment of marriage and child bearing
nImproved nutritional status
nContraceptive services.


Thank you