Professional Documents
Culture Documents
URINARY PROBLEMS IN
GYNAECOLOGY & TRAUMATIC FISTULAS
QUESTIONS
DE
1.
b. Cystoscopy
a. Gynae surgery
d. IVP
b. Irradiation
c. Urine culture
5.
c. Obstructed labour
d. Trauma
2.
b. Urge incontinence
3.
c. Stress incontinence
a. 6 weeks
d. Uretero-vaginal fistula
b. 8 weeks
[AI 04]
d. 6 months
7.
a. VVF
c. Foleys catheterisation
b. Stress incontinence
d. Sterile speculum
c. Urethrocoele
[AI 10]
[AIIMS 87]
c. 3 months
4.
d. Enterocoele
[AMU 05]
9.
15.
b. Bladder Training
b. Vaginal vault
c. Electrical stimulation
c. Ureteric tunnel
d. Vaginal cone/weights
11.
12.
14.
17.
[AIIMS 96]
b. Vault prolapse
c. Rectal prolapse
d. Uterine prolapse
e. Cervical incontinence
18:
19.
Version I.
Which of the following surgeries for stress
incontinence has highest success rate: [AI 2011]
a. Bursch colposuspension
a. Uretherovaginal
b. Pereyra sling
b. Vesico-vaginal
c. Kellys stitch
c. Vesico-uterine
d. Uretero-uterine
13.
10.
19.
Version II.
a. VVF
a. Burchs colposupension
b. UVF
b. Stameys repair
c. Bladder Endometriosis
c. Kellys stitch
d. Ca. Cervix
d. Aldridge surgery
20.
a. Colostomy
b. Posterior colporrhaphy
b. Primary repair
c. Colposuspension
c. Colporrhaphy
d. Anterior resection
e. Sling operation
103
23.
a. Retroverted uterus
a. Urinary retention
b. Pelvic hematocoele
24.
c. It is a cause of infertility
d. Causes menorrhagia
104
a. Cervical fibroid
c. Unilateral hydronephrosis
CHAPTER
AT A
GLANCE
DE
Urinary Fistulas
Vesicovaginal Fistula
M/C
Etiology
Hysterectomy
Maximum risk is with
wertheims hysterectomy
Chief Complaint
Methylene blue
3 swab test
(M oirs test)
Investigation
Of choice
Cystoscopy
Mgt of
Choice- Surgery
As early as possible
No continuous leakage
but when patient
urinates, urine leaks
from urethra and vagina.
Lower most cotton plug is
wet with dye, other two
are dry.
If it is due to surgery
And is recognised within24hrsImmediate repair.
If recognised later-repair
after 3-6 months
105
According to International continence society, incontinence is defined as the complaints of any involuntary
leakage of urine which is a social and hygienic problem to the patient.
Classification
Urethral cause :
Extra urethral
Stress urine
incontinence
Urge incontinence
congenital
Mixed incontinence
Acquired
overflow incontinence
urinary fistulas
Physiology of Micturition
Bladder Supply
Sympathetic
Parasympathetic
Via S2 S4
neurotrarsmitter
Acetyl choline
Via T11 L 2/ L3
Neuro transmitter
Nor epinephrine
Bladder neck
Descent (Including urethral
hypermobility) (75-80%)
Risk Factors
i.
Vaginal delivery
iii. Obesity/Pregnancy
106
ii.
Flow rate during voiding more than 15mL/sec with a detrusor pressure less than 15cm of water during filling
and less than 70cm of water during voiding
Abnormal cystometry
If there is leak of urine in the absence of a rise in detrusor pressure, stress incontinence is diagnosed. Urge
incontinence is diagnosed during the filling phase if there are spontaneous or provoked detrusor contractions
while the woman is trying to inhibit micturition. Thus stress incontinence is actually a diagnosis by exclusion.
Management:
1st line of mgt: Pelvic floor exercise called as kiegels exercises.
Definative management : Surgical management.
The choice of surgery is usually between a retropubic urethropexy and a sling operation. These are the currently
employed first line operations for stress incontinence. In general with concomitant prolapse a vaginal route is
preferred and sling surgery is done. If the woman is undergoing a laparotomy for any other reason urethropexy is
preferred. This can also be done laporoscopically.
Retropubic Urethropexy (Abdominal Procedure)
It involves attaching the fascia around the urethra and bladder neck to a supporting structure in the anterior
pelvis. This elevates the blader neck to an intra-abdominal position. The main problem is postoperative voiding
dysfuncion, detrusor overactivity and pelvic organ prolapse.
Two types of surgeries can be done in retropubic urethropexyA. The Burch colposuspension-most commonly done urethropexy wherby the fascia at the level of bladder
neck are attached to the iliopectineal ligament or Coopers ligament. The success rates are as high as 90%.
B. The Marshall-Marchetti-Krantz or MMK involves attachment of the periurethral facia to the back of the pubic
sympysis. A complication specific to this procedure is osteitis pubis and hence this procedure is no longer
used.
Sling operations
A sling is passed around the bladder neck and urethra and attached above to the anterior rectus facia so that a
supporting hammock is created for the urethra. The urethra is supported and also occluded when the intraabdominal pressure is increased, examples of this technique are-
107
Urethral hypermobility
Vaginal
Abdominal urethropexy
1. Kellys
1. Bursch (M/C)
2. Needlesuspension surgery
2. MMK
a. Pereyra
b. Stamey
c. Raz
3. Artificial
1. Sling surgeries
2. Periurethral collagen
Urinary
injection (through
sphincter
Urge Incontinence:
It is more common is older females.
Characterised by involuntary leakage of urine accompanied by urgency
It is can be mainly due to detrusor overactivity which can be
Idiopathic
Due to neurogenic causes like:
1. CVA
2. Alzheimers disease
3. Multiple sclerosis
4. Parkinsonism
5. Diabetes
It can also be due to causes like:
Cystitis/UTI
Bladder Stones/Cancer
Urethral obstruction
108
cystoscopy)
2.
VesicovaginalQ
Obstructed labourQ
Injury to ureter after gynaecological operationQ
especially Wertheim hysterectomyQ
Cesarean sectionQ
Cesarean perineal tearQ
Continuous dribbling of urine following hysterectomy points towards urinary fistulas as the diagnosis.
In case of urinary fistulas, if the patient never needs to void as there is continous dribbling it signifies that the
fistula communicates with the bladder. If, there is filling and emptying of bladder along with the fistula, it suggests
a fistula opening into one ureter i.e. Uretero vaginal fistula.Q
As far as urethral fistula are concerned, they give little trouble because the urethra is normally empty of urine.
However during micturition urine passes through the fistula and may then fill the vagina to dribble during body
movements for a short time afterwards.
This patient is developing symptoms on the seventh day can be explained by : Fistulas resulting from
accidental, surgical and obstetrical trauma are produced in two ways. They can be caused by direct injury
such as cuts and then they manifest themselves immediately by hematuria and incontinence. Alternatively
if they are the outcome of pressure necrosis or of ischemia, in such a case urinary incontinence, fever and
burning micturition develops 7-14 days after the accident.
...Jeffcoate 7/e, p 263
109
Urine culture is mandatory before surgery and infection should be treated. The urine is collected by
Catheterisation.
... Shaw 14/e, p 167
In VVF
Preoperative collection is best to be done through ureteric catheterisation.
So friends undoubtedly Ureteric catheterisation. (Dont get confused it is not Foleys catheterisation) is the
best method for collecting urine for culture in a case of VVF. This option is not given, so, we will have to look for
next best option.
Urine collected through a sterile vaginal speculum will not serve the purpose because of contamination.
Supra pubic aspiration done after proper cleansing and draping the patient with full bladder, is easy and next
best method of urine collection after ureteric catheterization. But the only prerequisite for this method of collection
is A full bladder which cannot be fulfilled in a case of VVF as urine continuously dribbles from the vagina and
therefore bladder is never full. (Ruling out Option a)
By exclusion our answer is Foleys catheterization, although chances of contamination are present in Foleys
catheterization but they can be reduced if proper vaginal douching is done prior to collection of urine.
4.
5.
110
Number and size of VVF, with their exact localion in relation to the ureters and bladder neck.
The state of the margins of the fistulas If needed a biopsy can be taken from the margin of a post radiation
fistula.
6.
7.
Layer technique
Postop Management
Antibiotic coverage.
Extra Edge :
This question is an old one so here answer will be 3 months but if this question is repeated now remember the
following lines from Williams Gynae. 1/e, 575 - 576 :
Timing of repair : Traditional teaching recommends delayed repair of fistulas at 3 to 6 months afte injury.
However, this old dictum is probably no longer applicable. Most agree that unless there is severe infection or
acute signs of inflammation, waiting is not necessary . Early surgical intervention of uncomplicated fistulas does
not affect closure rates, yet appears to reduce social and psychological patient distress (Balivas, 1995). Fistulas
identified within the first 24 to 48 hours postoperatively can be safely repaired immediately with success rates of
90 to 100 percent.
8.
The three swab test helps to confirm the Vesico Vaginal Fistula and to differentiate between vesico vaginal
fistula, uretero vaginal and urethrovaginal fistula.
Procedure of Three swab test A catheter is introduced into the bladder through the urethra.
Three cotton swabs are placed in the vagina as follows :
One at vault,
111
Interpretation
1.
Upper most swab soaked with urine but unstained with dye
2.
Upper and lower swab remain dry but the middle swab soaked with dye
3.
The upper two swab remain dry but lower one soaked with dye
9.
10.
movement
The crossing of the uterine vessels and ureter is at the level of internal os. Over here the ureter runs below the uterine
vessels (water below the bridge)and the distance between the ureter and uterine vessels is only 1.5 2 cm.
The ureter can get injured at all the sites mentioned in the question but during gynaecological surgeries the commonest
site of injury to ureter is where it crosses below the uterine arteries.
The next common site of injury is behind the infundibulopelvic ligament at the pelvic brim.
At operation ureter is recognized by :
1. Its pale glistening appearance
2. By a fine longitudinal plexus of vessels on its surface
3. More particularly by its peristaltic movement
4. By palpation between finger and thumb as a firm cord which, when escapes, gives a characteristic snap.
Absence of pulsation does not serve to identify a structure as ureter because veins and obliterated umblical artery
are also non pulsatile.
11.
Uretero vaginal fistula most commonly follows trauma during pelvic surgeries like Total Abdominal Hysterectomy,
Wertheims hysterectomy and Vaginal hysterectomy.
Symptoms :
Escape of urine through the vagina (True incontinence)Q
Besides incontinence patient has also got the urge to pass urine and can pass urine normally.Q
Patient may complain of :
Flank pain
Temperature
Retroperitoneal fluid collection (caused by urinary leak into the abdominal cavity due to transection of the
ureter i.e. option a is correct).
Investigation :
1. Three swab test differentiates it from VVF.
2. I.V. Indigocarmine test : if the urine in the vagina is unstained following three swab test, indigocarmine is
injected intravenously, if urine becomes blue diagnosis of uretero vaginal fistula is confirmed.
3. IVP : In case of ureteric transactions partial or complete, pyelography fails to show part or whole of the ureter
on the transected side and there may be pooling of dye in the peritoneal cavity.
4. USG : Following ureter ligation, USG may reveal hydronephrosis and dilated ureter proximal to the site of
block.
5. CT scan.
112
The best chance of healing with primary repair is when reoperation is done within the first 48 hours. Our
opinion is that some form of immediate intervention must be undertaken no matter what the type of injury
has occurred.
... Telinde Operative Gynecology 9/e, p 1088
Uretero vaginal fistula should be repaired as early as possible to prevent upper urinary tract damage
... Dewhurst Obs. & Gynae. 7/e, p 543
Technique of Repair
a. When ureteral sheath is denuded for a short segment, it is best to do nothing.
b. When ureter is kinked due to a suture, it should be removed or deligated immediately.
c. If clamped tissue is healthy and viable, splinting/stenting is done for 7-10 days for further.
Ureteric transection :
a. Ureteroneocystostomy (implantation of ureter into the bladder) when injury is near bladder.
b. Uretero ureterostomy : end to end anastomosis : done when ureter is dissected above mid pelvis.
c. Bladder flap operationQ (MODIFIED BOARISQ) : done when ureter is short or injury is at the level of pelvic brim.
d. Segment of small intestine may be used for repair.
Ref. Shaw 15/e pg -188; Jeffcoate 7/e, p 266
12.
13.
The condition of cyclical passage of menstrual blood in urine is called as Menouria. ... Jeffcoate 7/e, p 266
Menouria :
14.
The patient complains of hematuria/passage of menstrual discharge via urethra at the time of menstruation.
Patient does not have Urinary incontinence.Q
Mensouria is seen when Utero vesical fistula opens into the uterus above the isthmus.Q
The presence of the fistula can be demonstrated by hysterography (but not by cystography) and cystoscopy.Q
Anoscopy / Proctoscopy
113
Classification :
Congenital
Acquired
Trauma
Inflammatory bowel disease
Irradiation
Neoplasia
Infection
Other causes
Now lets talk about Rectovaginal fistula that results due to obstetric injury :
Initial Treatment : A small rectovaginal fistula may be managed with conservative medical approach, in hope that
decreasing the fecal stream will allow closure of fistula. Large rectovaginal fistula for which there is no hope of
spontaneous closure, are best managed by performing initial diverting colostomy.Q
Ref. Novak 14/e, p 704; 15/e p 711
Definitive Treatment : However the initial management is either medical conservative approach (small fistula) or
a diverting colostomy (large fistula) to allow for the pelvic inflammation to subside, but the definitive treatment is
surgical repair.
If even after several months (3-6 months) of conservative approach Fistula does not heal, surgical repair is done.
15.
Interference with
the opening of
internal sphincter
Spasm of external
urethral sphincter
Obstruction
of Urethra
Due to
Due to
Due to
Inhibition of detrusor
muscle due to emotional
Nervousness
Congenital atresia
uterus, cervical
Perineal injuries
Foreign body /
Paralysis of excitatory
leiomyoma, impacted
ovarian cyst,
disease of CNS
hematocolpos, hemat-
Operations on
Urethritis
complicated ectopic
Neurological disease
radical hysterectomy)
Buttressing of tissue
Calculi (Rare)
Paralysis of excitatory
tissues
Stenosis following
injury or infection
Paraurethral cysts or
abscess
Angulation of urethra
in gross prolapse
cases.
Over enthusiastic
urethrocystopexy
114
Retroverted gravid
17.
18.
Bonneys test is performed in the clinical evaluation of SUI. In the Bonneys test, two fingers are placed in the
vagina at the UV junction on either side of the urethra and the bladder neck is elevated.
On straining or coughing, leakage of urine indicates of positive test. A positive test indicates that the SUI is due to
bladder neck descent and urethral hypermobility and can be corrected by bladder neck suspension surgeries.
A negative test i.e. leakage of urine-means SUI is due to intrinsic urethral sphincteric deficiency and results of
performing bladder neck suspension surgery will not be good.
Note : Marchetti test is same as Bonneys test, but two Allis forceps are used instead of fingers.
19.
Version I
Ans. is d i.e. Tension Free Vaginal Taping (TVT):
Evidence Based Urology (Wiley Blackwell) 2010/193 Pelvic Floor Dysfunction. A multidisciplinary Approach
(Springer) 2006/117: Hernia Repair Sequalce (Springer) 2010/440; Assessing and Managing A cutely III Adult
Surgery Patient (John Wiley and Sons) 2007/182
115
Version II
Ans. is a i:e Bursch colpo suspension
As discussed in preceding text SUI is managed basically by performing either of the two surgeries viz1. Burch colposuspension
2. Tension free vaginal tapes/tension free obturator tapes.
The rates of success of these two surgeries are comparable, so if either of them is given in options, we will chose
it.
So in version II- Answer is Burch colposuspension
Procedure
Burchs colposuspension
89.5
Stameys repair
85
Kellys repair
50-60
Aldridge Repair
85
Now suppose both Burch colposuspension and TVT is given (Like in version I), then rememberTension Free Vaginal Tape (TVT) has emerged as the treatment of choice for genuine stress incontinence in
recent years
Tension Free Vaginal Tape (TVT) is a simple procedure that may be performed under local anesthesia, has a
decreased operative and recovery time, and is as effective as Burch colposuspension which was earlier considered
the procedure of choice.
A number of surgical procedures have been developed to treat genuine stress incontinence and most aim to
elevate and support the bladder neck. Burch colposuspension was the procedure of choice, but in recent years
this has been superseded by the Tension free Vaginal Tape which is showing comparable results and is less
invasive
Ref. Assessing and managing Acutely III Adult Surgery Patient (John Wiley and sonsd) 2007/440
Tension Free Vaginal Tape (TVT)
20.
Tension Free Vagina Tape (TVT) is a type of suburethral sling that does not have typical suspension sling like
mechanism of action.
TVT involves placement of synthetic polypropylene mesh/tape under the urethra. The sling is placed at the
level of mid-urethra (midurethral sling)
TVT is a simple procedure that can be performed under local anesthesia, and has the advantage of decreased
operative time and decreased recovery time, while providing a good outcome.
TVT is believed to be as effective as Burchs colposuspenstion with cure rates approaching > 80%.
Ans. is a, c , d and e i.e. anterior colporrhaphy, colposuspension, pelvic floor excercises and sling operation.
Ref. Shaw 14/e, p 174, Dutta gynae 5/e p387 389, Textbook of gynae, shielaBalakrishnan 1/e, p 329 - 330
As explained in preceeding text:
Pelvic floor exercises
Sling operation
Colposuspension (Burch) are all done for management of SUI.
As far as anterior colporhaphy is concerned - kellys plication is anterior colporhaphy + Bladder neck repair, so I
have included it in correct option also.
21.
116
Ans. is a, b, and d i.e. Cervical fibroid; Retroverted Gravid uterus; and Severe UTI
Ref. Jeffcoate 7/e, p 855
Important gynaecological causes of acute retention :
Acute retention
Other symptoms
Diagnosis
Retention +
Primary amenorrhea
Hematocolposcopy
Retention +
Secondary amenorrhea
Retention +
Menorrhagia
Retention +
No menstrual upset
Retention +
Irregular bleeding
Besides the above causes Jeffcoate 6/e, p 855-858 gives an exhaustive list of other causes of urinary retention- in
which urethritis causing spasm of voluntary external urethral sphincter and acute urinary retention is given.
23.
24.
117
Acquired
Mobile retroversion
Prolapse
Puerperium
Fibroid
Ovarian cyst
(pushes uterus backward)
Fixed retroversion
PID
Pelvic tumors
Chocolate cyst of ovary
Pelvic endometriosis
Symptoms :
Mobile retroversion is usually symptomless, main disadvantage being increased risk of perforation of the uterus
at the time of instrumentation.
Symptoms which can be seen are :
Spasmodic dysmenorrheaQ
Pelvic congestion syndrome causing :
Congestive dysmenorrhea
Polymenorrhagia
Premenstrual low backache
Dyspareunia (it is the most specific and genuine complain in case of retroversion)
Leucorrhoea
Infertility : as cervix is directed forward away from the seminal pool and the ejaculation of semen directly into the
external os.
Abortion : can cause abortion between 10th to 14th week.
Treatment :
If retroversion is mobile no treatment is required.
In patient complaining of dyspareunia backache with retroverted uterus : Hodge pessary may be used to keep
uterus in anteverted position.
Surgical management : Modified Gilliams operation
Plication of round ligamentQ
Baldy webster operationQ
25.
118
REVIEW QUESTIONS
DE
1.
2.
3.
4.
5.
Answer
1. b. Posterior ...
6. d. Methylene ...
2. a. Obstructed ...
7. b. Three ...
6.
7.
8.
9.
10.
3. d. 14 days
8. a. Obstetric ...
4. c. Hormone ...
9. d. After ...
5. b. Vesicovaginal
10. a. Stress ...
119
12.
13.
14.
15.
16.
Answer
120
11. a. Colpo-sus....
16. None
21. c. Improper ...
17.
18.
19.
(RJ 2009)
a. VVF
b. RVF
c. Ureterovatinal fistula
d. Procidentia
[Ref. Shaw 15/e pg -336]
20.
21.
14. e. All
19. d. Procidentia
23.
24.
25.
26.
27.
Answer
28.
29.
30.
121