2.

1 Urovagina Fistula

A fistula is defined as an abnormal communication between 2 or more epithelial

surfaces. Urovaginal fistula is a devastating condition in which an abnormal

channel is created between the vagina and the urinary tract. Most frequently it

involves bladder, but sometimes to the urethra or to the ureter. It results in

continuous leakage of urine from the vagina, which for most women is a major

personal and social problems.

For countries in the industrialized world, gynecological surgery is the most

common cause of urovaginal fistulae development with hysterectomy as the leading

cause of this complications, followed by complicated obstructive labor. The

incidence of urovaginal fistula formation is lower in the well-developed countries.

2.2 Vesicovaginal Fistula

Vesicovaginal fistula is an abnormal communication between bladder and

vagina. This is the most common urovaginal fistula.

2.2.1 Etiology of Vesicovaginal Fistula

There are some causes of vesicovaginal fistula, such as congenital, trauma,

inflammatory disease, malignant neoplasm, and radium necrosis. Obstetric trauma

(necrotic and traumatic obstetric fistula) is the most common cause of vesicovaginal

fistula due to trauma, followed by surgical trauma and direct trauma.

Prolonged and obstructed labour may result in necrotic obstetric fistula.

Prolonged compression of soft tissues between head and brim of a narrow pelvis

causes pressure, ischemia, necrosis, and sloughing of the base of bladder. Slough
takes some days to separate. Incontinence develops 5-7 days after labour. This type

of fistula are often surrounded by dense fibrosis. Traumatic obstetric fistula is

caused by direct injury to the bladder wall by sharp instrument (perforator or

decapitation hook) during a difficult labour. Incontinence usually appears

immediately after labour. Traumatic fistula due to surgical trauma usually occurs

during vaginal operation (such as anterior colporrhaphy) or during abdominal

operation (such as hysterectomy). Direct trauma is a rare cause.

Vesicovaginal fistula due to inflammatory disease results from bilharziasis of

bladder, tuberculosis, and pelvic abscess. Malignant neoplasms (carcinoma of

cervix, bladder, or vagina) may invade directly and create fistula. Radium treatment

used for malignant disease in pelvis cause sloughing of bladder.

2.2.2 Symptoms of Vesicovaginal Fistula

Patients with vesicovaginal fistula usually come to the hospital with urinary

incontinence as the main symptoms. Patients complain about continuous dribbling

of urine and may be accompanied with vulvitis (pruritus, burning pain due to

continuous discharge of urine) and cystitis (due to ascending infection from vulva).

The symptoms may affect the quality of life and patients self confidence.

2.2.3 Diagnosis of Vesicovaginal Fistula

History taking may revealed the history of incontinence following labour or

operation. Large fistula can be palpated during palpation of anterior vaginal wall.

Small fistula is usually surrounded by fibrotic tissue. Inspection of the anterior

vaginal wall is performed using Sims speculum in Sims position or left lateral

(semi-prone) position.

For small and high fistula, dye test may be helpful. Methylene blue is injected

into the bladder using a catheter to ourline the fistula while anterior vaginal wall is

inspected by use of Sims speculum. Sometimes a metal catheter or sound is passed

through the urethra to appear at the fistulous opening. Fistulography gives the clear

image of vesicovaginal fistula.

2.2.4 Management of Vesicovaginal Fistula

Vesicovaginal fistula due to gynecologic or obstetric procedures can be

prevented by proper antenatal screening (contracted pelvis, malpresentations). If

injury to the bladder is discovered during difficult labour, do not suture the tear due

to tissue edema and friability. Insertion and fixation of rubber catheter through

urethra for 10 days will help the tear to heal completely or be smaller. If the injury

is detected some times after labour, surgical repair should be performed at least 3

months after delivery to allow for maximum involution to the tissues. Other

complications should be treated prior to reconstruction procedure. Cystoscopy is

performed to determine the relation of the fistula to the ureteric openings in the

bladder, exclude multiple fistulas, and reveal associated bladder pathology.

2.3 Uretero-vaginal Fistula

Vesicovaginal fistula is an abnormal communication between ureter and vagina.

2.3.1 Etiology of Uretero-vaginal Fistula

Uretero-vaginal fistula may occurs following the injury to ureter during a

gynecological procedure (such as hysterectomy) or difficult labor.

2.3.2 Symptoms of Uretero-vaginal Fistula

The main symptom of uretero-vaginal fistula is incomplete incontinence. Urine

from affected ureter escapes from vagina while bladder fills up and empties

normally from other ureter. The fistula is always small and high up in vagina lateral

to cervix.

2.2.3 Diagnosis of Uretero-vaginal Fistula

Uretero-vaginal fistula is differentiated from a vesico-vaginal fistula by

methylene blue test and cystoscopy (shows ureteric efflux on one side only).

2.2.4 Management of Uretero-vaginal Fistula

Uretero-vaginal fistula can be avoided by pre-operative intravenous

pyelography, ureteric catheterization, and proper surgical technique. The surgical

intervention for uretero-vaginal fistula are abdominal re-implantation of ureter into

bladder or sigmoid colon (if not possible into the bladder). If the kidney function is

very poor on the affected side, the kidney can be sacrified.