Vesicovaginal Fistula

Symptoms

Following are the symptoms in case of vesicovaginal fistula:

Urinary incontinence: this is the major symptoms in which patient cannot control the urinary discharge and soil the cloths frequently.

Foul smelling discharge: Patients also have the experience that foul smelling discharge and gas coming out from the vagina.

Genital Organ Infection: Patients frequently suffer from genital organ infection. Continuous wetting is one of the reasons of infection.

Causes

Delayed labour: Prolonged obstructed labour generates pressure in the vaginal wall and also in the bladder neck and urethra. The pressure is generated due to compression created between fatal head and the pubis. Tissue necrosis is common and which leads to vasicivaginal fistula.

Surgical intervention Hysterectomy (removal of uterus), often causes an unrecognized bladder injury and in the majority of the cases turn to urinoma which follows flow of urine will change the path  and passes through the vaginal cuff suture line due to resistance grow.

The following factors are influencing Vesicovaginal fistula:

• Young maternal age (physical immaturity of the mother’s body leads to cephalopelvic disproportion)
• Malnutrition
•  Anemia
• Frequent steroid use
• Obstetric infections
• Pelvic malignancy
• Erosion
• A foreign body and
• Vaginal trauma

Diagnosis

The flowing diagnosis measures are conducted for the detection of the Vesicovaginal fistula:

• Fluid examination: Laboratory test is necessary for the examination of fluid discharges from the vagina. The test is conducted for urea, creatinine, or potassium concentration determination for differentiating the Vesicovaginal fistula and vaginitis. To differentiate the urine and serous fluid, biochemical analysis of the fluid helps to detect.
• Physical examination of the vagina helps to identify the actual problem arises in the particular area which includes analysis of the severity of the swelling of the associated tissue, accumulation of fluid and infection.  This also helps to determine the rectovaginal fistula association.
• Cystoscopic examination: Before conducting surgical intervention, cytoscopic examination is required.
• Urine culture: Urine culture is conducted for identification.
• Biopsy: In case of suspecting the local malignancy, then fistula track biopsy is required.
• Microscopic examination: Microscopic examination is also required in case of cancer cell identification.
• Intravenous urogram (IVU) or retrograde pyelography: This test is done along with cystoscopic examination of upper urinary tract assessment.

Treatment

• Catheterization: After hysterectomy catheter drainage of the bladder can decrease the incidence of VVF.
• Fibrin-based glue injection: Fibrin glue augments healing due to presence of a combination of fibroblasts and collagen and the nature of these are easily biodegradable.
• Electrocoagulation of the fistula tract: This technique is applied for transvaginally or transurethrally. But this is applicable only for tiny fistula, which has less 3 mm in diameter. This process is applied because to minimize the chances of enlargement of fistula by administering the tiny electrode and applying the minimal coagulation current.
• Surgical repair: The surgical intervention is conducted in two ways transvaginally and transabdominally and in some cases the combination of these processes is also applied. The objective of surgical process is quick healing with adequate watertight and infection free process. The success of the surgery depends upon the pre-planning of the surgical intervention, according to patient condition and also the skill of the surgeon.
• Transvaginal approach: This is most commonly used technique. This approach is also known as vaginal flap. This technique is widely used due to it need not to open the bladder and also reduce the associated complications.
• Transabdominal approach: If the distal ureters are generated fistula then transvaginal approach cannot be applied and is this case transabdominal approach is preferably applicable.  In this process, the bisection of the bladder is conducted.  For providing the protection to the ureters, the ureteric catheters are placed.
• Laproscopic technique: during the process ureteric catheters are placed by cystoscopic placement. This technique does not require any open surgery and less post operative complications are reported. But for gain the success of the laparoscopic surgery, skilled and experience laparoscopic surgeon is required.
• Robotic repair: This is a novel approach and the acceptance of this technique is not yet established widely. In this process, robotic technology helping for suturing during the operation. The post-operative morbidity rate is minimal.
• Post-operative care: One of the major reasons of delayed wound healing is obtained because of insufficient bladder drainage, which can be achieved by urethral catheter. The additional suprapubic catheter is required for transabdominal repairs. Insertions of both the catheters help to maintain the drainage even when one catheter is blocked.

Pictures:

Source: http://www.wlsa.org.mz/wp-content/uploads/2014/11/Fistula.jpg

Source: http://images.ddccdn.com/cg/images/en3054077.jpg

Source: http://www.drshivdikarivfcenter.com/images/ipanel-vesico-vagina-fistula-repair.jpg

References:

1. Vaginal Fistula – Topic Overview, symptoms, Diagnosis, Treatment at http://www.webmd.com/women/tc/vaginal-fistula-topic-overview
2. http://emedicine.medscape.com/article/267943-overview
3. http://emedicine.medscape.com/article/267943-treatment
4. Vesicovaginal fistulae at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938551/