Urogenital Fistula

Clinical description

Obstructed labour is the most common cause of urogenital fistulas in Malawi. Other aetiologies include surgery, cervical cancer, radiation therapy and traumatic or instrumental vaginal delivery.

Signs and symptoms

History Continuous leakage of urine from vagina, +/- vulvar irritation, +/- infections, +/- chronic pyelonephritis leading to renal insufficiency Exam External examination often demonstrates urine dermatitis.Speculum exam to identify fistula. Normal vaginal discharge usually suggests NO fistula.

Investigations

• Dye test
• Use catheter to retrograde fill bladder with sterile milk or methylene blue (2-3 drops) mixed with NS in 60

ml aliquots

• Inspect for obvious fistula and describe location
• Place tampon or large cotton swabs in vagina and check for sterile milk or dye
• Staining likely indicates vesicovaginal fistula
• If no leakage, ask patient to cough or bear down (Valsalva manoeuvre)
• Wetness with clear fluid while bladder filled with dye may indicate ureterovaginal fistula. Consider oral

phenazopyridine to turn urine orange (vs. blue for vesicovaginal fistula)

• Intravenous pyelogram may be indicated if complex history or examination
• US to assess upper renal tract dilation (dilated ureter or renal pelvis)
• Cystoscopy in OT can be useful but often not necessary in large obstetric fistula and usually not available
• Check for stone---often urine is more malodorous and discolored or with particulates.

Treatment

Timing

• If urogenital injury is noted at time of surgery or within a few days of surgery, then repair immediately
• Excise and repair within 6-12 wks of delivery when the surrounding tissues are healthy.
• Small fistulae may heal spontaneously with prolonged catheterization.
• If a stone is present: remove stone and delay repair unless extensive dissection already done, then can attempt to

close.

• All patients with stones are infected, so post-operative antibiotics are indicated, especially if

extensive dissection was done.

Types of repair depending on fistula location (general management scheme)

• Small midvaginal, Suburethral or juxtaurethral VVF: simple vaginal tissue mobilization with layered closure +/-

anterior bladder wall mobilization

• Circumferential or massive VVF: wide tissue mobilization into the paravaginal spaces bilaterally to facilitate

closure of the bladder and reapproximation to urethra.

• Consider anti-incontinence procedure with Pubococcygeal sling or other procedure.
• Consider skin graft to augment or preserve vaginal caliber or depth,
• Juxtacervical VVF: Vaginal approach usually possible, but depends on degree of uterine/cervical descent.
• Consider suprapubic, extraperioneal approach.
• Vesico-uterine fistulas: examination +/-cystogram confirms diagnosis
• Often requires repair via laparotomy with resection of the fistulous tract from both bladder and

uterus, closure of the openings, and then interposition of the omentum or peritoneum; alternative is hysterectomy with excision of fistula from bladder

• Vesico-colonic fistulas: excision of fistula from bladder and colon and interposition of omentum or peritoneum
• Fistulas with total urethral loss: create a neourethra from mobilized anterior bladder, vulvar/labial tissue