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    VVF Clinical Presentation 1

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    georgeloto12
    1) Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary incontinence. 2) In developing countries, over 90% of VVF cases are caused by prolonged obstructed labor during childbirth, while in developed countries most are caused by gynecological surgeries. 3) Clinical examination and dye tests are used to confirm VVF and determine the location and size of the fistula. Surgical repair is then performed to close the abnormal connection.

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    VVF Clinical Presentation 1

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    georgeloto12
    497 views24 pages
    1) Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary incontinence. 2) In developing countries, over 90% of VVF cases are caused by prolonged obstructed labor during childbirth, while in developed countries most are caused by gynecological surgeries. 3) Clinical examination and dye tests are used to confirm VVF and determine the location and size of the fistula. Surgical repair is then performed to close the abnormal connection.

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    VVF

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    1) Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary incontinence. 2) In developing countries, over 90% of VVF cases are caused by prolonged obstructed labor during childbirth, while in developed countries most are caused by gynecological surgeries. 3) Clinical examination and dye tests are used to confirm VVF and determine the location and size of the fistula. Surgical repair is then performed to close the abnormal connection.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    497 views24 pages

    VVF Clinical Presentation 1

    Uploaded by

    georgeloto12
    1) Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary incontinence. 2) In developing countries, over 90% of VVF cases are caused by prolonged obstructed labor during childbirth, while in developed countries most are caused by gynecological surgeries. 3) Clinical examination and dye tests are used to confirm VVF and determine the location and size of the fistula. Surgical repair is then performed to close the abnormal connection.

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    of 24

    VESICO-VAGINAL

    FISTULA
    INTRODUCTI0N
    A fistula is defined as an abnormal
    communication between two or more epithelial
    surfaces.
    The common gynaecological fistulae are:
    -VVF, RVF and UVF. VVF being the commonest.
    VVF is a pathological communication between
    the bladder mucosa and vaginal epithelium which
    allows free and continuous flow of urine from the
    bladder to the vagina such that the woman is wet
    all the time.
    EPIDEMIOLOGY
    Real incidence –unknown.
    Related to socio-economic status in the comm.
    More in teenagers
    More in primipara
    Accounts for 7% of Gynae. consultations in
    northern parts of Nigeria.
    UPTH, accounted for 9 out of 452 (1%) Gynae.
    Admissions in 2001 (Annual Report)
    WHO estimates 500,000 untreated cases of VVF
    worldwide.
    AETIOPATHOLOGY
    VVF could be congenital or acquired.
    In most third world countries, > 90% of fistulae are of obstetric
    aetiology whereas in United Kingdom, >70% follow pelvic
    surgery.
    1. Prolonged obstructed labour : Commonest cause of VVF in
    our environment
    -Accounts for >80% of the cases.
    2. Caesarean section:
    -Incision involving the posterior bladder wall.
    -During reflection of the bladder.
    -Accidental passage of a suture through the posterior
    bladder wall during repair of the incision.
    3. Uterine rupture:
    -Rupture of a previous caesarean section scar.
    -Rupture of the unscarred uterus from obstetric manipulations.
    -The bladder may be caught in the sutures during repair.
    4. Direct trauma during operative vaginal delivery:
    Forceps delivery, craniotomy, symphysiotomy, repair of vaginal
    or cervical lacerations.
    AETIOPATHOLOGY CONTD.
    5. Gynaecological operations:
    -Pelvic floor repair, vaginal hysterectomy,
    abdominal hysterectomy, colporrhaphy
    -Commonest cause of VVF in developed
    countries, where it accounts for 75.3%
    -Accounts for only 2.5% of VVF in Nigeria.
    -Risk factors for post operative fistulae are
    as shown below.
    Risk factors for
    post operative fistulae.
    Risk factor Pathology Specific e.g.‟s
    1.Anatomical Fibroids, Ovarian
    distortion mass
    2.Abnormal tissue Inflammation Infections
    adhesions Endometriosis
    Pelvic surgery C/S, Vag-Hys.
    Colporrhaphy
    Malignancy
    3. Impaired Ionizing Preop.
    vascularity radiation Radiotherapy
    4. Compromised H Anaemia,Nutri def.
    AETIOPATH. CONTD.
    6. Radiation necrosis.
    7. Malignancies: Ca Cervix, vagina, rectum and bladder.
    8.Traditional practices: Gishiri cut, circumcision, caustic
    soda.
    -Gishiri cut accounts for 10-13% of all cases of VVF in
    the northern Nigeria.
    9. Infections: Lymphogranuloma venerum,
    schistosomiasis, tuberculosis.
    10. Social factors: Early marriage and early delivery.
    ->50% of cases in northern Nigeria are below 20 yrs.
    ->50% are in their first pregnancy.
    11.Others: Coital injuries, excision of a urethral
    diverticulum.
    Aetiology of fistulae in NE England
    and SE Nigeria
    Aetiology England (n=85) Nigeria (n=2,485)

    1.Obstetric 11.8% 93.3%


    -Obstr.labour 1.2% 81.4%
    2. Surgical 75.3% 2.5%
    -Abd. hyst. 42.4% 0.8%
    -Vag. hyst. 2.4% 0.6%
    3. Radiation 10.5% 0.0%
    4.Malignancy 0.0% 2.0%
    5.Miscellaneous 2.4% 2.2%
    CLASSIFICATION
    VVF are classified according to the site of injury;
    Juxta-urethral fistula
    Mid-vaginal fistula
    Juxta-cervical fistula
    Very large fistula
    Vault fistula
    Combined fistula
    Circumferential fistula
    Residual fistula
    CLINICAL PRESENTATION
    Typical history is that of total incontinence soon after
    a prolonged obstructed labour, operative vaginal
    delivery, or caesarean section.
    In direct surgical injury to the bladder, the leakage of
    urine may occur from day one.
    Most surgical and obstetric fistulae symptoms
    develop between 3 or 5 – 14 days.
    In a review of cases from Nigeria, the average time
    for patient presentation was >5yrs. And in some
    cases, >35yrs. after the causative injury.
    History of previous surgeries or prolonged obstructed
    labour.
    Secondary amenorrhoea.
    Secondary infertility.
    MANAGEMENT OF VESICOVAGINAL-
    FISTULA
    by Dr. JAMES ENIMI OMIETIMI

    History
    Clinical Examination
    Investigations
    Treatment
    Clinical Presentation
    Hx. of previous pelvic or abdominal surgery

    Symptoms develop early, may be Day 1

    Postoperative urinary leakage, oliguria,


    abdominal distension, pyrexia or loin pain

    Present earlier for repair than obstetric cases

    Hx. of previous unsuccessful attempt(s) at


    repair
    FINDINGS ON
    CLINICAL EXAMINATION
    O\E -Ill looking, malnourished, pale
    with evidence of inter current
    infections
    Abd. –kidneys may be enlarged &
    tender
    Pelvic Exam. –vulva & thigh
    excoriations
    (ammoniacal dermatitis)
    Clinical Examination contd.
    V/E –best performed in lateral position,
    -may also be done in dorsal position.
    -digital to precede speculum exam.
    -insert speculum of appropriate size
    -visualize ant. Vaginal wall & then
    -post. Vaginal wall
    -Do digital rectal exam. to R\O RVF
    EXAMINATION UNDER
    ANAESTHESIA + DYE TESTS
    Digital vaginal examination and
    examination with a Sim‟s speculum may
    not confirm or exclude a fistula, thus
    necessitating examination under
    anaesthesia + DYE TESTS
    A malleable silver probe is passed
    through openings in the vaginal wall;
    -For VVF and UVF, a metallic click
    against a silver catheter may be felt or
    seen via a cystoscope.
    -For RVF , the probe may be felt digitally
    in the rectum or seen via a proctoscope.
    EUA + DYE TEST Continued.

    Enables assessment of available access


    and the mobility of tissues for vaginal
    repair.

    The decision to repair vaginally or an


    abdominal approach can also be taken
    then.
    SPECIFIC INVESTIGATIONS

    DYES STUDIES
    Investigations of first choice
    Confirm if discharge is urinary
    If leakage is extra-urethral rather than
    urethral
    To establish the exact site of leakage
    Phenazopyridine -200mg tds orally
    Indigo carmine -intraveneously
    Methylene blue instillation
    DYE STUDIES contd.
    Patient in lithotomy position
    Examination best done under direct vision
    „Three Swab Test‟ has limitations and is
    not recommended.
    Adequate distension of the urinary bladder
    If clear fluid leaks after instillation of dye,
    ureteric fistula is likely.
    Differentiate by “two dye test”
    Phenazopyridine to stain renal urine and
    Methylene blue to stain the bladder urine
    OTHER SPECIFIC
    INVESTIGATIONS
    Cystoscopy – small vvf
    Cystography – vesico uterine fistulae (lat.
    view)
    Hysteroscopy/Hysteosalpingography-vesico
    uterine fistulae ( lat.
    view)
    Fistulography –small intestinal fistulae
    Colpography –small fistulae involving vagina

    Endoanal Ultrasound, MRI –anorectal &


    perineal fistulae
    Barium enema, Barium meal & follow through
    GENERAL INVESTIGATIONS

    FBC + Blood film + Malaria Parasite


    Urine for urinalysis & m.c.s.
    Stool for Parasitic Infestations
    CXR
    Serum E/U/Cr
    Intravenous Urography
    PREOPERATIVE
    TREATMENT
    Timing of definitive repair
    Improve Patient‟s General Health; high protein
    diet, antimalarials, antihelmintics, haematinics &
    Rx inter current infections/ diseases
    Rx vulval dermatitis with silicone barrier
    creams, zinc oxide cream & castor oil
    Bowel Preparation
    Prophylactic Antibiotics/ Urinary Antiseptics
    REPAIR OF VVF

    Route of Repair; vaginal or abdominal


    Position of Patient; lithotomy or reverse
    lithotomy (knee-elbow position)
    Type of suture materials; absorbable -
    vicryl 2/0 or chromic catgut 2/0
    Types of Repair;(1) Dissection & repair in
    layers (2) Saucerization
    POST OPERATIVE
    MANAGEMENT
    Fluid Balance; intake 3-4 litres per day
    output 120-150mls/hr
    Bladder Drainage; check drainage & vol. of
    urine hourly
    Post Operative antibiotics
    Prevention of Deep Vein Thrombosis
    Care of the perineum with vulva pads
    Duration of Drainage; 10-14 days on the
    average
    Retraining of urinary bladder before discharge
    Post Operative Mgt. Contd.
    Instructions on Discharge
    Repeat EUA & dye test on day 21 before
    discharge
    Refrain from sexual intercourse for
    3months
    Counsel for antenatal care & hospital
    delivery in all subsequent pregnancies
    Elective Caesarean Section next
    pregnancy

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