Fistula.defination,types causes,managment

Definition

This is an abnormal communication between two internal hollow organs or between an internal hollow organ and the exterior of the body.

Types

• Vesicovaginal fistula (VVF)
• Rectovaginal fistula (RVF)
• Urethral vagina fistula (UVF)

Incidence

It occurs in 65-90% of the women.

Causes

Radiotherapy

If the patient has cancer of the cervix and is undergoing radiotherapy for long standing time, the rays penetrate the bladder hence destroying it.

Malignancy

Advanced carcinoma of the cervix, vagina and bladder may produce fistula by direct spread.

Trauma

Fistula can be due injuries following a fall on pointed objects, use of sticks in criminal abortion or following fracture of the pelvic bone.

Operative injury in gynaecological procedures

During operations such as hysterectomy and cesarean section the bladder may be injured accidently. Also, during dilatation and curettage.

Prolonged obstructed labour due to cephalopelvic disproportion

The baby’s head while descending through the pelvis compresses the anterior vaginal wall against the back of the symphysis pubis. This results into prolonged pressure on the tissues which under go ischemia, necrosis, sloughing and fistula in 3-5 days following delivery.

Signs and Symptoms

• History of cesarean section, obstructed labour, criminal abortion etc
• Urine incontinence
• Offensive ammonia like smell
• Patient looks miserable and psychologically unfit due to wet pants and bed.
• On examination, there is vulvitis and vaginitis due to alkaline media which attracts micro-organisms.
• Itching of the vulva

How to Come to a Diagnosis

History taking

Vaginal examination

To visualize the fistula using a speculum.

Cystography

Dye test

A speculum is introduced and the anterior vaginal wall is swabbed dry. When methylene blue solution is introduced into the bladder by a catheter, the dye will be seen coming out through the opening.

Three swab test

Three cotton swabs are placed in the vagina; one at the vault, one in the middle and one just above the introitus. Methylene blue dye is instilled in the bladder through the catheter. Patient is asked to walk about for 5 minutes and she is then inspected.

Catheter test (rare)

A mental catheter is passed through the external urethral meatus, when it passes out through the fistula VVF is confirmed.

Management

Aims

• To prevent or treat infections
• To promote quick healing
• Health education
• To reassure the patient

1. The patient is admitted on a gynaecological ward that is clean and well ventilated. Normal admission procedures are carried out. Establish good patient nurse relationship.
2. Inform the doctor. The doctor will carry out digital examination. e.g.
   • Cystography
   • Ultrasound scan
   • Hb, grouping and cross match
   • Cervical biopsy
   • Urinalysis
3. Self-retaining catheter is passed and patient is kept on continuous bladder drainage for 6-8 weeks. This may cause spontaneous closure of the fistula if it is small with minimal tissue damage.
4. Patient is put on appropriate antibiotics to treat or counteract infections.
5. Give a balanced diet to the patient to promote quick wound healing.
6. Continuous psychological care through reassurance to allay anxiety.
7. If there is foul vaginal discharge due to disloughing of necrotic tissue, it is treated with antiseptic vaginal douches.
8. At the end of puerperium, the patient is assessed by means of a speculum. Enough time has to be given to allow the tissue heal and strengthen up sufficiently. Therefore the patient will have to be sent back home and asked to re-attend surgery after 3 months.

Treatment

Local repair of fistula is the treatment of choice.

Day Before Operation

• Obtain an informed consent from the patient
• Psychological care is done to allay anxiety
• Check for the required investigations results and book units of blood for transfusion to restore general health.
• Ensure rest and sleep
• Starve the patient 6 hours to operation.

Morning of Operation

• Shaving is done
• The patient is encouraged to have a bathe and a clean gown is provided.
• Theatre staffs are informed about the patient
• The patient together with clinical charts is taken to theatre.

Post-operative Care

• Position the patient in prone to prevent pressure on the sutures.
• Provide plenty of oral fluids to flush the bladder.
• Maintain a strict fluid balance chart
• Observe the drainages and the odour of urine.
• Remove the pad on the 2nd day of operation.
• Do vulva swabbing 8 hourly
• Take vital observations TPRBP
• Daily observation of the bed
• Observe the catheter and drainages so that the patient does not lean on it as it will prevent the urine from draining causing bladder distension.
• Give light diet with plenty of roughages to prevent constipation.
• Keep patient on complete bladder drainage for 14 days.

Bladder Training

This is started on the 14th and 15th day post-operatively and if the dye test is negative.

• 1st day – ½ hourly
• 2nd day – 1 hourly
• 3rd day – 2 hourly
• 4th day – 3 hourly

At night the urinary bag is placed back. This is done in order to avoid disturbing the patient’s sleep. While training, observe for bed wetting and if dry remove the catheter. Reassure and counsel both partners.

Advice on Discharge

• Abstain from sex for 3 months
• Advise to pass urine 2 hourly following removal of catheter.
• Do light exercises to avoid putting strain on the healing wound.
• Practice family planning methods so as to prevent early pregnancies.
• If contraception occurs report to the physician and must have antenatal checkup and hospital delivery.
• Always come back for review on appointed dates.

Complications

• Urinary tract infections secondary to blockage of catheter.
• Depression or psychological torture
• Stigma
• Divorce
• Social out cast

Prevention

• Encourage hospital delivery. This is done through health education during antenatal.
• Encourage regular attending of antenatal clinics to rule out risk factors.
• Proper monitoring of labour using a partograph.
• Careful use of instruments during assisted deliveries.
• Health educate on criminal abortion by giving counselling services to teenagers.
• Minimal use of radiotherapy treatment in case of cancer.
• Encourage immunization against poliomyelitis during childhood. This is because polio affects pelvic bones leading to a contracted pelvis thus obstructed labour.
• Health educate on prevention of early marriages which predispose young girls to difficult deliveries.
• Early detection and treatment of malignant diseases.