GENITAL FISTULAS

This is communication between the genital tract and the urinary or alimentary tracts and may occur singly or in combination. It is due to:

  • Obstetrical injury: Obstructed labour usually leads to pressure necrosis of the bladder and vaginal wall and the rectum. Necrotic tissue sloughs off, leading to vesicovaginal fistula (VVF) and recto-vesical fistula (RVF).
  • Instrumental delivery may cause perforation of the vagina and rectum.
  • Operative injury: A fistula may be caused during total abdominal hysterectomy and caesarean section.
  • Extension of disease: Malignancy of the bowel or any pelvic abscess may perforate into the rectum and posterior vaginal wall.
  • Radiotherapy: Heavy radiation of the pelvis causes ischaemic necrosis of the bladder wall and bowel, causing urinary or faecal fistula.

Clinical Features

The patient complains of urinary or faecal incontinence or both. Secondary amenorrhoea is common.

Management

  • Confirm diagnosis using Sims’ speculum.
  • Examination under anaesthesia is always mandatory for the diagnosis and definition of fistula. In the case of recently formed VVF, continuous bladder drainage for 2 weeks is useful because a small fistula may close or a large fistula may reduce in size.
  • Vulval excoriation is treated by water repellent substances, e.g., KY jelly, to be applied before the repair is done. If a VVF co-exists with RVF, the VVF is repaired first.
  • Admit for
    • Confirmation of diagnosis and definition to planning treatment.
    • Physiotherapy for sphincter strengthening and for lower limb weakness.
  • Refer to a higher level if
    • Diagnosis is confirmed after an examination.
    • Reconstructive surgery is deferred 3 months after the initial injury or after a previous attempt at repair to allow all tissue reaction to subside.