CN.212 Obstetric/vaginal fistula – Nurses Online Discussion

Gynecological Nursing

Subtopic:

Vaginal Fistula/Obstetric Fistula

A Vaginal Fistula represents an irregular channel or passageway connecting the vagina to nearby pelvic organs, often resulting from childbirth-related events or obstetric complications during delivery.

Urogenital Fistula: This term describes an abnormal link between the urinary system (which includes the ureters, bladder, and urethra) and the reproductive system (uterus, cervix, and vagina).

In broader medical terms, a fistula is defined as an atypical connection or pathway between two or more surfaces lined by epithelial cells.

Types of Vaginal/Obstetric Fistulae:

Vaginal Fistula: This is a broad term encompassing any fistula that develops within the vaginal wall itself.
1. Vesicovaginal Fistula (VVF): This specific type of vaginal fistula occurs when the abnormal opening extends into the urinary system, creating a connection between the bladder and the vagina. It is the most frequently encountered form of urogenital fistula.
2. Rectovaginal Fistula (RVF): This type is diagnosed when a vaginal fistula creates a pathway into the rectum, the final section of the large intestine.
3. Colovaginal Fistula: This occurs when a vaginal fistula forms a connection with the colon, which is another part of the large intestine.
4. Enterovaginal Fistula: This type is identified when a vaginal fistula links to the small intestine or small bowel.

General Causes of Urogenital Fistula

Urogenital fistulas, abnormal connections between the urinary and reproductive tracts, can arise from a variety of factors, broadly categorized as follows:

Obstetric Conditions/Procedures: Issues related to childbirth are a major contributor.
- Prolonged, Obstructed Labor: Extended pressure from the baby’s head during difficult labor can cut off blood supply to vaginal and bladder tissues, leading to tissue death (necrosis) and eventually a fistula, often between the bladder and vagina.
- Caesarean Section (Especially Repeat Cesareans): Surgical deliveries, particularly when repeated, carry a risk. Incisions made during surgery can directly injure or reduce blood flow to the bladder, potentially causing a vesicovaginal fistula if the bladder is accidentally cut or damaged during the procedure. This can occur during:
  - Accidental Bladder Incision: The bladder may be cut during the surgical incision itself.
  - Bladder Wall Suturing: Stitching the bladder during uterine closure can cause harm.
  - Adherent Bladder: In women with prior C-sections, the bladder may stick to the old uterine scar and tear when separated.
  - Caesarean Hysterectomy: Removing the uterus after a C-section increases fistula risk due to the bladder’s proximity, making it vulnerable to injury.
- Operative Vaginal Delivery: The use of instruments like forceps or vacuum extractors can cause tissue trauma to the vagina and bladder, potentially leading to necrosis and fistula formation.
- Ruptured Uterus: A tear in the uterus, especially in women with prior uterine scars, can involve the bladder, as it might be adhered to the uterus.
  - Bladder Injury During Repair: During uterine repair or hysterectomy following a rupture, the bladder might be unintentionally cut or stitched.
- Symphysiotomy: Surgical widening of the pelvis during delivery can damage the bladder and urethra if they are not properly protected, potentially causing vesicovaginal or urethrovaginal fistulas.
- Cervical Cerclage: A stitch placed around the cervix to prevent premature birth can, if improperly placed, injure surrounding tissue and lead to a fistula between the cervix and bladder.
- Other Gynecological and Urological Procedures:
  - Hysterectomy: Uterus removal can injure the bladder or ureters due to their close location, possibly resulting in vesicovaginal or ureterovaginal fistulas.
  - Myomectomy: Fibroid removal from the uterus can inadvertently damage the bladder or ureters, leading to similar fistula types.
  - Loop Excision of Cervix: Treatment for abnormal cervical cells may injure nearby structures if the bladder is unintentionally harmed during tissue removal, potentially creating a fistula.
  - Voluntary Pregnancy Termination: Procedures to end a pregnancy can sometimes cause trauma to the bladder or ureters, leading to fistula formation.
  - Anterior Colporrhaphy: Surgery to fix bladder prolapse can sometimes damage the bladder itself, resulting in a vesicovaginal fistula.
  - Periurethral Bulking: Injections around the urethra for incontinence treatment can sometimes cause trauma, potentially leading to a urethrovaginal fistula.
  - Urethral Diverticulum Repair: Surgery to remove a urethral pouch can damage surrounding tissues, possibly causing a urethrovaginal fistula.
  - Ureteral Wall Stent: Stents placed in the ureters can occasionally cause trauma to the ureters or bladder, potentially resulting in ureterovaginal or vesicovaginal fistulas.
  - Insertion of Shirodkar Stitch: Cervical stitches to prevent preterm birth, if not carefully placed, can damage the bladder, creating a vesicocervical fistula.
  - Dilatation and Curettage (D&C): This procedure, especially for pregnancy termination, can injure the bladder or urethra, potentially leading to fistula development.
  - Manchester Operation: Surgery for uterine prolapse can cause damage to the bladder or urethra, potentially resulting in vesicovaginal or urethrovaginal fistulas.
Pelvic/Medical Conditions: Various medical issues can contribute.
- Endometriosis: Endometrial tissue growing outside the uterus can invade the bladder or ureters, causing fistulas due to chronic inflammation and tissue damage.
- Gynecologic Cancers: Tumors from cervical, uterine, or ovarian cancer can invade the bladder or ureters. Both the tumor itself and its surgical removal can lead to fistula formation.
  - Cervical Cancer (Stage 4): Advanced cervical cancer can directly invade bladder tissues, creating a vesicocervical fistula.
- Pelvic Irradiation: Radiation therapy for pelvic cancers can cause tissue death in the bladder and surrounding areas, leading to vesicovaginal fistulas.
- Infections (Tuberculosis, Lymphogranuloma Venereum): Certain infections can cause long-term inflammation and tissue damage in the urinary and genital tracts, potentially resulting in fistulas.
- Intrauterine Device (IUD): Rarely, an IUD can perforate the uterus and migrate, causing bladder damage and potentially a vesicovaginal fistula.
- Retention of Vaginal Foreign Object: Forgotten objects like tampons, diaphragms, or pessaries left in the vagina can cause chronic inflammation and tissue damage, leading to fistula formation.
- Accidental Trauma: Injury to the pelvic area, whether blunt or penetrating, can directly harm the bladder or urethra and lead to fistula formation.
- Sexual Trauma: Forced or violent sexual activity can severely injure vaginal and bladder tissues, potentially resulting in vesicovaginal fistulas.
- Mitomycin C Instillation: This chemotherapy drug used for bladder cancer can cause severe bladder irritation and necrosis, potentially leading to fistula formation.
- Bladder Stone: Large bladder stones can cause ongoing irritation and erosion of the bladder wall, eventually creating a vesicovaginal fistula.

Risk Factors of Fistula

Several factors increase the likelihood of developing a fistula:

Poverty: Limited access to quality medical care can result in poorly managed obstetric and gynecological issues, increasing fistula risk.
Malnutrition: Poor nutrition weakens tissues, making them more vulnerable to damage during childbirth or surgery.
Lack of Education: Insufficient knowledge about prenatal care and safe delivery practices elevates the risk of complications leading to fistulas.
Early Childbirth: Young mothers often have less developed pelvic structures, increasing the chance of obstructed labor and subsequent fistula formation.
Lack of Healthcare Access: Inadequate access to skilled medical professionals during childbirth can lead to prolonged obstructed labor or poorly performed surgical procedures, both fistula risk factors.
High Parity (Multiple Births): Having many pregnancies can increase the risk of uterine and bladder prolapse, which in turn raises the risk of fistula development during childbirth or surgery.
Prolonged Labor without Medical Assistance: Lack of timely medical intervention during labor can lead to obstructed labor, increasing the risk of tissue damage to the bladder and surrounding areas due to reduced blood flow.
Inadequate Prenatal Care: Poor prenatal care can result in undiagnosed or poorly managed conditions like a large baby or abnormal fetal position, which can complicate delivery and increase fistula risk.
Pre-existing Medical Conditions: Conditions like diabetes or high blood pressure can impair wound healing and tissue strength, making individuals more susceptible to fistula formation.
Previous Pelvic Surgeries: Scar tissue from prior surgeries can complicate new procedures and increase the risk of bladder or urethral injury.
Harmful Traditional Practices: Practices like female genital mutilation or the Gishiri cut can directly injure the urinary and reproductive tracts, leading to fistula formation.

Symptoms of Urogenital Fistula

Urogenital fistulas can manifest with a range of symptoms:

Continuous Urinary Leakage: Persistent, uncontrolled leakage of urine from the vagina, often following recent surgery, a difficult vaginal birth, or pelvic trauma. This constant leakage is due to the abnormal connection between the urinary tract and vagina.
Recurrent Cystitis or Pyelonephritis: Frequent bladder or kidney infections. The fistula allows urine to stagnate and become infected, leading to repeated urinary tract infections.
Unexplained Fever: Persistent fever without an obvious cause. Chronic infections associated with the fistula can cause systemic symptoms like fever.
Hematuria: Blood in the urine. Trauma or infection around the fistula site can cause bleeding into the urinary tract.
Flank, Vaginal, or Suprapubic Pain: Pain in the sides of the body (flank), vagina, or above the pubic bone (suprapubic area). Inflammation, infection, and continuous urine leakage can cause significant pain in these areas.
Abnormal Urinary Stream: Changes in the normal urination pattern. The fistula can disrupt the usual flow of urine, leading to an altered urinary stream.
Vaginal, Vulvar, and Perineal Irritation: Irritation or discomfort in the vagina, vulva, and perineum (area between the genitals and anus). Constant exposure to urine can irritate these tissues, causing inflammation and discomfort.
Foul Ammoniacal Odor: A strong, unpleasant smell resembling ammonia. Bacteria in the urine produce ammonia, causing a foul odor.
Severe Perineal Dermatitis: Severe skin irritation and inflammation in the perineal area. Continuous urine contact can lead to dermatitis, characterized by redness, swelling, and skin irritation.
Greenish-Gray Phosphate Crystals in the Vagina and Vulva: Greenish-gray deposits on the vaginal and vulvar surfaces. Bacterial breakdown of urea in urine creates an alkaline environment, causing phosphate crystals to form and deposit in the affected areas.
Social Isolation, Disrupted Sexual Relations, Depression, Low Self-Esteem, Insomnia: Emotional and psychological distress due to the condition. The constant urine leakage and related symptoms can lead to significant social and emotional impacts, including isolation, sexual difficulties, depression, low self-worth, and sleep problems.

Diagnostic Signs and Examination Findings

Diagnosing a urogenital fistula involves a combination of history, physical exam, and tests:

Patient History:
- History of Prolonged and Obstructed Labor: A key indicator for potential fistula development.
- Patient Reports Urine Leakage: Uncontrolled, continuous leakage is a classic sign.
Physical Examination:
- No Palpable Bladder on Abdominal Palpation: Indicates urine is not accumulating in the bladder due to leakage.
- Urine Odor: The patient often has a noticeable urine smell.
- Signs of UTI and Low-Grade Fever: Recurrent infections are common due to urine leakage.
- Vulva Inspection: Visible urine dribbling from the vagina.
- Speculum Examination: Visual defect may be seen, with urine escaping through it.
Diagnostic Tests:
- Methylene Blue or Gentian Violet Test: Dye is injected into the bladder via a catheter. Dye leakage into the vagina confirms a fistula.
- Soft Tissue X-ray and Cystography: Can show defects and injuries in the bladder.
- Creatinine Content in Vaginal Fluid: Elevated creatinine levels indicate urine leakage.
- Cystoscopy: An endoscopic procedure allowing direct visualization of the bladder and urethra to precisely locate the fistula origin.
- Soft Tissue X-ray: Helps visualize the defect and confirm fistula presence.
- Speculum Examination: Direct visual inspection using a speculum to identify and assess the fistula.
- Digital Examination: Manual exam to feel the fistula and surrounding tissues.
- Subtraction Magnetic Resonance Fistulography: Advanced imaging technique providing detailed fistula visualization.
- Endocavitary Ultrasound: Ultrasound (transrectal or transvaginal), potentially with Doppler or contrast, to visualize the fistula, showing its exact location, size, and path.
- Biopsy: If cancer is suspected, a tissue sample is taken for microscopic examination to rule out malignancy.

VESICO-VAGINAL FISTULA

A Vesicovaginal Fistula, or VVF, is an atypical channel that develops between the urinary bladder and the vagina. This abnormal connection results in the constant and uncontrolled flow of urine from the bladder into the vaginal area.

Alternatively Defined: It represents an irregular opening between the vagina and the urinary bladder.

Development of a Urinary Fistula:

Tear-Induced Fistula: In cases where a fistula originates from a physical tear, urine leakage begins immediately. However, initial infection may not be present, and if the urinary flow is redirected (diverted), the tear can potentially heal primarily within one to two weeks.
Pressure Necrosis-Induced Fistula: When a fistula is caused by tissue death from prolonged pressure, the affected tissue will initially form a slough (dead tissue). This slough will eventually detach, leaving behind an opening – the fistula.
Large Fistula Characteristics: Fistulas exceeding 2 cm in diameter are unlikely to close on their own. Over time, scar tissue will develop around the fistula’s edge, forming a dense, whitish ring. This scar tissue can even anchor the fistula to the pubic bone.

Natural Healing Tendency: Urinary fistulas possess an inherent capacity for self-closure through processes of granulation tissue formation, fibrosis (scar tissue development), and contraction of the surrounding tissues.

Types of VVF

Vesico-Vaginal Fistulas can be broadly categorized based on their characteristics and complexity.

Simple VVF: Representing a smaller proportion of obstetric fistulas, estimated at around 20%, simple VVFs are characterized by their relatively small size. Typically, these fistulas have a diameter of less than 3 centimeters. Crucially, they present with minimal or no significant scar tissue surrounding the opening and, importantly, do not extend to involve the urethra. These are generally considered less complicated to manage due to their size and location.
Complex VVF: In contrast to simple fistulas, complex obstetric fistulas are often more extensive and challenging. A complex VVF is generally defined by a size exceeding 3 centimeters in diameter. A key feature is the involvement of the urethra in the fistula tract. Furthermore, these fistulas are frequently associated with significant scarring, which can lead to a reduction in the vaginal space. In some cases, the bladder’s capacity may also be diminished. While a fistula might occasionally be solely urethrovaginal, it is more common for complex cases to involve both the urethra and the bladder, leading to the term urethro-vesicovaginal fistula to accurately describe this combined involvement. Complex VVFs require more intricate management strategies due to their size, location, and associated tissue changes.

Management of Vesico-Vaginal Fistula

The approach to managing vesico-vaginal fistula (VVF) depends on the patient’s overall health and the characteristics of the fistula itself.

Initial Conservative Management:

For women who are significantly unwell, and if the fistula is small and does not involve the urethra, initial management can be conservative. This involves focusing on treating the underlying illness while observing the fistula.

Management of Small Fistulas:

Catheterization for Healing: Small VVFs often have a good chance of successful repair. A urinary catheter is inserted into the bladder and left in place for a period. This continuous drainage keeps the bladder empty, promoting tissue healing around the fistula.

Management of Larger or Complex Fistulas:

Delayed or Reconstructive Surgery: For fistulas that are larger, involve the urethra, or occur in scarred and inflexible tissues, immediate surgical repair might not be suitable. In these cases, a period of conservative management with catheterization is initiated before considering delayed or more complex reconstructive surgical options.
Catheter Drainage: Similar to small fistulas, a urinary catheter is placed to ensure continuous bladder drainage. This allows tissues to rest and potentially heal before further intervention is considered.

General Catheter Management:

Duration of Catheterization: Following any fistula repair attempt (surgical or conservative), an indwelling catheter typically remains in place for 2 to 3 weeks.
Purpose of Catheter: The catheter’s primary function is to continuously drain urine, preventing bladder distension and allowing the tissues around the fistula to heal undisturbed.
Troubleshooting Catheter Issues:
- Blocked Catheter: If urine drainage stops, suspect a blockage in the catheter.
- Bladder Muscle Dysfunction: If the bladder isn’t emptying despite a seemingly clear catheter, bladder muscle weakness might be a factor.
- Incorrect Catheter Placement: If the catheter is positioned in the vagina instead of the urethra and bladder, urine will not drain effectively.

Management at Different Healthcare Levels:

Health Center Level:
- Hygiene Promotion: Emphasize the importance of personal hygiene to the patient.
- Referral to Hospital: Immediately refer the patient to a hospital equipped for fistula management.
Hospital Level:
- Admission: Admit the patient to a gynecology ward.
- Doctor Consultation and Examination: Inform the doctor, who will perform a gynecological examination. This often includes:
  - Gentle Digital Examination: Examination using fingers only, avoiding instruments initially to prevent widening the fistula opening.
  - Speculum Examination (Possible): A speculum examination might be carefully performed to visualize the fistula.
- Catheter Insertion and Continuous Drainage: A self-retaining catheter is inserted to establish continuous bladder drainage. Preventing urine leakage is crucial for healing.
- General Health Improvement: Focus on improving the patient’s overall health:
  - Balanced Diet: Provide a nutritious diet.
  - Nutritional Supplements: Administer iron and vitamin supplements.
  - Blood Transfusion (If Necessary): Consider blood transfusion to address anemia and improve general condition.

Conservative Management for Spontaneous Closure:

Spontaneous Closure Potential: With continuous bladder drainage, good general health, and infection control, many fistulas may close spontaneously within approximately 6 weeks.
Vaginal Hygiene: Antiseptic vaginal douches may be used to minimize odor and maintain hygiene.
Assessment at Puerperium End: At the end of the postpartum period, reassess the fistula using a speculum examination.

Timing of Surgical Repair:

Traditional Delayed Approach (Previously): Historically, a waiting period was recommended to allow tissues to heal and strengthen before surgery, often advising patients to return for surgery after 3 months.
Modern Early Repair (Current Practice): Currently, surgical repair can often be undertaken as soon as the fistula is diagnosed, provided the patient’s condition is stable.

Pre-Surgical Care (During Waiting Period, if any):

Psychological Support: Provide reassurance and emotional support.
Rest: Encourage ample rest.
Nutritious Diet: Emphasize a diet rich in protein and vitamins to promote healing.
Hygiene Practices: Maintain strict vulvar hygiene.
Absorbent Pads: Use absorbent pads to manage urine leakage, changing them frequently.
Barrier Cream: Apply a barrier cream (e.g., Zinc and Castor oil) to the vulva to protect the skin from urine irritation and prevent excoriation.
Continuous Bladder Drainage: Maintain continuous bladder drainage via catheter.

Surgical Treatment (Fistula Repair):

Early Surgical Repair: Perform surgical repair as soon as feasible after initial assessment and patient stabilization.
Examination Under Anesthesia: Conduct a detailed examination under anesthesia to precisely locate the fistula and determine the optimal surgical approach.
Dye Injection for Localization: Inject dye through a catheter into the bladder during surgery to visually confirm the fistula opening and its location.
Surgical Repair: Proceed with surgical repair of the fistula using appropriate techniques.

Post-Operative Care:

General Post-Operative Care: Provide care similar to any post-operative patient or someone recovering from obstructed labor.
Positioning: Nurse the mother in a supine (lying on the back) position to minimize pressure on the surgical repair site.
Continuous Bladder Drainage: Maintain continuous bladder drainage via catheter to rest the bladder and promote healing.
Fluid Management: Encourage plenty of fluids to:
- Flush the bladder, removing clots and debris.
- Prevent bladder pressure.
- Reduce the risk of urinary stasis and infection.
Fluid Balance Monitoring: Maintain a fluid balance chart to track intake and output.
Urine Observation: Regularly check the amount and color of urine, monitoring for blood clots that could obstruct the catheter.
Bed Wetness Monitoring: Daily check the bed for any urine leakage indicating potential issues.
Catheter Removal (Timing): If the bed remains dry, consider removing the catheter after 2 weeks. Prolonged catheterization could sometimes hinder complete closure in small areas.
Addressing Persistent Leakage: If continuous urine leakage onto the bed occurs despite catheter drainage, it may suggest a breakdown of the repair, requiring consideration of repeat surgery.
Catheter Patency: Ensure the catheter remains unobstructed by blood clots or debris for free urine drainage.
Bladder Training (Post-Catheter Removal): After catheter removal and if drainage is successful, initiate bladder training to gradually restore bladder capacity and muscle tone. This involves encouraging urination at progressively longer intervals.

Detailed Post-Operative Catheter Care:

Free Drainage is Crucial: The catheter must always drain freely. Blockage can lead to surgical failure.
Catheter Stabilization: Secure the catheter to the mother’s thigh to prevent accidental displacement.
Avoid Pressure on Catheter: Ensure the patient does not lie directly on the catheter tubing.
Prevent Kinking: Check that the catheter or drainage tubing is not twisted or kinked.
Proper Drainage Collection: Position the drainage tubing to empty into a collection basin or bucket placed at the bedside, ensuring gravity drainage.
Maintain Hydration: Encourage the patient to drink fluids freely as soon as recovery from anesthesia allows.
Urine Color as Hydration Indicator: Urine should ideally be very pale yellow, almost clear. Darker urine indicates dehydration, and fluid intake should be increased.
Immediate Action for Catheter Issues: If drainage stops or the patient reports bladder fullness, address the catheter immediately.
- Irrigation: Attempt to irrigate the catheter to clear any blockage.
- Catheter Change (If Irrigation Fails): If irrigation is unsuccessful, a catheter change, usually performed by a doctor, is necessary.
Skin Protection: Apply Vaseline or a similar protective ointment around the catheter insertion site on the thigh to prevent skin irritation.

Discharge Advice:

Sexual Abstinence: Advise against sexual intercourse for at least 3-6 months to allow complete healing.
Rest and Medication: Emphasize rest and adherence to prescribed medications.
Vulvar Hygiene: Continue maintaining good vulvar hygiene.
Follow-up Appointment: Schedule a follow-up review appointment.
Continued Nutrition: Encourage continued good nutrition.
Future Delivery Plan: Recommend elective Caesarean section for future deliveries to minimize recurrence risk.

Complications of VVF:

Recurrent Fistula: If bladder drainage is inadequate post-repair, pressure build-up can rupture the repair, leading to fistula recurrence.
Sepsis: Infection leading to sepsis is a potential complication; antibiotics are necessary if fever or sepsis develops.
Social Isolation: The social stigma associated with VVF can be severe, causing isolation, marital problems, and reduced self-esteem due to constant urine leakage and odor.
Persistent Urinary Incontinence: Despite surgery, some women may experience ongoing urine leakage due to tissue scarring, urethral damage, or impaired bladder function.
Reduced Bladder Capacity: Long-term leakage can shrink or damage the bladder, reducing its ability to store urine.
Fertility Issues: Damage to the cervix and uterus, or uterine infections related to VVF, can impair fertility and ability to carry a pregnancy to term.

Prevention of VVF:

Community Health Education: Educate communities about VVF causes, prevention, and available care.
Emphasis on Antenatal Care: Promote and ensure access to quality antenatal care.
Training Traditional Birth Attendants (TBAs): Train TBAs to recognize prolonged labor and ensure timely referral for emergency obstetric care.
Timely Hospital Referral: Facilitate prompt referral to hospitals for emergency Caesarean sections when needed for obstructed labor.
Government Support for Healthcare: Advocate for government investment in improving healthcare facilities and staffing to manage obstetric emergencies effectively.

RECTO-VAGINAL FISTULA

A Recto-Vaginal Fistula (RVF) is an abnormal connection that forms between the rectum and the vagina. This opening allows fecal matter and gas from the intestines to pass into the vagina.

Causes

Childbirth Complications:
- Perineal Tears: During a difficult vaginal delivery, tearing of the perineum (the tissue between the vagina and anus) can occur.
- Episiotomy: An incision made in the perineum to enlarge the vaginal opening during delivery can sometimes lead to fistula formation.
Inflammatory Bowel Disease (IBD): Conditions like Crohn’s disease and ulcerative colitis, which cause digestive tract inflammation, can, in rare instances, contribute to fistula development.
Cancer and Pelvic Radiation:
- Pelvic Cancers: Cancers affecting the vagina, cervix, rectum, uterus, or anus can directly cause RVFs.
- Radiation Therapy: Radiation treatment for these cancers in the pelvic area can also result in fistula formation.
Surgical Complications: Procedures involving the vagina, rectum, perineum, or anus can sometimes lead to injury or infection that results in an RVF.
Infections: Infections, including those associated with HIV, can increase the risk.
Sexual Assault: Trauma from sexual assault can be a cause.

Signs and Symptoms

Passage of Feces or Gas: Experiencing stool or gas escaping from the vagina.
Bowel Control Issues: Difficulty controlling bowel movements (fecal incontinence).
Foul Vaginal Discharge: Presence of a bad-smelling discharge from the vagina.
Recurrent Vaginal Infections: Experiencing repeated infections in the vagina.
Vaginal or Perineal Pain: Pain in the vagina or the perineum (area between vagina and anus).
Dyspareunia: Painful sexual intercourse.

Risk Factors

Prolonged Labor: Lengthy labor increases the risk of perineal damage.
Obstructed Labor: Labor where the baby’s passage is blocked increases tissue pressure and damage.
Episiotomy: Having an episiotomy during childbirth is a risk factor.
Infections: Existing infections like abscesses or diverticulitis can increase fistula risk.
Pelvic Cancers and Radiation: History of cancers in the pelvic area or radiation treatment.
Pelvic Surgeries: Previous surgeries in the pelvic region, including hysterectomy, can be risk factors.

Diagnosis

Medical History: The doctor will ask about your symptoms and medical history.
Physical Examination: A physical exam will be conducted, including:
- Visual Inspection: Examination of the vagina, anus, and perineum, often using a speculum to better visualize the vagina.
- Proctoscopy: A proctoscope (a lighted instrument) may be used to examine the anus and rectum.
Diagnostic Tests:
- Anorectal or Transvaginal Ultrasound: An ultrasound probe is inserted into the anus/rectum or vagina to create images of the pelvic area using sound waves.
- Methylene Blue Enema: A tampon is placed in the vagina, and blue dye is inserted into the rectum via enema. If the tampon turns blue after a short time, it indicates a fistula.
- Barium Enema: A contrast dye is used during an enema to make the fistula visible on an X-ray.
- CT Scan: Detailed images of the pelvis are created using X-rays.
- MRI: Detailed pelvic images are created using magnetic fields and radio waves, which can reveal fistulas or other issues like tumors.

Management

Surgery: Surgery is the primary treatment to close the fistula. However, surgery is typically delayed until any infection or inflammation is resolved. Tissues need to heal before surgical intervention.
- Waiting Period: Doctors may wait 3-6 months for healing or spontaneous closure, especially if infection is present.
- Pre-operative Treatment: Antibiotics are used to treat infections, and medications like infliximab (Remicade) may be used to reduce inflammation in cases of Crohn’s disease.
Pre-surgical Care:
- Medications: Antibiotics and pain relievers (analgesics) are used.
- Hygiene: Keep the area clean by gently washing the vagina with warm water after bowel movements or discharge. Use mild, unscented soap and pat dry.
- Gentle Wipes: Use unscented wipes instead of toilet paper.
- Barrier Creams/Powders: Apply talcum powder or moisture-barrier cream to prevent irritation.
- Loose Clothing: Wear loose-fitting, breathable cotton clothing.
- Absorbent Products: If stool leakage occurs, use disposable underwear or adult diapers to protect the skin.
Surgical Options:
- Vaginal Repair: Typically used for fistulas located in the lower vagina or near the perineum.
- Abdominal Repair: May be necessary for fistulas higher in the vagina, especially after hysterectomy or radiation, often performed by a general surgeon. This may involve using tissue flaps or grafts to close the opening.
- Colostomy: In some cases, especially with large fistulas or suspected malignancy, a temporary colostomy (diverting stool to an external bag) may be needed to allow healing.
- Anal Sphincter Repair: If the anal sphincter muscles are damaged, they will also be repaired during surgery.

Complications

Sexual Dysfunction: RVFs can negatively impact sexual life.
Fecal Incontinence: Difficulty controlling bowel movements can persist.
Recurrent Infections: Repeated vaginal or urinary tract infections are possible.
Inflammation: Inflammation of the vagina (vaginitis) or perineum (perineal dermatitis).
Abscess Formation: Abscesses can develop within the fistula tract.
Fistula Recurrence: Even after treatment, the fistula may reappear.

Prevention

Health Education: Educate women about the importance of antenatal care.
Risk Detection and Referral: Early identification of risk factors and timely referral to appropriate medical facilities.
Labor Monitoring: Properly monitor labor using a partograph to identify and address prolonged or obstructed labor.
Skilled Birth Attendance: Ensure all births are attended by skilled healthcare providers.

General Signs and Symptoms of Fistula

History: Prolonged or obstructed labor.
Urinary Leakage (VVF): Continuous, involuntary urine leakage from the vagina.
- No palpable bladder on abdominal exam (urine constantly leaks).
- Urine odor.
- Visible urine dribbling from the vagina on vulvar inspection.
- On speculum exam, fistula opening may be visible, bladder mucosa may prolapse through it.
- Complete wetness of underwear.
- Signs of urinary tract infections (UTIs).
Fecal Leakage (RVF): Stool or gas passage from the vagina.
Pain: Pelvic or vaginal pain.
Offensive vaginal discharge: Foul odor, possible vaginal itching.

Vesico-Vaginal Fistula (VVF)

Definition: An abnormal connection between the urinary bladder and the vagina.
Investigations of VVF:
- Retrograde pyelography (ureter visualization).
- Intravenous urography (ureter and bladder abnormalities).
- Ultrasound scanning (internal organ imaging).
- Cystography (bladder and uterine cavity imaging).
Management of VVF:
- Conservative (Small Fistulas): Continuous catheter drainage for spontaneous closure.
- Surgical Repair: Primary treatment, timing depends on fistula size and tissue condition.
- Pre-operative Care: Improve general health, manage infection.
- Post-operative Care: Continuous catheter drainage, prevent infection, bladder training.
Prevention of VVF:
- Antenatal care.
- Skilled birth attendance.
- Timely referral for obstructed labor.
Complications of VVF:
- Recurrent fistula.
- Sepsis.
- Social isolation.
- Persistent incontinence.
- Reduced bladder capacity.
- Fertility issues.

Bladder Training Post-Operatively for Vesico-Vaginal Fistula

Bladder training is a structured program to regain bladder control after VVF repair surgery. It involves gradually increasing the time between catheter removals to strengthen bladder muscles and restore normal function.

Bladder Training Schedule (Example):

Day 15: Catheter off for 30 minutes, then back on.
Day 16: Catheter off for 1 hour, then back on.
Day 17: Catheter off for 2 hours, then back on.
Day 18: Catheter off for 3 hours, then back on.
Day 19: Catheter off for 4 hours, then back on.
Day 20 onwards: Gradually increase catheter-free intervals if successful.

Key Aspects of Bladder Training:

Progressive Intervals: Gradually increase time without catheter.
Patient Monitoring: Closely watch for retention, infection, discomfort.
Fluid Intake: Encourage fluids.
Hygiene: Maintain perineal hygiene.
Reassurance: Provide psychological support.
Documentation: Record fluid intake, output, and symptoms.

Purpose of Bladder Training:

Strengthen Bladder Muscles: Increases bladder capacity and control.
Prevent Incontinence: Regain urinary control.
Promote Recovery: Essential for restoring normal bladder function.