VVF/RVF - Dr Zahida Qureshi Anatomic Classification

Type I: Not involoving the closing mechanism

Outline Type II: Involing the closing Mechanism
Definition A : Not involving (sub)total urethra
Classification a : without circumferential defect
Etiology b: with circumferential defect
Prevention B: involving (sub)total urethra
Clinical assessment a: without circumferential defect
Investigations b: with circumferential defect
Early Rx Type III: miscellaneous, eg ureteric fistula
Surgical approach
Pre and post operative counselling Classification according to size
Pre and post operative management • small < 2 cm
Complications • medium 2-3 cm
• large 4-5 cm
Definition
Vesicovaginal fistula (VVF) is a subtype of female
• extensive > 6 cm
urogenital fistula (UGF). VVF is an abnormal fistulous
tract extending between the bladder and the vagina Classification according to type of fistula
that allows the continuous involuntary discharge of • Vesico-vaginal
urine into the vaginal vault. In addition to the medical • Vesico-uterine
sequelae from these fistulas, they often have a • Vesico-cervical
profound effect on the patient's emotional well-being. • Vesico-utero-cervico-vaginal
• Uretero-vaginal
Classificaiton of VVF
• Recto-vaginal: an abnormal communication between
the rectum and the vagina, sometimes referred to as
stool fistula

Etiology
Direct causes
1. Obstetric-necrosis due to obstructed labour, the obstetric
fistula- most common cause
2. Surgery: hysterectomy, colporrhaphy, cesarean section
3. Instrumentation at inducted abortion
4. Radiation, e.g. cervical carcinoma- ischaemia
5. Malignancy-cervical cancer
6. Trauma—trauma-rod iron, anterior episiotomy , RTA
leading to # pelvis
7. Congenital malformation
8. Infection-TB, LGV
9. Fgm
10. HIV
11. Sexual abuse in childhood

Indirect causes
• Low status of women in the society (voiceless and
powerless)
• Poverty and gender discrimination
o Chronic malnutrition: contracted pelves
• Lack of education
• Culture/ traditions
o Early marriage & conception
o Fgm- outlet obstruction
o Health seeking practices
• Limited access to medical services

Prevention
• Proper management of labour
• Use of partograph to prevent abnormal labour • Future deliveries by c/section
• c/section within 1 hour of diagnosis of obstructed labour
• In case of obstructed labour –ensure continuous urinary
drainage for 7-10 days irrespective of mode of delivery
• Proper surgical technique-
o hysterectomy/section, cystectomy etc Complications
• Intra-operative
• Prevention of cervical cancer
o Creation of another fistula
Clinical Assesment o Ligation of ureter
• History of leakage of urine-details of event • Post-operative
• Examination in lithotomy position o Break down of repair
o Blocked catheter
• Legs-muscle power - foot drop.
o Incontinence after anatomical closure of fistula
• Sim’s speculum
• Failure to achieve complete closure of fistula
o Size, site, number of fistulae
• Dye test if necessary RVF CLASSIFICATION
• Decide on mode of repair o I Proximal fistula
• Investigations- IVU if no dye noted o without rectum stricture
o with rectum stricture
Early treatment o with circumferential defect - very seldom
The management of obstetric fistula starts as soon as urine o II distal fistulas
leakage is noted o without sphincter ani involvement
• insert FOLEY‘s catheter Ch 18 for 4 weeks o with sphincter ani involvement
• Increased oral fluid intake of 6-8 litres/24hrs o III miscellaneous, e.g ileouterine fistulas after
• Ensure free urine drainage instrumental abortion
• No routine antibiotics since it is pressure necrosis o An additional classification is made to the size: small,
• Antibiotics only on indication, eg puerperal sepsis medium, large and extensive,
• Immediate mobilization of patient, if necessary with
walking stick Frequently asked questions
• oral iron preparations; sytemic if needed o Can the two fistulae be repaired at the same sitting
• high protein diet o Does every woman with an RVF need a colostomy?
• If it seems to be healing leave catheter in situ o How soon can a urinary fistula be repaired?
o How long does a woman have to abstain from coitus after
• 50% of small < 2 cms fistuale close with catherter
a repair?
treatment or become smaller –easier closure
• if not healing excise slough and prepare for early closure
NOTES
• as soon as wound clean perform an early closure
• mobilize patient at all times
• attend to the other needs of the patient

Surgery
• Vaginal or abdominal route
• Usually spinal anesthesia
• Episiotomy if necessary
• Wide dissection
• Repair of fistula in one layer
• Dye test
• Closure of vaginal mucosa

Post op care/Follow up
• Retain catheter for 14 days
• Increased fluid intake > 5litres daily
• Avoid coitus for 6 months
• clinic follow up-2 weeks –dye test if negative remove
catheter
• If positive consider retaining catheter for further 2-4
weeks