Trauma of the female genital tract fistulae
Genital tract fistulae may occur between the vagina or the uterus and any adjacent organ, but the most frequently encountered fistulae are between the bladder and vagina called vesico vaginal fistula or the rectum and vagina calledrecto vaginal fistula. Other types may occur, but are rare, and occasionally multiple fistulae may be found in the same woman.
Cause: In developing countries
· about 85% of fistulae follow an obstructed labour
· 15% surgery or radiation for gynecological conditions Obstetrical and surgical fistulae arise either immediately due to direct trauma, or 5 to 14 days after delivery or operation when the traumatized, ischaemic tissue sloughs. Fistulas following irradiation rarely appear until one or more years after treatment.
· In vesico vaginal fistulae
- the patient complains incontinence of urine
- urinary incontinency is continuous night and day
- If the fistula is large, the defect can be seen, but pin point fistulae may require special tests for diagnosis. One such special test is to place three cotton wool swabs in the vagina, one above the other, and to run methyl lene blue dye into the bladder.
- if only the lowest swab stains the fistula is urethral
- if the middle swab stains, it is vesical
- if no swab stains but the upper most swab is wet, the fistula is ureterial.
- In recto vaginal fistulae
- The patient complain incontinence of faeces
· May be obvious or extremely difficult to identify, and photocopy or the introduction of dyes may be required.
The treatment of all fistulae, except small fistulae which have formed recently following child birth or operation, is surgical. Some recently formed vesico vaginal fistulae will heal if the bladder is drained continuously for 21 to 28 days and some recto vaginal fistulae will heal if a low residue diet is given for the some period. Most fistulae require operation.
· the fibrosed edges of the fistulous tract must be excised so that well vascularized viable tissue may be brought in to apposition
· the apposition must be effected with out tension on the apposed edges
· The tissues must not be placed under tension for at least 3 weeks (this principle implies constant bladder drainage in cases of vesicovaginal fistulae)
· The best results are obtained if fistulae are treated in special units, where experience in the operative technique and, more important, the meticulous postoperative management of the case can be offered.