What is Urinary Fistula?
Urogenital fistula – a difficult and relatively frequent complication in obstetric and gynecological practice. They arise mainly as a result of injuries of the urinary organs or trophic disorders during pathological labor, obstetric and gynecological operations. Less common causes are chemical burns, household trauma or gunshot wounds.
Symptoms of Urinary Fistula
Depending on the organs involved in the pathological process, there are distinguished vesicular-genital, ureteral-genital and urethro-vaginal and combined (urinary and urinary) fistulas. The formation and clinical picture of urogenital fistulas depend on the causes of their occurrence.
Bladder-genital fistulas constitute the majority of urinary fistulas (55-65%). Depending on the cause of the occurrence, vesicular-vaginal fistulas of traumatic, inflammatory, oncological and radiation genesis are distinguished.
Bladder-genital fistula traumatic genesis
Etiology. Damage to the urinary tract during gynecological operations remains the most common type of injury, leading to the appearance of vesicovaginal fistulas. Traumatic cystic genital fistula after gynecological operations are mainly due to the severity of gynecological pathology and the complexity of the surgical manual, as well as the insufficient qualification of the surgeon. With the widespread introduction of laparoscopic access in operative gynecology in the last decade, blister-genital fistulas of burn genesis have appeared.
Bladder-genital fistulas as a result of obstetric trauma are more likely to occur after surgery for severe obstetric pathology and are the result of an extreme situation and the need to urgently remove the fetus or remove the uterus.
Clinic. The main symptom of cystic vaginal fistula is involuntary and constant leakage of urine from the vagina. If the fistula is the result of an unsung bladder injury, urine leakage begins on the very first days after the operation, and with trophic changes of the bladder wall, it is delayed and depends on the nature and extent of the pathological process (usually days 7-11). It is clinically very important to establish whether urine is leaking while urinating is preserved or the latter is completely absent. For this symptom, one can judge the diameter of the cystic fistula: in case of point fistulas and fistulas located above the ureteral fold (high), spontaneous urination may persist. With the progression of the disease, pain in the bladder and vagina. Constant symptom – psycho-emotional disorders caused by leakage of urine.
Diagnosis is based on a carefully collected history, analysis of the clinical course of the disease and data of examination of the patient. Difficulties arise when highly located fistulas opening in a scarred modified vaginal fornix. The scheme of examination of patients with vesicovaginal fistulas:
- history taking and gynecological examination;
- a three-step test;
- cystoscopy and vaginography;
- Ultrasound of the kidneys;
- according to indications, excretory urography, radionuclide renography, cystography in 3 projections.
Bladder-genital fistulas of inflammatory genesis are formed due to inflammatory diseases of the internal genital organs. Unlike vesicovaginal fistulas of traumatic genesis, in which the general condition of patients is more often satisfactory, in bladder-appendage, parametrically-appendage and complex fistulas of purulent-inflammatory etiology, the state of patients is disturbed due to intoxication and the destructive process in the pelvis.
The clinic of the disease is determined by the stage and prevalence of purulent-inflammatory process. The main complaints are pain over the womb of varying intensity, radiating to the hip and lower back, dysuric phenomena, fever, chills, pussy discharge from the genital tract, pyuria, rarely menouria.
- laboratory research;
- Pelvic and kidney ultrasound;
- excretory urography;
- CT scan;
- cystoscopy, chromoscopy, hysteroscopy, fibrocolonoscopy.
In identifying vesicovaginal fistula, as a rule, an attempt is made to conservative treatment: installing a permanent catheter into the bladder for 8-10 days, washing the bladder with antiseptics, ointment tampons in the vagina, antibacterial therapy, uroseptics. According to the literature, in 2-3% of patients, small fistulas are scarring, but the majority of patients with vesicovaginal fistulas have to be operated on. There are vaginal and abdominal access operations. The choice of surgical benefits depends on the location of the fistula and the accompanying genital pathology. The indication for vaginal access is considered the possibility of full mobilization of the fistulous course, excision of scar tissue, adequate and complete restoration of the functional usefulness of the organ.
The peritoneal access operation is indicated for purulent and non-purulent pathology in the pelvic cavity, requiring surgical treatment: narrowing of the ureter, causing impaired passage of urine, fistula of complex localization, requiring plasty of a number of pelvic organs and anterior abdominal wall, high location of a fistula close to the urethral mouth, urinary ducks.
In the treatment of cystic vaginal fistula, it is important to determine the timing of surgical intervention. The classic strategy is to wait 3 to 6 months after injury in order to maximize the inflammatory response caused by surgery.
Prevention of background diseases of the urinary and genital tract, improvement of contraception methods, prediction of the course of labor, early diagnosis of postpartum purulent-septic diseases, adequate treatment of developed complications.
Ureteral-genital fistulas (uretero-vaginal, uretero-uterine) make up 25-30% of urogenital fistulas. Ureteric-genital fistulas are always of traumatic genesis, and the ureter is usually injured during operations, often radical gynecological, less often obstetric. Only in 20% of cases, damage to the ureter is recognized during surgery, and therefore in the postoperative period complications such as urinary peritonitis, cellulitis, purulent pyelonephritis, and ureteral stricture often occur.
Uretero-uterine fistulas are extremely rare.
Clinic. The main complaint of patients is urine leakage. According to the time of onset of urine leakage and the preceding symptoms, one can judge the nature of the injury to the ureter (flashing, parietal injury, ligation). With a parietal injury of the ureter, urinary leakage almost immediately forms, causing an increase in body temperature, and 2-3 days after this, urine leakage. During ligation of the ureter, dystrophy and necrosis of its wall develop against the background of disturbed outflow of urine, which is accompanied by intense pain in the kidney area. Then the temperature rises, and urine leakage appears only on the 10-12th day.
For all ureteral-vaginal fistulas, spontaneous urination is preserved during urine leakage.
It is advisable to start the diagnosis with cystoscopy and chromocytoscopy. In the absence of the ureteral endoscope, a retrograde catheterization of the mouth of the injured ureter is necessary with the introduction of a catheter through it, which will determine the level of ureteral injury and, accordingly, the localization of the fistula. Intravenous urography shows the condition of the kidneys and the healthy ureter on the affected side, the degree of hydronephrosis, hydroureter, the amount of urinary leakage.
The examination complex necessarily includes renal ultrasound and functional studies of the excretory system (biochemical blood tests, Zimnitsky, Nechiporenko, radionuclide kidney tests).
Treatment only with surgical, abdominal access (ureterocystoneostomy, intestinal ureteroplasty). The time of execution and the method of surgical intervention are determined individually, but the main condition is the absence of an inflammatory reaction in the fistula zone. Consequently, from the beginning of urine leakage to surgery, 5-7 weeks should pass.
Skilled performance of surgical benefits, control of the ureter during surgery.
Urethro-vaginal fistulas are formed as a result of trauma to the urethra during childbirth or during gynecological operations (more often after anterior colporrhaphy, when removing a Hartner’s cyst, anterior vaginal wall cyst).
Clinic. The main complaint is involuntary discharge of urine from the vagina. If the fistula is located in the middle or proximal part of the urethra, then the urine is not held either vertically or horizontally in the patient. With the localization of the fistula in the distal urethra, urination is arbitrary, but urine is excreted through the fistula.
Diagnosis of urethro-vaginal fistula is quite simple. Large defects are available for inspection and palpation. The fistula can be determined by inserting the probe into the external opening of the urethra, with the tip of the probe being output through the fistula. A simple and affordable method of diagnosis is the introduction into the bladder warm isotonic sodium chloride solution, stained with methylene blue; the colored solution is excreted through the fistula. For point fistulas, urethrocystoscopy and vaginography are indicated.
Surgical treatment. To suture urethral defects or to form it again should be provided that the genital and urinary tracts are completely rehabilitated. Usually, the cure takes 3-6 months and success is directly related to the restoration of the reparative properties of tissues. Preparation of the intervention zone is facilitated by short-term fixation of the Foley catheter, which removes urine from the bladder.
Prevention. Careful management of labor and qualified performance of gynecological operations.