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    Add as FriendVesicovaginal Fistula

    by: uma

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    1 : Vesicovaginal Fistula Dr.Uma Gupta MD,FICMCH. Professor,Dept of Obstetrics & Gynecology Era’s Lucknow Medical College.Lucknow umankgupta@gmail.com Dr.N.K.Gupta,MS,M.Ch. Professor,Dept of Surgery,Era’s Lucknow Medical College.Lucknow. drnkgupta2000@yahoo.com
    2 : Specific Learning Objectives Definition of fistula Definition Vesicovaginal fistula. Etiopathogenesis Clinical presentation Diagnosis Investigation and management Special reference to postoperative management and advise for future. 2 Uma NK Gupta 10/29/2013
    3 : INTRODUCTI0N A fistula is defined as an abnormal communication between two or more epithelial surfaces. The common gynaecological fistulae are: -VVF, RVF and UVF. VVF being the commonest. VVF is a pathological communication between the bladder mucosa and vaginal epithelium which allows free and continuous flow of urine from the bladder to the vagina such that the woman is wet all the time. 3 Uma NK Gupta 10/29/2013
    4 : Definition Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. 4 Uma NK Gupta 10/29/2013
    5 : 5 Uma NK Gupta 10/29/2013
    6 : Epidemiology Real incidence –unknown. Related to socio-economic status in the comm. More in teenagers More in primipara WHO estimates 500,000 untreated cases of VVF worldwide 6 Uma NK Gupta 10/29/2013
    7 : Aetiology Developing countries Numerous factors - VVF in developing countries. Marriage & conception at a young age, often before full pelvic growth has been achieved. Chronic malnutrition further limits pelvic dimensions, increasing the risk of CPD and malpresentation. Few women are attended by qualified health care professionals or have access to medical facilities during childbirth; their obstructed labour may be protracted for days or weeks. Effect of prolonged impaction of the fetal presenting part in the pelvis- tissue edema, hypoxia, necrosis, and sloughing resulting from prolonged pressure on the soft tissues of the vagina, bladder base, and urethra. 7 Uma NK Gupta 10/29/2013
    8 : Aetiology Developing countries Typically, the Urogenital fistulas (UGF) is large and involves the bladder, urethra, bladder trigone, and the anterior cervix. Complex neuropathic bladder dysfunction and urethral sphincteric incompetency often result, even if the fistula can be repaired successfully. 8 Uma NK Gupta 10/29/2013
    9 : AETIOPATHOLOGY VVF could be congenital or acquired. In most third world countries, > 90% of fistulae are of obstetric aetiology 1. Prolonged obstructed labour Commonest cause of VVF in our environment -Accounts for >80% of the cases. 2. Caesarean section Incision involving the posterior bladder wall. -During reflection of the bladder. -Accidental passage of a suture through the posterior bladder wall during repair of the incision. 3. Uterine rupture -Rupture of a previous caesarean section scar. -Rupture of the unscarred uterus from obstetric manipulations. -The bladder may be caught in the sutures during repair 9 Uma NK Gupta 10/29/2013
    10 : Direct trauma during operative vaginal delivery: Forceps delivery, craniotomy, symphysiotomy, repair of vaginal or cervical lacerations 10 Uma NK Gupta 10/29/2013
    11 : AETIOPATHOLOGY CONTD. 5. Gynaecological operations -Pelvic floor repair, vaginal hysterectomy, abdominal hysterectomy, colporrhaphy -Commonest cause of VVF in developed countries, where it accounts for 75.3% -Accounts for only 2.5% of VVF in Nigeria. -Risk factors for post operative fistulae are as shown below. 11 Uma NK Gupta 10/29/2013
    12 : AETIOPATH. CONTD. Specific e.g.’s Pathology Risk factor 6. Radiation necrosis. 7. Malignancies: Ca Cervix, vagina, rectum and bladder. 8. Traditional practices: Gishiri cut, circumcision, caustic soda. -Gishiri cut accounts for 10-13% of all cases of VVF in the northern Nigeria. 9. Infections: Lymphogranuloma venerum, schistosomiasis, tuberculosis. 10. Social factors: Early marriage and early delivery. ->50% of cases in northern Nigeria are below 20 yrs. ->50% are in their first pregnancy. 11. Others: Coital injuries, excision of a urethral Diverticulum 12 Uma NK Gupta 10/29/2013
    13 : Risk factors for post operative fistulae. Anaemia,Nutritional deficiency. Radiotherapy Ionizing radiation Impaired vascularity , Infections, Endometriosis , C/S, Vag-Hys.Colporrhaphy Inflammation Pelvic surgery Malignancy Abnormal tissue adhesions Fibroids, Ovarian mass Anatomical distortion 13 Uma NK Gupta 10/29/2013
    14 : Classificaiton of VVF Anatomic Classification Type I: Not involving the closing mechanism Type II: Involving the closing Mechanism A : Not involving (sub)total urethra a : without circumferential defect b: with circumferential defect Type III: miscellaneous, e.g. ureteric fistula 14 Uma NK Gupta 10/29/2013
    15 : Classificaiton of VVF Classification according to size small < 2 cm medium 2-3 cm large 4-5 cm extensive > 6 cm 15 Uma NK Gupta 10/29/2013
    16 : CLASSIFICATION VVF are classified according to the site of injury; Juxta-urethral fistula Mid-vaginal fistula Juxta-cervical fistula Very large fistula Vault fistula Combined fistula Circumferential fistula Residual fistula 16 Uma NK Gupta 10/29/2013
    17 : Classificaiton of VVF Classification according to type of fistula Vesico-vaginal Vesico-uterine Vesico-cervical Vesico-utero-cervico-vaginal Uretero-vaginal 17 Uma NK Gupta 10/29/2013
    18 : 18 Uma NK Gupta 10/29/2013
    19 : CLINICAL PRESENTATION uncontrolled leakage of urine into the vagina is the hallmark symptom of patients soon after a prolonged obstructed labour, operative vaginal delivery, or caesarean section. In direct surgical injury to the bladder, the leakage of urine may occur from day one. Most surgical and obstetric fistulae symptoms develop between 3 or 5 – 14 days. History of previous surgeries or prolonged obstructed labour. Secondary amenorrhoea. Secondary infertility 19 Uma NK Gupta 10/29/2013
    20 : Clinical Presentation H/o of previous pelvic or abdominal surgery Symptoms develop early, may be Day 1 Postoperative urinary leakage, oliguria, abdominal distension, pyrexia or loin pain Present earlier for repair than obstetric cases H/o. of previous unsuccessful attempt(s) at Repair 20 Uma NK Gupta 10/29/2013
    21 : radiation-induced UGFs are associated with slowly progressive devascularization necrosis and may present 30 days to 30 years later. Patients with radiation-induced VVFs initially present with symptoms of radiation cystitis, hematuria, and bladder contracture. 21 Uma NK Gupta 10/29/2013
    22 : FINDINGS ON CLINICAL EXAMINATION O\E -Ill looking, malnourished, pale with evidence of inter current infections Abd. –kidneys may be enlarged & tender Pelvic Exam. –vulva & thigh excoriations (ammoniacal dermatitis) 22 Uma NK Gupta 10/29/2013
    23 : Clinical Examination contd V/E –best performed in lateral position, may also be done in dorsal position. -digital to precede speculum exam. -insert speculum of appropriate size visualize ant. Vaginal wall & then post. Vaginal wall -Do digital rectal exam. to R\O RVF 23 Uma NK Gupta 10/29/2013
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    25 : EXAMINATION UNDER ANAESTHESIA + DYE TESTS Digital vaginal examination and examination with a Sim’s speculum may not confirm or exclude a fistula, thus necessitating EUA+ DYE TESTS A malleable probe is passed through openings in the vaginal wall; -For VVF and UVF, a metallic click against a catheter may be felt or seen via cystoscope. -For RVF , the probe may be felt digitally in the rectum or seen via a proctoscope 25 Uma NK Gupta 10/29/2013
    26 : EUA + DYE TEST Continued. Enables assessment of available access and the mobility of tissues for vaginal repair. The decision to repair vaginally or an abdominal approach can also be taken then. 26 Uma NK Gupta 10/29/2013
    27 : Once the diagnosis of urine discharge is made, the physician must identify its source. A full vaginal inspection is essential and should include assessment of tissue mobility; accessibility of the fistula to vaginal repair; determination of the degree of tissue inflammation, edema, and infection; and possible association of a rectovaginal fistula. Urine should be collected for culture and sensitivity, and patients with positive results should be treated prior to surgery. 27 Uma NK Gupta 10/29/2013
    28 : SPECIFIC INVESTIGATIONS DYES STUDIES Confirm if discharge is urinary If leakage is extra-urethral rather than urethral To establish the exact site of leakage *Phenazopyridine -200mg tds orally *Indigo carmine -intravenously *Methylene blue instillation 28 Uma NK Gupta 10/29/2013
    29 : DYE STUDIES contd. Patient in lithotomy position Examination best done under direct vision ‘ ‘Three Swab Test’ has limitations, Adequate distension of the urinary bladder If clear fluid leaks after instillation of dye, ureteric fistula is likely. Differentiate by “two dye test” Phenazopyridine to stain renal urine and Methylene blue to stain the bladder urine 29 Uma NK Gupta 10/29/2013
    30 : OTHER SPECIFIC INVESTIGATIONS Cystoscopy – small vvf Cystography – vesico uterine fistulae (lat. view) 30 Uma NK Gupta 10/29/2013
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    32 : GENERAL INVESTIGATIONS FBC + Blood film + Malaria Parasite Urine for urinalysis & m.c.s. Stool for Parasitic Infestations CXR Serum E/U/Cr Intravenous Urography 32 Uma NK Gupta 10/29/2013
    33 : PREOPERATIVE TREATMENT * Timing of definitive repair Improve Patient’s General Health; high protein diet, antihelmintics, haematinics & treatment of inter current infections/ diseases, vulval dermatitis with zinc oxide cream *Bowel Preparation, Prophylactic Antibiotics/ Urinary Antiseptics 33 Uma NK Gupta 10/29/2013
    34 : REPAIR OF VVF Route of Repair; vaginal or abdominal Position of Patient; lithotomy or reverse lithotomy (knee-elbow position) Type of suture materials; absorbable -vicryl 2/0 or chromic catgut 2/0 Types of Repair;(1) Dissection & repair in layers (2) Saucerization 34 Uma NK Gupta 10/29/2013
    35 : Excellent success rates for both the vaginal and abdominal approaches if the following general surgical principles are followed: (1) complete preoperative diagnosis, (2) exposure, (3) hemostasis, (4) mobilization of tissue, (5) tissue closure under no tension, (6) watertight closure of bladder with any cystotomy repair, (7) timing to avoid infection and inflammation of tissue, (8) adequate blood supply at area of repair, (9) continuous catheter drainage postoperatively. 35 Uma NK Gupta 10/29/2013
    36 : POST OPERATIVE MANAGEMENT Fluid Balance; intake 3-4 litres per day output 120-150mls/hr Bladder Drainage; check drainage & vol. of urine hourly Post Operative antibiotics Prevention of Deep Vein Thrombosis Care of the perineum with vulva pads Duration of Drainage; 10-14 days on the average Retraining of urinary bladder before discharge 36 Uma NK Gupta 10/29/2013
    37 : Post Operative Mgt. Contd. Instructions on Discharge Repeat EUA & dye test on day 21 before discharge Refrain from sexual intercourse for 3months Counsel for antenatal care & hospital delivery in all subsequent pregnancies Elective Caesarean Section next Pregnancy 37 Uma NK Gupta 10/29/2013
    38 : Surgical procedures for the vaginal approach Latzko partial colpocleises procedure Numerous authors hold this time-honored procedure, with success rates of 93-100%, to be the standard for repair of simple post hysterectomy VVFs. 38 Uma NK Gupta 10/29/2013
    39 : Flap-splitting techniques In this technique, the vaginal wall is incised circumferentially around the fistula and widely dissected from the underlying endopelvic fascia in a standard anterior colporrhaphy technique. Leaving the tract unresected, the bladder is closed, tension-free, in 2 layers. The surgery is completed with the vaginal closure over the bladder defect. 39 Uma NK Gupta 10/29/2013
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    41 : Abdominal approach Exposure: As with the transvaginal approach, exposure with the transabdominal approach can be augmented with the use of traction sutures and with catheterization of the fistula with a Fogarty catheter. 41 Uma NK Gupta 10/29/2013
    42 : Vaginal approach interposition grafts or flaps Martius flap Gracilis muscle flap The predominant application for this flap is in total vaginal reconstruction following pelvic exenteration. Peritoneal flap 42 Uma NK Gupta 10/29/2013
    43 : Thank You 43 Uma NK Gupta 10/29/2013

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