- Involuntary discharge of urine from the vagina.
- Pain, pain when urinating.
- Frequent urination.
- The appearance of blood in the urine (hematuria).
- Pain in the bladder and vagina.
- Lack of independent urination and excretion of all urine through the vagina with large diameter fistulas.
- Narrowing of the vagina - pain during sexual intercourse.
- Surgery. During the operation, there may be damage to the bladder wall, which remains unnoticed by the surgeon.
- surgery through the incision of the vaginal walls,
- surgery on the uterus through the incision of the abdomen.
- Hernia repair. Hernia surgery - protrusion of the intestinal loop through the anterior abdominal wall.
- Caesarean section (delivery using abdominal surgery, in which the newborn is removed through an incision in the abdominal wall and uterus).
- Protracted labor (childbirth lasting more than 18 hours).
- Malignant tumors of the bladder and vagina.
- Stone in the bladder.
- Foreign bodies in the bladder.
- Genital perversions (introduction to the woman's urethra of various solid objects).
- Radiation therapy (use for therapeutic purposes of various types of ionizing radiation, different energies for the treatment of malignant neoplasms).
- Breakthrough of various abscesses (cavities with pus), located in the pelvic cavity, in the vagina.
- Specific infectious diseases that affect the bladder, the vaginal wall:
- venereal lymphogranuloma (a sexually transmitted disease characterized by the appearance of ulcers on the genitals, then there is an increase in lymph nodes (glands of the immune system) in the inguinal areas),
- schistosomiasis (a tropical parasitic disease caused by flatworms: if a bladder is damaged, blood appears in the urine, bladder scarring occurs later on, which can lead to fistula development)
- actinomycosis (a fungal disease in which any organs and tissues are affected, but more often an area of the face, neck, jaws),
- bladder tuberculosis (a widespread infectious disease of humans and animals in the world caused by various types of mycobacteria, as a rule, Mycobacterium tuberculosis (Koch's wand)).
A doctor urologist will help in the treatment of disease
- Analysis of the history of the disease and complaints - when (how long) urine excretion from the vagina appeared, pain in the lumbar region, was there any treatment for this, examination, with which the patient associates the occurrence of these symptoms.
- Analysis of the history of life - what diseases a person suffers, what operations he has undergone. Particular attention is paid to gynecological surgery, course, duration of labor.
- Gynecological examination - inspection of the vaginal walls in the mirrors (cylindrical (or tubular), hollow (or spoon-shaped) tools, allowing to expand the vagina) - allows you to identify the location of the fistula.
- The sensing method is the introduction into the fistula opening of thin metal tubes, which allows to evaluate the anatomical location of the fistulous passage.
- Introduction to the cavity of the bladder of various coloring agents (either taking tablet preparations or administering the substance intravenously), which, standing out by the kidneys, stains urine. At the same time, a tampon is injected into the cavity of the vagina, soaked in a special substance, which, reacting with the drug in the bladder, changes color. The method allows to determine the location of the fistulous opening and its anatomical affiliation.
- Complete blood count - allows you to determine the signs of the inflammatory process: increased white blood cells (white blood cells), erythrocyte sedimentation rate (ESR), that is, red blood cells.
- Urinalysis - allows you to determine the presence of red blood cells and identify the degree of bleeding, the presence of leukocytes, the level of which assessed the degree of inflammation.
- Blood chemistry. With this analysis, it is possible to identify signs of impaired kidney function: an increase in the end products of protein metabolism (creatinine, urea, uric acid).
- Ultrasound examination (ultrasound) of the kidneys, bladder - allows you to assess the size and structure of the kidneys, the degree of violation of the outflow of urine from them.
- Intravenous urography. An x-ray-positive drug is injected into a patient's vein, which in 3-5 minutes is excreted by the kidneys. At this time, several shots are taken. The method allows you to identify the spread of the drug outside the bladder, which may indicate the presence of a fistula. Also using this method, you can assess whether there is a violation of the kidneys.
- Nephroscintigraphy. A safe radioactive drug is injected into the patient's vein, which is excreted by the kidneys. Using a special device, it is evaluated how the kidneys filter the substance. The method allows to evaluate the function of the kidneys (urination and urination).
- Retrograde cystography. A substance visible on the x-ray is injected into the bladder through the urethra. The method allows to estimate the location of the localization (location) of the fistula.
- Vaginografiya - the substance visible on a roentgen is entered into a vagina. The method allows to assess the location of the local fistula.
- Magnetic resonance tomography (MRI) is a high-precision diagnostic method based on the possibility of layer-by-layer examination of an organ. The method allows to determine the location of the message of the bladder with the vagina.
- Computed tomography (CT) is an x-ray study that allows to obtain a spatial (3D) image of an organ. With it, you can accurately determine the localization of the fistula.
Treatment of urinary and vaginal fistula
- In some cases (with small sizes of the fistulous opening) spontaneous healing of the fistula is possible. In order to reduce the amount of fistula healing time, a permanent urethral catheter is inserted into the bladder (a rubber tube inserted into the bladder through the urethra).
- Cauterization of the edges of the fistulous opening with silver preparations, electric current (including from the side of the bladder).
- Types of surgery:
- through the incision of the vagina - excision of the tissue around the fistula, suturing of the vaginal wall and the wall of the bladder separately from each other,
- through the incision of the anterior abdominal wall with the opening of the bladder wall, excision of the tissues around the fistula and suturing of the vaginal wall and bladder wall separately from each other,
- in case of extensive defects, patches of their own tissues (vaginal mucosa, pelvic muscles, etc.) are used to close the fistula.
Complications and consequences
- Mental Disorder.
- Violation of the quality of sexual life.
- Inflammation of the skin around the vagina.
- Vaginitis (inflammation of the vaginal walls).
- Acute pyelonephritis (bacterial inflammation of the kidney).
- Vaginal stenosis (narrowing of the lumen of the vagina).
Prevention of urinary bladder vaginal fistula
- Regular visits to the gynecologist (2 times a year).
- Timely registration for pregnancy and regular monitoring by an obstetrician-gynecologist (up to 6-8 times (up to 12 weeks, 16 weeks, 20 weeks, 28 weeks, 32-33 weeks, 36-37 weeks), provided regular (every 2 weeks) observation by a specially trained midwife after 28 weeks gestation.
- Immediate treatment to the gynecologist in case of complaints from the external genital organs.
- Timely treatment of diseases of the uterus.
- Kan D.V. Guide to obstetric and gynecological urology. M .: Medicine, 1986, 4–5.
- Mazhbitz A.M. Operative urogynecology. M .: Medicine, 1964, 4–10.
- Atabekov D. N. Essays on urogynecology. M. Medgiz. 1954
They distinguish colonic-vaginal, vesicular-vaginal, urethrovaginal, ureter-vaginal, enteric-vaginal and rectovaginal fistulas of the vagina. By location, they are divided into high (in the upper part of the vagina), medium (in the middle part) and low (in the lower part of the vagina).
Usually the pathology has an acquired character. Vaginal fistulas are formed for various reasons. Most often - as a result of injury to the vaginal wall, urinary tract and intestines during operations and invasive manipulations in obstetrics, proctology and urology. Urogenital fistulas are a complication of reconstructive procedures for supravaginal and radical hysterectomy, stress urinary incontinence, urethral diverticula, cysts, prolapse of the anterior wall of the vagina, etc.
The cause of rectovaginal fistulas is caused by injuries during obstetric actions, trophic defects, and delivery of the abnormal type. These include childbirth with surgery, pelvic presentation of the fetus, rupture or damage to the birth canal when they do not match the size of the fetus, ischemia and necrosis of soft tissues during prolonged oxygen-starved labor.
Fistulas of inflammatory nature are formed due to perforation of acute diverticulitis or paraproctitis, opening into the lumen of the vagina abscesses. Less commonly, burns (electrical, chemical), ectopia of the ureter, household injury to the rectovaginal septum, pelvic tumor lesions (benign and malignant), pelvic radiation during radiation therapy, Crohn's disease, cholecystitis, atrophic forms of gastritis can be the causes of pathology.
The course of the disease is recurrent, chronic. With urinogenital fistulas, the patient is worried about involuntary full or partial urinary incontinence, frequent urinary tract infections. In the area of the hips and perineum, maceration of the epidermis (changes caused by the effect of fluid on the tissue), hyperemia and swelling of the vaginal mucosa is observed.
With preserved urination, urine leakage indicates a highly located or pinpoint fistula. When they are located in the proximal or middle part of the urethra, urine is not held either horizontally or vertically in the body. With the progression of the pathology there are pains in the bladder and vagina.
When entero-vaginal fistulas are characterized by complaints of fecal incontinence (with large education) and gas (with pinpoint fistula), itching and burning of the genitals due to irritation of the mucous around the fistula. Constant infection of the vagina is manifested by frequent exacerbations of vulvitis and colpitis, pain in the perineum during sexual intercourse and at rest. Rectovaginal fistulas are accompanied by failure of the pelvic floor muscles, cicatricial deformity of the posterior wall of the perineum and vagina, and rectal sphincter defect.
In case of fistula-purulent-inflammatory genesis, the general condition of the patient deteriorates dramatically. There is a fever, loose stools with an abundance of pus and mucus, purulent leucorrhoea, pain in the pubic region and lower abdomen, radiating to the lower back or rectum, pyuria, dysuria, and sometimes menouria. Against this background, develop psycho-emotional disorders.
Forecasts and Prevention
The main complications that occur after surgery are dysfunction of intestinal sutures and fistula recurrence. Therefore, surgery can be repeated.
In general, vaginal fistula has a positive prognosis. Improvement of the condition and return to a natural lifestyle is possible already in 3-4 months. For women planning pregnancy, it is recommended to wait a period of time up to 3 years. In this case, delivery will be carried out exclusively by caesarean section.
The following measures are necessary to prevent the development of vaginal fistulas:
- timely detection and treatment of infectious lesions of the vaginal mucosa, diseases of the pelvic organs,
- treatment of chronic diseases (including the genitourinary system),
- preventing obstetric injuries,
- conducting operations with highly qualified specialists,
- avoiding gynecological procedures for curettage of the vaginal cavity.
It is also important for the patient to observe the hygiene of the genitals and to visit the gynecologist once a year.
This article is posted solely for educational purposes and is not a scientific material or professional medical advice.
What is vaginal fistula
A fistula is an abnormal canal that forms in different parts of the vagina during fetal development or as a result of injury. The walls of the vagina are in close proximity to the intestines and bladder. In the event of defects in the walls, urine and feces enter the cavity of the vagina. In most cases, the deviation is acquired.
Causes of vaginal fistula formation
But sometimes they are a congenital defect in the structure of organs. In this case, the problem is formed in the womb as a result of toxic poisoning or lack of nutrients. Symptomatology is directly dependent on the factors causing the disease. Possible causes of pathology include:
- birth injuries
- inflammatory process,
- complications after surgery,
- mechanical damage,
- congenital anomalies.
One of the most common causes of fistula formation is birth trauma. The risk of developing the pathology increases with complicated labor. When a child passes through the birth canal, the vaginal tissue is torn. Most often, gaps are localized on the back of the vagina. Damaged areas are stitched with special medical instruments. But over time, defects can form in this place. Therefore, in the postpartum period, it is especially important for women to regularly visit the gynecologist's office.
Sometimes fistulae form in the absence of mechanical damage. This happens if the fetus remains in one position for a long time. As a result of excessive compression of the organs, necrosis begins, gradually turning into fistulas. The factors provoking the development of pathology after childbirth include the following:
- wrong location of the fruit,
- fast delivery
- vaginal muscle weakness
- long anhydrous period,
- too large fruit in relation to the size of the pelvis of a woman
- violation of the implementation of cesarean section.
For any surgical procedures there is a risk of complications. One of them is the occurrence of a fistula on the vaginal wall. When operating the organs of the urinary system may accidental injury to the tissues of the vagina. The likelihood of fistulous passages increases with the removal of cystic formations and organs of reproduction.
After inflammatory processes in the pelvis
As a result of inflammatory diseases, the position of the internal organs changes. Adhesions develop, which provoke the stagnation of the purulent contents of inflammation foci. In this case, there may be characteristic pain in the lower abdomen. Sooner or later, purulent masses form a channel in the form of a fistulous passage. Most often this happens in the presence of the following diseases:
- anal fissures and hemorrhoids,
Fistulas may also appear for other pathological conditions. Mechanical factors include damage. during intimacy and various forms of burns. Sometimes false moves appear with malignant tumorsespecially if they are located in the rectal area. In some cases, fistulas appear after radiotherapy.
On average, the duration of fistula formation is 3 weeks. But sometimes this process stretches over months. At the initial stages of the development of pathology, the symptoms are mild. With mechanical injuries, they appear immediately. The clinical picture of the disease is as follows:
- There is a periodic leakage of urine. With a low location of the fistula its selection is permanent.
- Concomitant diseases developamong which are colpitis, candidiasis and hydrosalpinx. This happens when inflammation spreads to other organs. In this case, the body temperature increases and muscle weakness appears.
- With extensive ruptures and as a result of seam divergence disrupted sphincter of the rectum. This provokes the incontinence of gases and feces.
- From the cavity of the vagina periodically leaves the liquid feces. Fistulae passages most often have small sizes. Therefore, the solid mass can not penetrate through them.
- If the fistula is located in the immediate vicinity of the urinary organs, signs of cystitis and urethritis appear.
The disease affects the mental health of women. Discomfort leads to intimate problems. With a strong tension of the muscles can escape the gases from the vaginal cavity. This process is accompanied by characteristic sounds. As a result, the woman begins to avoid communicating with others.
The approach to treatment depends on the location of the fistula and its size. It also matters the state of the pelvic floor muscles. Drug therapy effective only in the initial stages of the disease. Small passages are eliminated by electrocoagulation. In other cases required surgical intervention. Damaged tissues are sutured, and sphincteroplasty can be performed at the same time.
If the vagina has developed an inflammatory process, treatment is carried out in two stages.Initially appointed anti-inflammatory therapy. For discharge of urine and feces form colostomy. It is an artificial output of the rectum. Only after the symptoms of inflammation disappear, the excision of the scar formed at the site of the fistula is performed. If the pathology affects the urethra, ureterocystoneostomy is indicated. After surgery, a woman can relieve themselves in a natural way.
The method of access for surgical intervention is selected on the basis of the local location of the scar. The operation can be done rectally, through the vagina or by perineal access. Sometimes anterior levatoroplasty is performed, which can also be combined with vaginoplasty. With extensive cicatricial lesions make a laparotomy.
Prognosis and prevention
After the operation, the patient's quality of life is significantly improved. In some cases, there are relapses, but the probability of their occurrence is extremely small. Pregnancy can be planned no earlier than 2 years after surgery. Disease prevention includes the following principles:
- to normalize the stool It is recommended to diversify the diet foods rich in dietary fiber. This will avoid chronic constipation, which provoke relapses of fistulous passages,
- to strengthen the pelvic floor muscles need to perform kegel exercises,
- timely treatment of inflammatory processes genital organs, rectum and urinary system will reduce the risk of fistula,
- It is recommended to take measures to prevent birth injuries. This will help the gynecologist leading the pregnancy
- It is desirable to avoid surgeries involving curettage of the uterus. Regular visits to the gynecologist will allow you to diagnose the disease at an early stage, when the problem can be solved in a conservative way.
Fistula in the vagina is considered a serious disease that changes the lifestyle of a woman. They affect the intimate sphere and cause psychological problems. Avoiding the disease is easier than treating its effects. Every woman has the power to prevent the disease, observing preventive measures.
To treat the disease by folk methods is extremely undesirable. This can aggravate the symptoms and lead to complications.
Causes of vaginal fistula
The main causes of vaginal fistulas are surgical procedures that injure the vagina, intestines, and urinary tract. Most often it is associated with surgical interventions in gynecology, urology, proctology, less often - there is a defect in obstetric procedures.
The reasons for the formation of urogenital fistulas are postoperative complications during surgical procedures to remove the following defects:
- stress urinary incontinence,
- urethral diverticulum,
- vaginal cyst,
- loss of the wall of the anterior region of the vagina,
- performing hysterectomy of the radical type.
The cause of rectovaginal fistula may be the resulting injuries during obstetric actions, delivery of the abnormal type, trophic defects. These include:
- too large fetus, resulting in ruptures and injuries during childbirth,
- previa pelvic type
- surgical intervention during childbirth, which can damage the rectum in conjunction with the connective-miotic tissue, the vagina.
In addition, the causes of the disease may be the following factors:
- necrosis of soft tissues during delivery with further oxygen starvation, damage to the integrity of the vaginal framework,
- ischemia of prolonged nature in complicated childbirth,
- autopsy of the vaginal mouth at the apostema,
- discovery of acute form of diverticulitis, paraproctitis,
- uretonic ectopia,
- Gastrointestinal diseases: Crohn's disease, atrophic forms of gastritis, cholecystitis,
- the use of chemotherapy or radiotherapy of the pelvic organs,
- the presence of malignant / benign tumors of the pelvis,
Symptoms of fistula in the vagina
Symptoms of the development of the disease depends on the form of flow of the fistula. When urinary orifice manifests urinary incontinence of partial or complete character, its outflow into the vagina. Characteristic features:
- vaginal hyperimia,
- swelling of tissues
- changes in the epidermis in the area of the buttocks, perineum - irritation, redness, ulcerative foci.
With the development of urinogenital fistulas with preserved urination function and a slight erosion of urine, the fistula is stated as high or pointed. With a different location: the middle of the vagina or the proximal area of the urethra, the urine cannot be kept inside at any position of the body, the development of the disease leads to a constant pain syndrome in the vagina and the urethra.
Symptoms of enteric vaginal fistula are determined by the following symptoms:
- independent loss of fecal masses: manifests itself at large mouths,
- gas incontinence: in the presence of point fistulas,
- defecation and gas outlet through the vagina,
- genital itching, burning.
When the rectovaginal fistula is formed, a scar (one or many) of the posterior vaginal wall together with the perineum, rectal sphincter defect, limping mioticheskie pelvic tissue.
Fistula in the vagina, together with infection and the progress of the inflammatory process is characterized by:
- lower abdominal pain
- pain in the groin area, followed by a transition to the sacral region, rectovaginal septum,
- purulent vaginal discharge,
- diarrhea with impurities of pus, mucus,
Symptoms of vaginal fistula manifested in pain in the perineal region, discomfort during intimate intercourse and in the resting stage, the occurrence or exacerbation of colpitis, vulvitis. Also inherent psycho-emotional disorder on the basis of chronic pain and general discomfort.
Treatment of fistula in the vagina
Methods of treating fistula in the vagina depend on its location, shape and size, anatomical disturbances of adjacent tissues, the presence of scars, the state of the small pelvis and rectum, together with the functionality of the sphincter.
The cystovaginal orifices can independently pass through with medication. And fistulas of the bladder and urethra are shown to be treated with electrocoagulation.
Urogenital fistula must be surgically removed. During the operation, the vaginal walls are stitched, removing the defect. Also sutured bladder tissue and urethra. To do this, apply patchwork plastic.
The operation is indicated only in the event of rapid symptoms, not earlier than after 4 months.
In case of ureterovaginal ostium, ureterocystoneostomy is performed.
Rectovaginal injuries should be removed as soon as possible - up to 18 hours from the onset of fistula. The operation involves incision of atrophied tissue around the circumference of the fistula and their further stitching.
Fistulas in the vagina and rectum are surgically removed in several ways:
Further treatment consists of levatoroplasty and sphincteroplasty. Perform removal of the damaged epithelium and sew it along the vagina and intestine lines.
The presence of the inflammatory process inside the fistula lengthens the treatment process. First, it is necessary to clean the area for the operation by diverting intestinal effusions into the vaginal cavity, preventing this in the future. To do this, use the colostomy. The following shows the operation - no earlier than 3 months.
Disease prevention and prognosis after treatment
The main problems that arise after surgery in patients are:
- fistula recurrence
- intestinal sutures dysfunction.
In connection with these indicators, the operation is repeated.
A fistula in the vagina has a positive prognosis, improvements are observed in dynamics and a natural lifestyle can be maintained as early as 3-4 months after the operation. For women who want to get pregnant, you must wait a period of time up to 3 years. In the future, childbirth is carried out exclusively by caesarean section in order to avoid rupture of the cicatricial link.
For the prevention of vaginal fistula measures are needed:
- treatment of chronic diseases
- treatment of diseases of the genitourinary system,
- timely examination of vaginal abnormalities, pelvic organs,
- conducting operations with qualified specialists,
- avoid gynecological operations for curettage of the vaginal cavity and further cicatricial level,
- timely diagnosis and treatment of infectious diseases of the vaginal mucosa,
- preventive measures of the urinary system on the basis of diet.
In order to avoid the occurrence of this disease, it is necessary to adhere to hygiene, visit the gynecologist with a frequency of not less than once a year and not start the treatment of diseases.
Vaginal fistula - a serious complication, often found in obstetrics and gynecology. The vaginal wall is in direct contact with the walls of the rectum and urinary organs, therefore, when a pathological message occurs between them, a fistulous defect is formed.
Among the fistulas of the vagina, there are vesicular vaginal, ureterovaginal, urethrovaginal, rectovaginal, colorectal, vaginal, small bowel vaginalis. The location of the vaginal fistula is divided into low (in the lower third of the vagina), medium (in the middle third) and high (in the upper third of the vagina). Most vaginal fistulas have an acquired character, and the characteristics of the development and clinical signs of the disease depend on the causes of the defect.
Causes of vaginal fistula
The most common traumatic vaginal fistula occurs as a result of damage to the intestinal wall, urinary tract and vagina during invasive procedures and operations in urology, proctology, obstetrics and gynecology. Urogenital fistulas usually are a complication of reconstructive operations for urethral diverticula, stress urinary incontinence, prolapse of the anterior wall and vaginal cysts, radical hysterectomy, supravaginal amputation of the uterus, etc.
Rectovaginal fistulas are more often formed as a result of obstetric trauma or trophic disorders in pathological births. Injury or rupture of the birth canal with the discrepancy between the size of the fetus, pelvic presentation of the fetus, operative delivery may be accompanied by damage to the walls of the vagina, rectum and her musculoskeletal system. The development of vaginal fistula may be based on prolonged ischemia and necrosis of soft tissues due to compression between the head of the fetus and the bones of the pelvis during prolonged labor and a prolonged anhydrous period.
Fistulas of an inflammatory nature are usually formed as a result of opening into the lumen of the vagina abscesses or perforation of acute paraproctitis or diverticulitis. Less commonly, burns (chemical, electrical), rectovaginal septal trauma, ectopia of the ureter, Crohn's disease, pelvic irradiation during radiation therapy, pelvic pelvic disease can be the causes of vaginal fistula.
Symptoms of vaginal fistula
For the vaginal fistula, as a rule, has a chronic, recurrent nature. When urinary fistula patients worried about involuntary partial or complete incontinence due to leakage from the vagina, frequent urinary tract infections. Observed maceration of the epidermis in the perineum and thighs, swelling and hyperemia of the vaginal mucosa.
Dribbling of urine while urinating is usually referred to as point or high-lying fistulas. When finding urethro-vaginal fistulas in the middle or proximal urethra, the urine can not be held either in the vertical or horizontal position of the patient. With the progression of pathology observed pain in the vagina and bladder. When entero-vaginal fistulas are characterized by complaints of gas incontinence (with point fistulas) and feces (with large fistulas), discharge of gas and feces through the vagina, burning and itching of the genitals due to irritation of the mucous membrane around the fistula.
Constant infection of the vagina from the rectum is manifested by frequent exacerbations of colpitis, vulvitis, causing pain in the perineum at rest and during sexual intercourse. Rectovaginal fistulae are often accompanied by gross cicatricial deformity of the posterior vaginal wall and perineum, failure of the pelvic floor muscles and a defect in the rectal sphincter.
In case of vaginal fistula of inflammatory inflammation, there can be a deterioration of the general condition, fever, pain in the lower abdomen and pubic region, radiating to the rectum or lower back, purulent leucorrhea, loose stools with an abundance of mucus and pus in feces, dysuria, pyuria, sometimes menuria. Symptoms of vaginal fistula cause physical discomfort and are often accompanied by psycho-emotional disorders.
Treatment of vaginal fistula
Tactics of treatment of vaginal fistula depends on the main characteristics of the fistula, the state of the surrounding tissues, pelvic floor muscles and rectal sphincter. Small cystovaginal fistulas can heal themselves after conservative treatment, the fistulae of the urethra and bladder can be closed by electrocoagulation.
With most urogenital fistulas, 3 to 6 months after injury, with relieving of inflammatory processes, surgical excision of cicatricial lesions in the fistula area is shown, followed by separate suturing of defects of the vaginal wall, bladder or urethra using patchwork plastics. In case of ureterovaginal fistula, ureterocystoneostomy is performed. Acute rectovaginal injuries are urgently eliminated within the first 18 hours: after pretreatment of the wound edges, nonviable tissues near the fistula are excised and the levator, rectum and vaginal walls are sutured in layers.
Surgical intervention in the formation of fistulas of the vagina and rectum is determined by the specific situation and is carried out by vaginal, perineal or rectal approaches, with a significant cicatricial lesion - laparotomic. After excision of the scar tissue and the fistulous opening, anterior levatoroplasty is performed, if necessary it is combined with vaginoplasty, sphincteroplasty is performed with a defect in the pulp with subsequent suturing of the intestinal and vaginal defects. In the cicatricial or purulent process in the area of the fistula, first for 2-3 months impose colostomy to discharge fecal masses from the area of the future operation.
Averages 25-30% of all urinary fistulas. They can be:
- ureteral-uterine, which are extremely rare,
As a traumatic complication, they are encountered during the carrying out of large-scale surgical interventions - mainly, due to a malignant neoplasm of the cervix. According to various statistical data, damage to the ureter during these operations is found in 1-12% of cases. These complications are caused not so much by the inaccuracies of the operating surgeon as by the changes in the anatomical relationships of the organs and tissues of the small pelvis that occur with tumor growth.
The most dangerous in this regard are tumors located in the wide ligament of the uterus, which grow out of the body or appendages of the uterus, since the anatomical changes in them are very variable, and the location of the ureter depends largely on the direction of growth of tumors. During operations in 80% of the damage to the ureter go unnoticed. Because of this, after surgery, various severe complications develop - purulent pyelonephritis, peritonitis, development of stricture (narrowing) of the ureter.
With this kind of pathology, patients are mostly worried about urine leakage. Depending on the onset of the onset of this symptom and the nature of the symptoms that preceded it, the doctor has the opportunity to make a preliminary (before the examination) conclusion about the nature of the surgical damage to the ureter - parietal wound, ligation, flashing. In the first case, for example, urine flowed into the surrounding soft tissues almost immediately and the temperature increase associated with it. 2-3 days after this, urine leakage occurs.
In case of accidental ligation of the ureter, a violation of urine outflow occurs, against the background of which necrosis (necrosis) of its wall develops. All this leads to severe pain in the lumbar region (in the area of the projection of the corresponding kidney) and subsequent increase in body temperature, while urine leakage occurs only on the 10th - 12th day. Regardless of the nature of the ureteral-vaginal fistula, spontaneous urination persists along with urine leakage.
Diagnosis is carried out on the basis of the listed symptoms, echographic examination of the kidneys, biochemical blood tests, general urine tests and urine tests according to Nechyporenko, endoscopic examination with the help of a ureteral endoscope. The principle of treatment consists in the surgical creation of a new connection of the ureter with the bladder or with the intestine.
Of the total number of urogenital fistulas, an average of 12%.They are usually formed after such gynecological operations, such as removal of a cyst of the anterior wall of the vagina or a cyst of a Hartner stroke (longitudinal duct of the epididymis of the ovary), anterior colporrhaphy. Less commonly, this is noted in obstetric practice, for example, after prolonged labor or surgery, injury to the urethra during the suturing of deep gaps in the soft tissues of the birth canal.
This condition is relatively difficult, since the pathological process affects not only the urethra, but also the entire sphincter apparatus of the bladder, that is, the sphincter itself and its auxiliary elements in the form of vascular formations and folds of the mucous membrane.
When forming a fistula, the patient complains of urine excretion from the vagina. If it is localized in the distal urethra, then the patient may have an arbitrary urination, but there is also a discharge of urine through the fistula. If it is located in the proximal or middle sections of the urethra, the urine cannot be held either upright or horizontal.
Diagnosis is based on the patient's complaints, as well as on visual detection and palpation examination of large fistulas. The presence of a small fistulous passage can be detected by inserting a metal probe into the external opening of the urethra, the end of which goes through the fistula, or by introducing into the bladder a physiological solution stained with methylene blue, which then flows through the fistula. Very small defects (point), located in the rumen, especially in the proximal third of the urethra, are diagnosed with vaginography or urethrocystoscopy.
Treatment consists of surgical excision and suturing of the urethral defect or in its new formation.
Bladder and Genital Fistula
They occur most frequently and make up about 65% of all urinary fistulas. They are formed mainly as a result of surgical intervention for certain severe obstetric conditions, when there is an urgent need to extract the fetus or remove the uterus due to bleeding, as well as during gynecological operations, mainly for ligamentous or cervical fibroids.
The defect can also be formed in the case of a widespread form of endometriosis, accompanied by involvement of the bladder, a malignant tumor of the cervix or the body of the uterus, purulent-inflammatory processes of the internal genital organs and the formation of secondary infiltrates of the para-bladder tissue that develop secondary in the presence of purulent inflammation in the uterus. Due to the widespread laparoscopic access during gynecological operations in the last 10–15 years, cases of vesicular-genital fistula of burn origin have begun to appear (due to the use of electrocoagulation).
This pathology, formed as a result of traumatic injury, clinically proceeds in a satisfactory condition, especially in the initial stages, unlike those of purulent-inflammatory etiology. In the latter case, the clinical symptoms consist in elevated body temperature, possible chills, pain over the bosom of varying severity with irradiation to the lumbar and thigh areas, dysuric disorders, discharge from the genital tract, often purulent, urine purulent, and sometimes in the development of menouria .
Cystic-genital fistulas, in turn, can be:
- blister uterine,
- blister cervical,
There are quite rare. They occur mainly after the pathological course of labor, obstetric and gynecological operations. According to many authors, they are most often formed as a result of cesarean section in the lower segment of the uterus. At the same time, as a result of fetal extraction through a relatively small incision, uterine ruptures occur, involving the posterior wall of the bladder.
The main clinical manifestations of the cystic-uterine defect are amenorrhea and cyclic hematuria, or menouria (leakage of urine from the vagina during menstruation).
Treatment of patients with this type of pathology is a difficult task. Most authors prefer the closure of defects in the bladder and uterus and the placement of an omentum between them.
Among the defects of this group are characterized by the highest frequency of occurrence. They are divided into:
- low, which are localized in or below the cystic triangle,
- middle level - located in the zone of the cystic triangle in the area of the urethral fold,
- high - localized above folds.
The main symptom is the constant involuntary leakage of urine from the vagina. It can occur in the first postoperative days, if the cause was unnoticed during surgery, bladder injury. If the cause was a violation of the trophic (power) section of the bladder wall (for example, a burn during electrocoagulation), then leakage may occur after 7-11 days, depending on the degree and extent of the eating disorder.
Dribbling of urine is possible both in the complete absence of spontaneous urination, and at its preservation. This feature allows you to first conclude that the approximate diameter of the fistula and its localization: urination can be maintained with a high or / and point fistula. The progression of the pathological process with time leads to pain in the vagina and above the pubis (in the bladder area). The general condition is usually satisfactory, but the development of psycho-emotional disorders due to urine leakage is often noted.
Diagnosis of vesicovaginal fistulas is carried out on the basis of collecting the history of the disease and gynecological examination in the mirrors, in which in most cases the fistulous opening is well visualized. In a doubtful case, it is possible to use the sounding of the stroke, however, with its crimped form, it may be unreliable.
In addition, it is necessary to carry out a three-tamper test (in case of a combination of urine leakage from the vagina with the presence of arbitrary urination), cystoscopy or vaginography, ultrasound of the kidneys and bladder. In cases of detection of pathological changes during ultrasound or cystoscopy, it is additionally recommended to conduct excretory urography, cystography in 3 projections and radioisotope examination of the kidneys.
These methods make it possible to establish the presence of a fistula, its character, shape and localization, assess the state of the surrounding tissues, as well as the state of the upper urinary tract.
At the initial stage of treatment of vesicovaginal fistulas, an attempt is usually made to use a conservative method. It consists in installing a catheter in the bladder for up to 10 days, during which the bubble is washed with antiseptic solutions. In addition, tampons impregnated with antiseptic ointments are inserted into the vagina, antibacterial drugs and uroseptics are prescribed. The effect of such therapy in the form of scarring of small fistulas is noted in 2-3%.
In other cases, surgical treatment with vaginal or abdominal access is indicated. There are many surgical techniques for closing a fistula. The nature of the operational benefit depends on the localization of the defect and associated pathological changes in the genitals. Most surgeons use the technique of splitting tissues, removing scar tissue in the area of the fistulous opening and connecting its edges.
Bladder-neck and vesico-cervical-vaginal
Characterized by a variety of symptoms, which depends mainly on their topographical location. A permanent symptom of cystic cervical fistulas is menouria, in the absence of urinary incontinence, and vesicular cervical-vaginal fistulas are urinary incontinence.
Measures to prevent urinogenital fistula in women consist in preventing obstetric and gynecological injuries and inflammatory processes, predicting the course of pregnancy and childbirth as much as possible, in timely treatment of diseases of the urinary tract and genital organs, professional implementation of surgical interventions, as well as effective treatment of complications arising in the postoperative period.