Fistulas

Question 1

Fistula- A _________ between ______________________________

Answer 1

communication

two epithelial surfaces

Question 2

VVF- _________ leakage of _______ via the vagina _________ which (can or cannot?) be stopped or cleaned

Answer 2

Continuous; urine

24hours; cannot

Question 3

RVF- _____________ passing of ______ from the vagina which (can or cannot?) be stopped and cleaned.

Answer 3

Intermittent

stool; can

Question 4

( RVF or VVF ?) patients are far less socially acceptable than those
with (RVF or VVF?)

Answer 4

VVF

RVF

Question 5

NATIONAL OBSTETRIC FISTULA
CENTRES

List them

Answer 5

KATSINA
BAUCHI
ABAKILIKI

Question 6

Causes of Fistula

_____________ from ________________ labour

Answer 6

Pressure necrosis

prolonged obstructed

Question 7

Causes of Fistula

Anteriorly
1. _________________ wall and _________________
2. ________ lip of the _______ + _______________ (necrosis @ a higher level)

Answer 7

anterior vaginal ; bladder neck

Anterior ; cervix

Bladder trigone

Question 8

Causes of fistula

Anterior

Baby’s head is _______ , back of pubis symphysis is _______ – the head is wedged within the cavity causing __________ on the adjoining tissue (_________________ , _________________)»_space;> devoid of blood supply»_space;> devitalised»_space;> necrosis

Answer 8

bony; bony

pressure

posterior wall of bladder

anterior wall of vagina

Question 9

Causes of fistula

Posteriorly
The __________ is compressed between the _________________ and fetal presenting part.

______________ area separates as a slough between ____-____ days of puerperium

Answer 9

rectum

sacral promontory

Devitalized; 3rd-10th

Question 10

Causes of Fistula (OTHERS)

______________ during operative vaginal deliveries.e.g Forceps, Destructive surgery, symphysiotomy

___________, ______________

Other surgical procedures :Total abdominal, hysterectomy, Wertheim’s Operation, ___________ , vaginal hysterectomy, Manchester repair

Answer 10

Direct trauma

Uterine rupture

Caesarean section

Colporrhaphy

Question 11

Causes of Fistula

Infections –________________________ (inflammatory process involves fistulation within genital tract)

Radiation necrosis- Intracavity radium for ___________________ (may be seen in developed countries)

Answer 11

Lymphogranuloma venerum

Carcinoma of the cervix

Question 12

PREVALENCE/ INCIDENCE
u Isolated VVF-_____% of cases of fistula
u Combined VVF/RVF –_______ % of patients
u Isolated RVF- _________ (______ is protective), unless its due to direct injury like a __________________________ that was not well repaired
uMISCELLANEOUS e.g ureteric fistula, uterus

Answer 12

85; 10-15

Very rare; sacral

4th degree perineal tear

Question 13

Classification of Fistula
(contd.)
Based on location
u Juxta-urethral fistula- __________ and __________
u Mid-vaginal fistula- _________ and ____________

u Juxta-cervical fistula – close to _________ and _________

Answer 13

bladder neck and proximal urethra

sphincter & trigone are not involved

sphincter and trigone

Question 14

Classification of fistula

u Very large fistula- A ___________________
u Vault fistula- after ____________
u Combined fistula- _________________

Answer 14

combination of the above 3 types

hysterectomy; VVF & RVF

Question 15

___________ fistula is easiest to repair

Answer 15

Mid-vaginal

Question 16

Classification of Fistula
This could be based on location, size or functional loss.
Based on size
u Small <_____cm
u Medium _____cm
u Large ______cm
u Extensive ______cm

Answer 16

2

2-3

4-5 ; ≥6

Question 17

Presentations of Fistulas

Presentation
______________ - VVF
______________ - UVF
__________ – RVF
__________– damage to the peroneal nerve

Answer 17

Total urinary incontinence

Partial urinary incontinence

Faecal incontinence; Foot drop

Question 18

Presentations of Fistulas

_________ of the vulvar and perineum – due to ammoniacal dermatitis from breakdown of urine by bacteria
Patient Profile- Poor socio-economic, low education, teenage, primip, obstructed labour, abandoned, Anaemia,
intercurrent infections (helminthiasis, pulmonary TB, UTI)

Answer 18

Ulcerations

Question 19

Physical examination
u Assess __________
u Assess for ______
u Check for evidence of _________
u Palpate the kidneys for enlargement/tenderness
u___________ around the vulva & upper thigh
u Vaginal examination (_________ examination first – because along with the fistulation, there may be associated scar tissue formed causing constriction of vagina; do this first to know ___________)
u Speculum- left lateral or Sim position, Sim’s speculum – enables you to examine the entire length of vagina both
anteriorly and posteriorly.

Answer 19

nutritional status; anemia; inter-current infections

Excoriation; Digital

what size of speculum to use

Question 20

Investigations
u Assess FBC (Hb, WBC)
u Serum Electrolytes/Urea/Creatinine
u Catheter specimen urine microscopy culture and sensitivity – NOT _________ SAMPLE OF URINE (as patient cannot void voluntarily)!!!
u Chest X-ray to rule out _________
u____________
u X-ray of the pelvis to detect _______

Answer 20

MID STREAM ; Pulmonary Tuberculosis

Intravenous urogram; calculi

Question 21

VVF has a ____________ appearance on X-ray

Answer 21

CUP AND SAUCER

Question 22

Early Management of Urinary
fistula
u Conservative management - ___________for _______ – rests the bladder, weakness will not breakdown; causes healing
u Correct anaemia - hematinics
u Correct sepsis - antibiotics
u Improve morale/ psychology of the patient
u Attend to bedsores, foot drop and other challenges
u Hygiene

Answer 22

In-dwelling catheter ; 6 weeks

Question 23

Benefits of early
management
u Slough ______ – if due to prolonged obstructed labour and woman comes in 2 weeks later, ____________ to reduce the size, before operating.
u Inflammation subsides
u Improved local blood supply
u Better tissue planes
After ___________ of initial injury, the repair is done
For ureteric injuries – _______ repair or wait for ________

Answer 23

separates; put in a catheter

2-3 months

Immediate

3-4 weeks

Question 24

Pre-operative treatment
u High protein diet
u Improve general health
u Iron supplementation- aim at Hb ≥10gm/dl
u Give anti-helminthics
u Vulva dermatitis – Apply ______ or _______ (Vaseline may also be used). These serve as barrier to —————- from urine
u Treat infections- UTI, PTB

Answer 24

zinc ; Castor oil

ammoniacal dermatitis

Question 25

REPAIR AIM TO CLOSE FISTULA WITHOUT ________ APPROACH- ________ (preferred by gynecologist) OR __________ (preferred by urologists) SEPARATE VAGINAL WALL FROM BLADDER WALL CLOSE BLADDER DEFECT IN ________ THEN CLOSE THE VAGINA IN _________ DIFFICULT CASES MAY NEED GRAFTS OR URINARY DIVERSION

Answer 25

TENSION; VAGINAL; ABDOMINAL 2 LAYERS; 1 LAYER

Question 26

Post Operative care u Catheter drainage (__________ to reduce risk of infection) – 10 -14 days (no ________ over the repair) u Urine output should be 2-3 liters/ 24 hours. Do auto-irrigation (give adequate fluids) u Antibiotics to prevent infection u Avoiding __________ - Liquid paraffin from second day of surgery u Bladder drill before catheter removal – clamp catheter every 1 hour, then 2 hours, then 4 hours. Once she can tolerate 4 hours, that’s good. u Perineal care

Answer 26

silicon foley’s; tension constipation

Question 27

POST OPERATIVE CARE Test of cure u Old u New Instruction on discharge u No ______ for ________ after repair u Subsequent delivery is via ______________

Answer 27

sex for 3 months caesarean section

Question 28

Recto-vaginal fistula u This is classified into u High RVF – _________________ u Low RVF- _________________

Answer 28

above the pelvic floor below the pelvic floor

Question 29

Recto-vaginal fistula _____ days to surgery, __________ starts with low- residue diet (____ ), water, ducolax, antibiotics u To soften the stool, __________ is given p.o.

Answer 29

3 ; bowel preparation pap ; liquid paraffin

Question 30

REPAIR OF RVF u Primary repair- done ________ , if third degree perineal laceration, it must be done under ___________/__________ and good light. Usually, external anal sphincter may be ___________ when torn; has to be searched for to put it together. u Delayed repair

Answer 30

immediately; general anaesthesia/spinal anaesthesia retracted

Question 31

Post operative complications u Difficulties with _____________ u Urinary _________ u Vaginal bleeding u_________ into the bladder u Ureteric obstruction – particularly in the ___________ ones as ureteric orifices are close by. u __________ of the repair

Answer 31

bladder drainage; infection; Hemorrhage juxta-cervical; Breakdown

Question 32

Prevention of Fistula Pressure necrosis u Efficient obstetrics care u Identify and terminate ____________ u ________ the urinary bladder if prolonged obstruction has occurred u Control sepsis with antibiotics Surgical injuries u Surgeons should have the surgical competence of the procedure they are about to undertake – adequate training and supervision.

Answer 32

prolonged labour Rest