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Vesicovaginal Fistula Treatment in India

 

A fistula is an abnormal connection formed as a result of an injury, disorder or congenital (birth) defect which results in the formation of a passageway or duct between cavities, hollow organs and body surface, between hollow organs and abscesses.

Vesicovaginal fistula (also known as VVF) is a type of urogenital fistula (UGF). This is a fistula which connects the bladder and the vagina. This fistula results in constant and uncontrolled leakage of urine from the bladder directly into the vagina. Apart from this embarrassing situation, this condition also has an adverse effect on the emotional well-being of the patient.

Unsuccessful pelvic surgery often results in this complication. Over 50% of the fistulas form after a hysterectomy for a benign disorder.

What are the symptoms of Vesicovaginal Fistula?

A vaginal fistula is a painless condition but they cause leakage of urine and feces into the vagina (incontinence), which can lead to embarrassing situations.

These are the three main symptoms seen as a result of Vesicovaginal fistula (VVF):

• Urinary incontinence

• Irritation/itching in vulva with recurring UTI

• Hematuria or unidentifiable discharge from the vagina

How is Vesicovaginal fistula (VVF) diagnoses?

Vesicovaginal fistula is quite clearly identified through its visible signs. The doctor will discuss the exact symptoms, previous surgeries or trauma that could have resulted in the development of the fistula.

These are the diagnostic tests needed to determine the VVF development and its details:

• Dye test – This includes injecting a contrast dye into the bladder before taking x-ray images while asking you to cough or sit down. Signs of leakage may also be seen on tampons after a period of physical exercise.

• Cystoscopy – A cystoscope is used to view the vagina, bladder and ureters clearly.

• Retrograde Pyelogram – The doctor will inject a dye into the ureter, through the bladder, before taking x-ray images. This shows any leakage between the vagina and the ureter.

• Fistulogram – This is a special x-ray test of the fistula which also helps to detect if there are multiple fistulas.

• Flexible Sigmoidoscopy/Anoscopy – A sigmoidoscope is inserted to inspect the rectum and anus for fistulas.

What are the causes of Vesicovaginal Fistula (VVF)?

These are the known causes which develop Vesicovaginal Fistula (VVF) in a woman:

• Childbirth – It is also called as obstetric fistula. Around 80% of VVF cases develop due to prolonged labor where the unborn baby presses against the pelvis and disrupts the normal blood flow to the Vesicovaginal wall, resulting in dead tissue (tissue necrosis). This creates a hole in the tissue wall between the bladder and the vagina.

• Hysterectomy/other gynecological pelvic surgeries – At times, VVF can develop as a complication after a hysterectomy or another pelvic gynecological surgery. Myomectomy and other prolonged tumor removal surgeries are also the cause of VVF in some cases. This can also develop following radiation therapy for cancer treatment.

• Violent rape – Violent sexual penetration can also result in development of VVF in a woman.

• Gishiri – Also known as ‘salt cut’, this traditional practice is also known to cause VVF in sufferers of ‘Gishiri’ disease.

• Angurya – The practice of scraping the vagina and surrounding areas to remove the clitoris (part of female genital mutilation practices).

• Secondary VVF – This may be the result of STDs, tuberculosis, bladder stones, diabetes, endometriosis and anatomic abnormality in the pelvis.

The physiological and psychological that result from VVF need to be remedied as soon as possible to regain a better quality of life for the affected woman.

What are the types of Vesicovaginal Fistula (VVF)?

Vesicovaginal fistula (VVF) is classified into different types depending on the location, cause, severity and site of the blockage.

These are the classifications of Vesicovaginal fistula (VVF):

• Simple Vesicovaginal fistula – In this, the length of the vagina is normal and the fistula is less than 2 cm in length. There is also no prior surgery or radiation treatment done for cervical or vaginal malignancy. This is comparatively easier to repair.

• Complex Vesicovaginal Fistula – In this the length of the vagina is shortened and a pelvic malignancy has previously been treated with radiation. The fistula is also longer than 3 cm. This fistula is harder to repair.

What is the treatment for Vesicovaginal Fistula (VVF)?

VVF is most commonly caused as a complication from a gynecological or obstetric vaginal or abdominal surgical procedure. The main aim of the treatment is to surgically repair the Vesicovaginal fistula (VVF). Apart from this the treatment also focuses on building adequate exposure, wide mobilization of the vagina and the bladder, good homeostasis, cutting and removing foreign bodies in the vagina and effectively sealing the bladder and vaginal wall closed.

A Foley’s catheter may be attached for around 10 to 14 days following the surgery to help drain the fluid from the bladder.
There are mainly types of approach utilized for performing the surgical treatment of Vesicovaginal fistula (VVF):

• Vaginal approach – Also known as a Transvaginal approach, the surgical repair of the VVF is performed by dissecting the tissue wall of the vagina and the fistula tract. This helps to close the bladder mucosa using solvent sutures. Additional vaginal tissue is removed and the vaginal mucosa is closed, which completes the repair.

• Abdominal approach – In this, an incision is made around the belly button which allows access into the peritoneal cavity (abdominal cavity). This surgical approach is useful in repairing larger-sized fistulas or multiple numbers of VVF. A cystoscope may be used to attach a catheter to the fistulous tract. This approach also helps to sufficiently expose the bladder, place ureteral stents before closing the abdominal incision using fine sutures.

How to prepare for the surgical treatment of Vesicovaginal Fistula (VVF)?

Before surgery

• Bring your medicine bottles or a list of your medicines when you see your caregiver. Tell your caregiver if you are allergic to any medicine. Tell your caregiver if you use any herbs, food supplements, or over-the-counter medicine.

• Ask your caregiver if you need to stop using aspirin or any other prescribed or over-the-counter medicine before your procedure or surgery.

• Antibiotics may be given to help treat or prevent an infection caused by germs called bacteria.

• Your caregiver may do a pelvic exam. During a pelvic exam, your caregiver inserts a gloved finger into your vagina. He also may use a special tool called a speculum to help see your cervix.

• You may need to have urine and blood tests done. You may need to have a cystoscopy so your caregiver can look inside your bladder. Your caregiver also can check the size and location of your fistula during the cystoscopy. You also may need an intravenous pyelogram (IVP). An IVP is an x-ray of your kidneys, bladder, and ureters (tubes that carry urine). Ask your caregiver for more information about these and other tests that you may need. Write down the date, time, and location of each test.

The Night Before Your Surgery -

• Ask caregivers about directions for eating and drinking.

• Your bowel may need to be emptied and cleaned out before your surgery. Ask your caregiver for information on how to do this at home.

The Day of Your Surgery -

• Write down the correct date, time, and location of your surgery.

• Ask your caregiver before taking any medicine on the day of your surgery. These medicines include insulin, diabetic pills, high blood pressure pills, or heart pills. Bring a list of all the medicines you take, or your pill bottles, with you to the hospital.

• You or a close family member will be asked to sign a legal document called a consent form. It gives caregivers permission to do the procedure or surgery. It also explains the problems that may happen, and your choices. Make sure all your questions are answered before you sign this form.

• An anesthesiologist may talk to you before your surgery. This caregiver may give you medicine to make you sleepy before your procedure or surgery. Tell your caregiver if you or anyone in your family has had a problem using anesthesia in the past.

What are the post-surgical instructions after treatment of Vesicovaginal Fistula (VVF)?

At the hospital

Initially, following the surgery, the medical staff at the hospital will help with recovering from the anesthetic effects as well as help to eat and move around. Painkillers may be prescribed in case of excessive pain. The catheter will remain attached for a few weeks following the surgery.

At your home

Once you reach home, ensure to take any prescribed medication on time to prevent infection and alleviate pain. Avoid lifting heavy objects or performing heavy physical exercise for a few weeks following the surgery. Drink around 8 to 10 glasses of water every day to maintain sufficient fluid level in the body.

Abstain from sex till the doctor advises against it. Follow the instructions for showering, bathing, etc precisely as given by the doctor.

What is the prognosis of surgical treatment of Vesicovaginal Fistula (VVF)?

The success rate of surgical repair of Vesicovaginal fistula (VVF) is significant, over 90%. In case of complex Vesicovaginal fistula repair, the success rate of the treatment is almost 90% when done by experienced surgeons.

How to prevent Vesicovaginal Fistula (VVF)?

There is no definite way to prevent the formation of Vesicovaginal fistula (VVF). Even though the surgeon may be careful while performing a cervical or vaginal gynecological/obstetric surgery, there is a chance of bladder injury.

An untreated and undetected bladder injury can often form VVF. Apart from this, cancer and severe endometriosis make the surgical procedures more complicated and increase the risk of development of VVF. Even radiation therapy for cancer treatment is known to cause VVF in some cases.

What are the advantages of surgical treatment of Vesicovaginal Fistula (VVF)?

There is a higher success rate for efficient repair of Vesicovaginal Fistula (VVF) using any of the surgical approach. In case the fistula recurs, which is considerably rare, a repeat procedure can help to treat it efficiently.

In case the VVF develops after radiation treatment, the surgeon will create a urinary diversion to prevent the embarrassing symptoms from recurring. Apart from the physiological benefits, surgical treatment of Vesicovaginal Fistula (VVF) also results in improvement of the psychological well-being in the patient which is necessary for a better quality of life.

Are there any risks associated with surgical treatment of Vesicovaginal Fistula (VVF)?

These are the several risks that may be seen in rare cases following a surgical repair of Vesicovaginal Fistula (VVF):

• Transient VUR and bladder spasm

• Ureteral stricture

• Recurring fistula

• Excessive bleeding

• Infection

• Thrombo-embolism

• Injury to other surrounding organs

The doctor and surgeon will take every possible precaution to prevent these risks of additional complications from arising.

 

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