Sample Chapter 6

8/17/2019 Sample Chapter 6

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URINARY PROBLEMS IN

GYNAECOLOGY & TRAUMATIC FISTULAS

Q U E S T I O N S

6

1. Most common cause of vesicovaginal fistula in

India is : [AIIMS Nov. 02]

a. Gynae surgery

b. Irradiation

c. Obstructed labour

d. Trauma

2. Kam la , a 48 ye ars o ld la dy unde rw ent

hysterectomy. On the seventh day, she developed

fever, burning micturation and continuous urinary

dribbling. She can also pass urine voluntarily. The

diagnosis is : [AIIMS May 01]

a. Vesico vaginal fistula

b. Urge incontinence

c. Stress incontinence

d. Uretero-vaginal fistula

3. The most appropriate method for collecting urine

for culture in case of vesicovaginal fistula is :

a. Suprapubic needle aspiration [AI 04]

b. Midstream clean catch

c. Foley’s catheterisation

d. Sterile speculum

4. Most useful investigation for VVF is: [AI 10]

a. Three swab test

b. Cystoscopy

c. Urine culture

d. IVP

5. A 52 year old lady with VVF af ter abdominal

hysterectomy is not responding to conservativemanagement, most useful important next

investigation is: [AI 2010]

a. Triple Swab test

b. Urine culture

c. Cystoscopy

d. IVP

6. Post partum VVF is best repaired after :

a. 6 weeks [AIIMS 87]

b. 8 weeks

c. 3 months

d. 6 months7. Chassar Moir technique is used in : [AMU 05]

a. VVF

b. Stress incontinence

c. Urethrocoele

d. Enterocoele


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6Urinary Problems in Gynaecology & Traumatic Fistulas

103

8. In a case of incontinence of urine, dye filled into

the urinary bladder does not stain the pad in the

vagina, yet the pad is soaked with clear urine. Most

likely diagnosis is : [UPSC 00]

a. VVFb. Uretero – vaginal fistula

c. Urinary stress incontinence

d. Urethero – vaginal fistula

9. Commonest site of obstetric injury leading to

uretero vaginal fistula : [PGI 96]

a. Infundibulo pelvic ligament

b. Vaginal vault

c. Ureteric tunnel

d. Below cardinal ligament where uterine artery crosses

10. Ureter is identified at operation by : [AIIMS 96]

a. Rich arterial plexusb. Peristaltic movement

c. Relation to lumber plexus

d. Accompanied by renal vein

11. In women with ureterovaginal fistula, the following

statements are true except : [J & K 05]

a. Produces free fluid in abdominal cavity

b. 40% heals spontaneously

c. It is associated with hydronephrosis on affected side

d. Should be repaired as soon as diagnosed on IVP

12. A case of obstructed labour which was delivered

by caesarian section complains of cyclical passage

of menstrual blood in urine. Which is the most likelysite of fistula : [AI 04]

a. Uretherovaginal

b. Vesico-vaginal

c. Vesico-uterine

d. Uretero-uterine

13. Multipara With Lscs, Presents With Cyclical

Hematuria, Diagnosis can be: [PGI Dec 08]

a. VVF

b. UVF

c. Bladder Endometriosis

d. Ca. Cervix

14. Patient of Rectovaginal fistula should be initially

treated with : [AI 05]

a. Colostomy

b. Primary repair

c. Colporrhaphy

d. Anterior resection

15. A 55 year old woman has recurrent urinary retention

after a hysterectomy done for a huge fibroid. The

most likely cause is : [AI 03]

a. Atrophic and stenotic urethra

b. Lumber disc prolapse

c. Injury to bladder neck

d. Injury to hypogastric plexi

16. The recommended non surgical treatment of stress

incontinence is: [AI 09]

a. Pelvic Floor Muscle Exercises

b. Bladder Training

c. Electrical stimulation

d. Vaginal cone/weights

17. Kelly’s plication operation is done in :

a. Stress incontinence [PGI June 05]

b. Vault prolapse

c. Rectal prolapse

d. Uterine prolapse

e. Cervical incontinence

18: Bonneys test demonstrates-

a. Stress urinary incontinence


c. Overflow

d. All of the above

19. Version I.

Which of the following surgeries for stress

incontinence has highest success rate: [AI 2011]a. Bursch colposuspension

b. Pereyra sling

c. Kelly’s stitch

d. Tension free vaginal tape (TVT)

19. Version II.

Among the surgeries to correct SUI, the long-term

success rate is maximum with:[All India 2002, 2011]

a. Burch’s colposupension

b. Stamey’s repair

c. Kelly’s stitch

d. Aldridge surgery

20. Treatment of genuine stress incontinence :

a. Anterior colporrhaphy [PGI Dec. 04]

b. Posterior colporrhaphy

c. Colposuspension

d. Pelvic floor exercise

e. Sling operation


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6 Self Assessment & Review Gynaecology

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21. The disadvantage of Marshall marchetti -Krantz

procedure compared with other surgical

alternatives for treatment of stress urinary

incontinence includes-

a. Urinary retention

b. Increased incidence of urinary tract infections

c. High failure rate

d. Osteitis pubis

22. Cause(s) of retention of urine in reproductive age

group : [PGI Dec. 00]

a. Cervical fibroid

b. Retroverted gravid uterus

c. Unilateral hydronephrosis

d. Severe UTI

e. Posterior urethral valve

23. A woman treated for infertility, presents with 6 week

amenorrhea with urinary retention. The most likely

etiology is : [AI 00]

a. Retroverted uterus

b. Pelvic hematocoele

c. Impacted Cervical Fibroid

d. Carcinoma Cervix

24. Which is true regarding retroverted uterus :

a. May present congenitally [PGI Dec. 01]

b. Associated with endometriosis

c. It is a cause of infertility

d. Causes menorrhagia

e. Associated with PID

25. Urinary bacterial count is < 105 /ml is insignificant in

all except : [AIIMS June 00]

a. Pregnancy

b. Healthy ambulatory male

c. In a setting of antibiotics treatment

d. Mid stream clean catch sample.


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Urinary Fistula’s

C H A P T E R

AT A

G L A N C E

M/C

Etiology

Chief Complaint

Methylene blue3 swab test

(M oirs test)

Investigation

Of choice

Mgt of

Choice- Surgery

Vesicovaginal Fistula

VVF is the m/c urinary fistula

In Developing countries -Obstructed labor

It is due to ischaemic necrosis so

develops 3-5days after delivery.

In Developed countries- pelvic surgery

Continuous dribbling of urine from vagina

+ No normal urge for urination

Middle cotton plug is wet with dye andurine (blue in colour)

Cystoscopy

Technique- Layer technique/ Latzko

repair/ chassar moir technique

-Time of surgery- If it is due to

obstructed labour repair should be doneafter 3 months.(so that infection and

inflammation subside)

If it is due to surgery

And is recognised within24hrs-

Immediate repair.

If recognised later-repair

after 3-6 months

Uretero Vaginal Fistula

Hysterectomy

Maximum risk is with

wertheims hysterectomy

Continous dribbling of urine

from vagina + normal urge for

urination

Uppermost cotton plug is wetwith urine but not with dye.

Other 2 cotton swabs are dry

Dye test with indigo carmine

demonstrates urinary

extravasation and identifies

the location of injury +

Cystoscopy

Boari Flap technique

As early as possible

Urethro Vaginal Fistula

No continuous leakage

but when patient

urinates, urine leaks

from urethra and vagina.

Lower most cotton plug iswet with dye, other two

are dry.


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URINE INCONTINENCE

– According to International continence society,” incontinence” is defined as the complaints of any involuntary

leakage of urine which is a social and hygienic problem to the patient.

Classification

↓↓ ↓

Urethral cause : Extra urethral

– Stress urine ↓ incontinence ↓ ↓

– Urge incontinence congenital Acquired

– Mixed incontinence e.g. etopic ureter ↓

– overflow incontinence urinary fistulas

Physiology of Micturition

Bladder Supply

↓↓ ↓

Sympathetic

Via T11 – L 2/ L3

Neuro transmitter

Nor epinephrine

Which acts on 2 types of receptors

α receptor – located on urethra (close urethra

and↑ Urine Storage and Continence)

β receptor- located on bladder

(↑tone of bladder and promote storage of urine)

Stress Urinary Incontinence

– Defined as involuntary escape of urine when intra abdominal pressure is increased as in

sneezing/coughing/laughing.

– M/C type of urine incontinence in women.

SUI Can be due to

↓↓ ↓

Bladder neck Intrinsic sphincter defectDescent (Including urethral (20-25%)

hypermobility) (75-80%)

Risk Factors

i. Vaginal delivery ii. Post menopausal atrophy

iii. Obesity/Pregnancy iv. Pelvic organ prolapse

Parasympathetic

Via – S2 – S4

neurotrarsmitter

Acetyl choline

↓acts via muscuranic receptors in

bladder

↓1. Contracts detrusor muscle

2. Relaxes Urethra

↓Promote bladder emptying


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Test for detecting stress incontinence-

Bonney’s test : In this test the is patient asked to insert two fingers , in the paraurethral region and the bladder

neck is lifted up, and then the patient is asked to cough. If SUI gets corrected , then it is due to bladder neck

desent .If SUI persists, it is due to sphincter defect.Marchetti test : is same as Bonney’s test, except that instead of fingers, two Allis forceps are used.

Q tip test : A sterile cotton swab is introduced into the level of bladder neck. Then the patient is asked to

strain.Marked upward elevation of cotton tip (>30°) indicates urethra hypermobility. Goniometer is used to measure

the urethero – vesicle angle.

Cystometry – Main objective is to rule out urge incontinence.

Normal Values:

• Residual urine less than 50mL

• First desire to void between 150 and 200mL

• Capacity of strong desire to void more than 400mL

• No detrusor contractions during filling despite provocation

• No leakage on coughing or on any provocation

• Voiding by voluntarily initiated and sustained detrusor contraction

• Flow rate during voiding more than 15mL/sec with a detrusor pressure less than 15cm of water during filling

and less than 70cm of water during voiding

Abnormal cystometry

If there is leak of urine in the absence of a rise in detrusor pressure, stress incontinence is diagnosed. Urge

incontinence is diagnosed during the filling phase if there are spontaneous or provoked detrusor contractions

while the woman is trying to inhibit micturition. Thus stress incontinence is actually a diagnosis by exclusion.

Management:

1st line of mgt: Pelvic floor exercise called as kiegels exercises.

Definative management : Surgical management.

The choice of surgery is usually between a retropubic urethropexy and a sling operation. These are the currently

employed first line operations for stress incontinence. In general with concomitant prolapse a vaginal route is

preferred and sling surgery is done. If the woman is undergoing a laparotomy for any other reason urethropexy is

preferred. This can also be done laporoscopically.

Retropubic Urethropexy (Abdominal Procedure)

It involves attaching the fascia around the urethra and bladder neck to a supporting structure in the anterior

pelvis. This elevates the blader neck to an intra-abdominal position. The main problem is postoperative voiding

dysfuncion, detrusor overactivity and pelvic organ prolapse.

Two types of surgeries can be done in retropubic urethropexy-

A. The Burch colposuspension-most commonly done urethropexy wherby the fascia at the level of bladder

neck are attached to the iliopectineal ligament or Cooper’s ligament. The success rates are as high as 90%.

B. The Marshall-Marchetti-Krantz or MMK involves attachment of the periurethral facia to the back of the pubicsympysis. A complication specific to this procedure is osteitis pubis and hence this procedure is no longer

used.

Sling operations

A sling is passed around the bladder neck and urethra and attached above to the anterior rectus facia so that a

supporting hammock is created for the urethra. The urethra is supported and also occluded when the intra-

abdominal pressure is increased, examples of this technique are-


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Tension free vaginal tape (TVT) and Trans Obturator Tape (TOT): Both TVT and TOT are currently being

widely used as primary operations for stress incontinence.

In TVT-a propylene mesh is placed at the midurethra through retropubic space whereas in TOT it is passed

through a midurethral vaginal incision medial to obturator foramen instead of through the retropubic space.

Note : The most common complication of TVT is bladder perforation(5%), most serious is bowel or vascular

injuries (both


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Investigations

1. Urine culture (to rule out infection)

2. Cystourethroscopy (to rule out causes like bladder tumor/calculus)

3. Cystometry

Management:

Urge incontinence is best treated by behavioural therapy and anti cholinergic drugs. (To decrease detrusor

contractions).

Anti cholinergic used are:

1. Tolterodine

2. Hyoscyamine

3. Oxybutynin

4. Dicyclomine

So friends now with this background – lets get on to the Q’s on fistulas and incontinence.

EXPLANATION & REFERENCES

1. Ans. is c i.e. Obstructed labour Ref. Shaw 15/e pg -184; William Gynae. 1/e, p 573

“In developing countries, 90% of genito urinary fistulas arise from obstetric trauma, specifically from

prolonged or obstructed labour.” ... William Gynae. 1/e, p 573

Most common Genital Fistula is vesico vaginal fistula and so above statement holds good for VVF also.

The fistula resulting from pressure during long and difficult labour always involve the trigone of the bladder Q .

Whereas – “In developed countries, latrogenic injury during pelvic surgery is responsible for 90% of VVF.

In industralised countries, hysterectomy is the most common surgical cause of VVF, accounting for

approximately 75% of fistula cases. Laparoscopic hysterectomies were associated with the greatest

incidence followed be abdominal and vaginal.” ... Williams Gynae. 1/e, p 573

Extra Edge :

Most common in fistulae

MC urinary fistula VesicovaginalQ

MC cause of VVF in india Obstructed labour Q

MC cause of Uretero Vaginal Fistula Injury to ureter after gynaecological operationQ

especially Wertheim’ hysterectomyQ

MC cause of Vesico Uterine fistula Cesarean sectionQ

MC cause of Recto Vaginal fistula Cesarean perineal tear Q

2. Ans. is d i.e. Uretero vaginal fistula Ref. Jeffcoate 7/e, p 263, 265

• Continuous dribbling of urine following hysterectomy points towards urinary fistulas as the diagnosis.

• In case of urinary fistulas, if the patient never needs to void as there is continous dribbling it signifies that the

fistula communicates with the bladder. If, there is filling and emptying of bladder along with the fistula, it suggests

a fistula opening into one ureter i.e. Uretero vaginal fistula.Q

• As far as urethral fistula are concerned, they give little trouble because the urethra is normally empty of urine.

However during micturition urine passes through the fistula and may then fill the vagina to dribble during body

movements for a short time afterwards.

• This patient is developing symptoms on the seventh day can be explained by : “Fistulas resulting from

accidental, surgical and obstetrical trauma are produced in two ways. They can be caused by direct injury

such as cuts and then they manifest themselves immediately by hematuria and incontinence. Alternatively

if they are the outcome of pressure necrosis or of ischemia, in such a case urinary incontinence, fever and

burning micturition develops 7-14 days after the accident.” ...Jeffcoate 7/e, p 263


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Before concluding let’s rule out other options as well :

• In stress incontinence, dribbling of urine occurs only when intrabdominal pressure is raised.

• In urge continence the patient has urge to void urine at a moment’s notice and she is unable to control her

bladder and passes urine instantly.

3. Ans. is c i.e. Foley’s Catheterisation Ref. Shaw 15/e pg -185; Dutta Gynae 5/e, p 404

“Urine culture is mandatory before surgery and infection should be treated. The urine is collected by

Catheterisation.” ... Shaw 14/e, p 167

In VVF

“Preoperative collection is best to be done through ureteric catheterisation.” ... Dutta 5/e, p 404

So friends undoubtedly – Ureteric catheterisation. (Don’t get confused – it is not Foley’s catheterisation) is the

best method for collecting urine for culture in a case of VVF. This option is not given, so, we will have to look for

next best option.

• “Urine collected through a sterile vaginal speculum will not serve the purpose because of contamination.

... Dutta Gynae 5/e, p 405 (Option “d”)

• ‘Midstream clean catch’ sample is also contaminated in vesicovaginal fistulas. (Option “b”)• Supra pubic aspiration done after proper cleansing and draping the patient with full bladder, is easy and next

best method of urine collection after ureteric catheterization. But the only prerequisite for this method of collection

is ‘A full bladder’ which cannot be fulfilled in a case of VVF as urine continuously dribbles from the vagina and

therefore bladder is never full. (Ruling out Option “a”)

By exclusion our answer is Foley’s catheterization, although chances of contamination are present in Foley’s

catheterization but they can be reduced if proper vaginal douching is done prior to collection of urine.

4. Ans. is b i.e. Cystoscopy

5. Ans. is c i.e. Cystoscopy

Ref. Principles & Practice of Obs & Gynae Vol. II for P-G’s 3/e by Pankaj Desai, Narendra Malhotra p 613, Telinde

9/e,p1104

According to Dutta Gynae and Shaws –

Most useful test for fistula is the 3 swab test and cystoscopy is not routinely done.

But according to higher textbooks – (Like Principles & Practice of Obs & Gynae for P.G 3/e by Pankaj Desai )

Evaluation of any fistula includes 3 steps –

A. Clinical Examination – which includes:

a. Pelvic Examination

b. The three swab vaginal test – It helps in diagnosing fistula and differentiating between the other varieties of

fistula

B. Imaging study – It serves three functions.

a. To ascertain that there is no ureteric involvement either during initial injury or due to subsequent fibrosisb. To examine the surrounding tissue planes for abscess formation or unresolved urinoma.

c. To search for residual malignancy in a post radiation fistula

A spiral CT with 3D reconstruction is now the standard of care.

C. Cystoscopy –

“Cystoscopy is indispensable.”

... Principles & practice of obs & gynae for PG’S 3/e, p-613- Pankaj Desai Narendra Malhotra


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Cystocopy is useful for knowing the:

• Number and size of VVF, with their exact localion in relation to the ureters and bladder neck.

• The state of the margins of the fistulas – If needed a biopsy can be taken from the margin of a post radiation

fistula.

6. Ans. is c i.e. 3 months

7. Ans. is a i.e. VVF Ref. Shaw 15/e pg -186, 187; Dutta Gynae. 5/e, p 405

Management of VVF is : Surgical management :

Timing of surgery –

(a) Small urinary fistulas sometimes heal spontaneously during the first few weeks.

(b) However in a case of established fistula – it is better to wait for about 3 months Q for all tissue inflammation to

subside. If one attempt fails to heal fistula, second attempt is done after 3 months.Q

C) In fistulas following surgery waiting period is 3-6 months.

(d) In fistulas following radiation : 6 months to 2 years time can be taken before inflammation subsides.

Techniques of Repair –

• Layer technique

• Latzko procedure(for fistulas following hysterectomy)

• Chassar Moir technique.Q

Postop Management –

• Continuous bladder drainage for 14 daysQ .

• Antibiotic coverage.

• No vaginal examination, P/S, intercourse x 3 months.

• Avoid pregnancy for 2 years.

• In pregnancy after repair of vaginal fistula – elective cesarean is done.Q

Extra Edge :

This question is an old one so here answer will be 3 months but if this question is repeated now remember the

following lines from Williams Gynae. 1/e, 575 - 576 :

“Timing of repair : Traditional teaching recommends delayed repair of fistulas at 3 to 6 months afte injury.

However, this old dictum is probably no longer applicable. Most agree that unless there is severe infection or

acute signs of inflammation, waiting is not necessary . Early surgical intervention of uncomplicated fistulas does

not affect closure rates, yet appears to reduce social and psychological patient distress (Balivas, 1995). Fistulas

identified within the first 24 to 48 hours postoperatively can be safely repaired immediately with success rates of

90 to 100 percent.”

8. Ans. is b i.e. Uretero – vaginal fistula Ref. Dutta Gynae. 5/e, p 403, Shaw 15/e pg -186

The three swab test helps to confirm the Vesico Vaginal Fistula and to differentiate between vesico vaginalfistula, uretero vaginal and urethrovaginal fistula.

Procedure of Three swab test – A catheter is introduced into the bladder through the urethra.

Three cotton swabs are placed in the vagina as follows :

• One at vault,

• One at the middle

• One just above the introitus.


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Methylene blue dye is instilled into the bladder through a rubber catheter and swabs are removed for

inspection.

Observation Interpretation

1. Upper most swab soaked with urine but unstained with dye Uretero – vaginal fistulaQ

2. Upper and lower swab remain dry but the middle swab soaked with dye Vesico – vaginal fistulaQ

3. The upper two swab remain dry but lower one soaked with dye Urethro – vaginal fistulaQ

9. Ans. is d i.e. Below cardinal ligament where uterine artery crosses

10. Ans. is b i.e. Peristaltic movement Ref. Studd progress in Obs and GynaeVol 16 p 306

The crossing of the uterine vessels and ureter is at the level of internal os. Over here the ureter runs below the uterine

vessels (water below the bridge)and the distance between the ureter and uterine vessels is only 1.5 – 2 cm.

The ureter can get injured at all the sites mentioned in the question but during gynaecological surgeries the commonest

site of injury to ureter is where it crosses below the uterine arteries.

The next common site of injury is behind the infundibulopelvic ligament at the pelvic brim.

At operation ureter is recognized by :

1. Its pale glistening appearance

2. By a fine longitudinal plexus of vessels on its surface

3. More particularly by its peristaltic movement

4. By palpation between finger and thumb as a firm cord which, when escapes, gives a characteristic ‘snap’.

Absence of pulsation does not serve to identify a structure as ureter because veins and obliterated umblical artery

are also non pulsatile.

11. Ans. is b i.e. 40% heal spontaneously

Ref. Dutta Gynae 5/e, p 409-410; Telindes; Operative Gynaecology 9/e, p 1088 - 1089; Dew Hursts 7/e, p 543;

Shaw 15/e pg -187

• Uretero vaginal fistula most commonly follows trauma during pelvic surgeries like Total Abdominal Hysterectomy,

Wertheims hysterectomy and Vaginal hysterectomy.

Symptoms :

• Escape of urine through the vagina (True incontinence)Q

• Besides incontinence patient has also got the urge to pass urine and can pass urine normally.Q

• Patient may complain of :

– Flank pain

– Temperature

– Retroperitoneal fluid collection (caused by urinary leak into the abdominal cavity due to transection of the

ureter i.e. option ‘a’ is correct).

Investigation :1. Three swab test differentiates it from VVF.

2. I.V. Indigocarmine test : if the urine in the vagina is unstained following three swab test, indigocarmine is

injected intravenously, if urine becomes blue diagnosis of uretero – vaginal fistula is confirmed.

3. IVP : In case of ureteric transactions partial or complete, pyelography fails to show part or whole of the ureter

on the transected side and there may be pooling of dye in the peritoneal cavity.

4. USG : Following ureter ligation, USG may reveal hydronephrosis and dilated ureter proximal to the site of

block.

5. CT scan.


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Management :

Time of Repair -

• Ureteric injury/ureteric fistulas must be repaired as soon as the diagnosis is confirmed.

“The best chance of healing with primary repair is when reoperation is done within the first 48 hours. Our

opinion is that some form of immediate intervention must be undertaken no matter what the type of injury

has occurred”. ... Telinde Operative Gynecology 9/e, p 1088

“Uretero vaginal fistula should be repaired as early as possible to prevent upper urinary tract damage”

... Dewhurst Obs. & Gynae. 7/e, p 543

Technique of Repair –

a. When ureteral sheath is denuded for a short segment, it is best to do nothing.

b. When ureter is kinked due to a suture, it should be removed or deligated immediately.

c. If clamped tissue is healthy and viable, splinting/stenting is done for 7-10 days for further.

Ureteric transection :

a. Ureteroneocystostomy (implantation of ureter into the bladder) when injury is near bladder.b. Uretero ureterostomy : end to end anastomosis : done when ureter is dissected above mid pelvis.

c. Bladder flap operationQ (MODIFIED BOARI’SQ ) : done when ureter is short or injury is at the level of pelvic brim.

d. Segment of small intestine may be used for repair.

12. Ans. is c i.e. Vesico uterine Ref. Shaw 15/e pg -188; Jeffcoate 7/e, p 266

13. Ans. is b and c i.e. UVF (Uterovesical fistula) and Bladder endometriosis Ref. Shaw 15/e pg -188

The condition of cyclical passage of menstrual blood in urine is called as Menouria. ... Jeffcoate 7/e, p 266

Menouria :

• It is seen in uterovesical fistulaeQ

• Usually follows caesarean sectionQ

• The patient complains of hematuria/passage of menstrual discharge via urethra at the time of menstruation.

Patient does not have Urinary incontinence.Q

• Mensouria is seen when Utero vesical fistula opens into the uterus above the isthmus.Q

• The presence of the fistula can be demonstrated by hysterography (but not by cystography) and cystoscopy.Q

• Treatment is by abdominal repair.Q

• Another Important cause of cyclical hematuria is endometriosisQ of bladder.

14. Ans. is a i.e. Colostomy

Ref. Novak 14/e, p 704; 15/e p 711, Sabiston T.B. of Surgery 17/e, p 1500; Washington Manual of Surgery 3/e, p 279

Rectovaginal fistula is a communication between the epithelium lined Q surfaces of the rectum & the vagina.

Diagnosis :

• History of passing flatus, stool, mucus or blood per vagina.

• Diagnosis is made usually with :

– Speculum examination (P/S)

– Anoscopy / Proctoscopy

– Methylene blue enema


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• Endoanal ultrasound can determine the severity of trauma.

Classification :

Congenital Acquired

– due to congenital abnormalities – Trauma

– Inflammatory bowel disease

– Irradiation

– Neoplasia

– Infection

– Other causes

Now lets talk about Rectovaginal fistula that results due to obstetric injury :

Initial Treatment : A small rectovaginal fistula may be managed with conservative medical approach, in hope that

decreasing the fecal stream will allow closure of fistula. Large rectovaginal fistula for which there is no hope of

spontaneous closure, are best managed by performing initial diverting colostomy.Q

Ref. Novak 14/e, p 704; 15/e p 711

Definitive Treatment : However the initial management is either medical conservative approach (small fistula) or

a diverting colostomy (large fistula) to allow for the pelvic inflammation to subside, but the definitive treatment is

surgical repair.

If even after several months (3-6 months) of conservative approach Fistula does not heal, surgical repair is done.

15. Ans. is d i.e. Injury to hypogastric plexii Ref. Jeffcoate 7/e, p 857

Retention of urine in females can be explained by one of the four mechanisms.

Failure of Detrusor Interference with Spasm of external Obstruction

muscle to contract the opening of urethral sphincter of Urethra

internal sphincter

• Inhibition of detrusor Due to Due to Due to

muscle due to emotional • Retroverted gravid • Nervousness • Congenital atresia

upsets like hysteria, fear uterus, cervical • Perineal injuries • Foreign body /

• Paralysis of excitatory leiomyoma, impacted during child birth Calculi (Rare)

nerves to bladder due to ovarian cyst, • Operations on • Stenosis following

disease of CNS hematocolpos, hemat- perineum & perianal injury or infection

• Paralysis of excitatory ocoel crowding the tissues • Paraurethral cysts or

nerves to bladder due to the pelvic space, • Urethritis abscess

injury during extensive complicated ectopic • Neurological disease • Ca vulva, vagina &

pelvic surgery (like • Tight packing of vagina urethra

radical hysterectomy)Q • Buttressing of tissue • Angulation of urethra

• Bladder muscles become behind the urethro- in gross prolapse

atonic from over stretching vesical junction after cases.

surgery for stress in-

continence

• Ca cervix & Ca vagina

• Over enthusiastic

urethrocystopexy


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16. Ans. is a i.e. Pelvic Floor muscle Exercises

Ref. Dutta Gynae 5/e, p 586; Novak 14/e, p 875; Williams Gynae 1/e, p 525-526, Textbook of gynae, sheila

balakrishnan 1/e, p328

The most recommended non surgical treatment for stress incontinence is Pelvic floor muscle exercise.

“Pelvic floor muscle training should be offered as first line conservative management for stress

incontinance.” ... Novak’s 14/e, p 875; Dewhurst 10/e, p 486

“Pelvic floor exercises are the mainstay of conservative therapy for stress incontinance.”

... Urinary incontinence in primary care’ (2000)/73

Conservative management options for Stress Incontinance

• Pelvic floor muscle training exercises/Kiegels exercises (Mainstay/First line of management)

• Vaginal cones/Weights (also help strengthening the muscles)

• Electrical stimulation (alternative to pelvic exercises)

• Bladder training/Scheduled voiding (most useful for urge incontinence)

• Biofeedback

• Pharmacotherapy

– Duloxetine (First drug specifically developed and licensed for this indication. It is a selective serotonin and

norepinephrine reuptake inhibitor.)

– Tricyclic antidepressants

– α adrenergics (eg ephedrine)-to increase the tone of urethra.Main problem with these drugs is that theycan lead to hypertension.

– Estrogens (to be given in postmenopausal women who are atrophic)

Also know

• Avoiding Caffiene and carbonated drinks helps to control urine frequency and urgency.

17. Ans. is 17 is – a i.e. Stress incontinence

Ref: Shaw 14/e. p 174, Textbook of Gynae shiela Balakrishnan 1/e.p 330

As discussed in preceeding text, kellys plication/Kelley’s stitch was the standard first line of treatment for SUI

previously but due to low cure rates, it is not being done these days. 5 year failure rate for kellys plication is

approximately 50%

18. Ans. is a i:e Stress urinary incontinence Ref. Telinde 9/e, p 1035-1037

Bonney’s test is performed in the clinical evaluation of SUI. In the Bonney’s test, two fingers are placed in the

vagina at the UV junction on either side of the urethra and the bladder neck is elevated.

On straining or coughing, leakage of urine indicates of positive test. A positive test indicates that the SUI is due to

bladder neck descent and urethral hypermobility and can be corrected by bladder neck suspension surgeries.

A negative test i.e. leakage of urine-means SUI is due to intrinsic urethral sphincteric deficiency and results of

performing bladder neck suspension surgery will not be good.

Note : Marchetti test is same as Bonney’s test, but two Allis forceps are used instead of fingers.

19. Version I

Ans. is d i.e. Tension Free Vaginal Taping (TVT):

Evidence Based Urology’ (Wiley Blackwell) 2010/193 ‘Pelvic Floor Dysfunction. A multidisciplinary Approach’

(Springer) 2006/117: Hernia Repair Sequalce (Springer) 2010/440; Assessing and Managing A cutely III Adult

Surgery Patient’ (John Wiley and Sons) 2007/182


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19. Version II

Ans. is a i:e Bursch colpo suspension Ref. Telinde 9/e, p 1052-1056

As discussed in preceding text SUI is managed basically by performing either of the two surgeries viz-

1. Burch colposuspension

2. Tension free vaginal tapes/tension free obturator tapes.

The rates of success of these two surgeries are comparable, so if either of them is given in options, we will chose

it.

So in version II- Answer is Burch colposuspension Telinde, 9/e, p 1050-6.

Procedure Long-Term Success Rate (%)

Burch’s colposuspension 89.5

Stamey’s repair 85

Kelly’s repair 50-60

Aldridge Repair 85

Now suppose both Burch colposuspension and TVT is given (Like in version I), then remember-

Tension Free Vaginal Tape (TVT) has emerged as the treatment of choice for genuine stress incontinence in

recent years

Tension Free Vaginal Tape (TVT) is a simple procedure that may be performed under local anesthesia, has a

decreased operative and recovery time, and is as effective as ‘Burch colposuspension’ which was earlier considered

the procedure of choice.

‘A number of surgical procedures have been developed to treat genuine stress incontinence and most aim to

elevate and support the bladder neck. Burch colposuspension was the procedure of choice, but in recent years

this has been superseded by the ‘Tension free Vaginal Tape’ which is showing comparable results and is less

invasive’ Ref. Assessing and managing Acutely III Adult Surgery Patient’ (John Wiley and sonsd) 2007/440

Tension Free Vaginal Tape (TVT)

• Tension Free Vagina Tape (TVT) is a type of suburethral sling that does not have typical ‘suspension sling’ like

mechanism of action.

• TVT involves placement of synthetic polypropylene mesh/tape under the urethra. The sling is placed at the

level of mid-urethra (midurethral sling)

• TVT is a simple procedure that can be performed under local anesthesia, and has the advantage of decreased

operative time and decreased recovery time, while providing a good outcome.

• TVT is believed to be as effective as Burch’s colposuspenstion with cure rates approaching > 80%.

20. Ans. is a, c , d and e i.e. anterior colporrhaphy, colposuspension, pelvic floor excercises and sling operation.

Ref. Shaw 14/e, p 174, Dutta gynae 5/e p387 – 389, Textbook of gynae, shielaBalakrishnan 1/e, p 329 - 330

As explained in preceeding text:

– Pelvic floor exercises – Sling operation

– Colposuspension (Burch) are all done for management of SUI.

As far as anterior colporhaphy is concerned - kellys plication is anterior colporhaphy + Bladder neck repair, so I

have included it in correct option also.

21. Ans. is d i.e. Osteitis pubis

Ref. Telinde 9/e, p 1057-1058, Textbook of Gynae, Sheila Balakrishnan 1/e, p 329.


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Marshall – Marchetti-Krantz (MMK) procedure, involves the attachment of the periurethral tissue to the symphysis

pubuis. In approximately 3% of patients undergoing the procedure, osteitis pubis develops.

22. Ans. is a, b, and d i.e. Cervical fibroid; Retroverted Gravid uterus; and Severe UTI

Ref. Jeffcoate 7/e, p 855

Important gynaecological causes of acute retention :

Acute retention Other symptoms Diagnosis

Retention + Primary amenorrhea Hematocolposcopy

Retention + Secondary amenorrhea Retroverted gravid uterus

Retention + Menorrhagia Uterine leiomyoma (cervical fibroid)

Retention + No menstrual upset Ovarian or broad ligament tumor

Retention + Irregular bleeding Threatened abortion from a retroverted gravid

uterus or pelvic haematocoele or pelvic abscess

Besides the above causes Jeffcoate 6/e, p 855-858 gives an exhaustive list of other causes of urinary retention- in

which urethritis causing spasm of voluntary external urethral sphincter and acute urinary retention is given.

23. Ans. is c i.e. Impacted cervical fibroid Ref. Read below

The patient in the question :

• Was being treated for infertility.

• Now H/O a 6 weeks of amenorrhea.

• Presents with urinary retention.

The first diagnosis which comes in our mind is Retroverted gravid uterus.

Points which favour the diagnosis are : The woman is pregnant and has complain of urinary retention.

But friends, here it is important to understand that retroverted gravid uterus causes urinary retention at 14 - 15

weeks of gestation (not 6 weeks). ... Jeffcoate 7/e, p 299

So Option “a”. is ruled out

Option “b” Pelvic hematocele

“Pelvic hematocele is formed in a patient complaining of 6 weeks amenorrhea in case of ectopic pregnancy.”

... Jeffcoate 6/e, p 212

Though pelvic hematocele causes urine retention but then other symptoms (pain) and signs of ectopic pregnancy

should be present.

Option “c” Impacted cervical fibroid

“A cervical fibroid impacted in pouch of Douglas can cause retention of urine. The onset of retention is

acute and usually occurs immediately before menstruation, when the uterus is further enlarged by

congestion or during early pregnancy.” ... Jeffcoate 7/e, p 493

Fibroid is associated with infertility.

Thus an impacted cervical fibroid can explain all features seen this woman and is our option of choice.24. Ans. is b, c, d and e i.e. Associated with endometriosis; It is a cause of infertility; Causes menorrhagia;

and Associated with PID Ref. Shaw 15/e pg -345-347; Jeffcoate 7/e, p 295-297

The usual position of the uterus is one of anteversion and anteflexion, in which the body of the uterus is bent

forward at its junction with cervix.

Retroversion is a condition in which axis of cervix is directed upward and backward (instead of forward).


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Causes

Developmental Acquired

↓↓↓↓↓ ↓↓↓↓↓ ↓↓↓↓↓• Seen in 20% of patients Mobile retroversion Fixed retroversion

• Retroversion can never be • Prolapse • PID

congenital (it is always developmental) • Puerperium • Pelvic tumors

malformation as the uterus is without • Fibroid • Chocolate cyst of ovary

version and flexion at birth. • Ovarian cyst • Pelvic endometriosis

..... Jeffcoate 7/e, p 295 (pushes uterus backward)

Symptoms :

• Mobile retroversion is usually symptomless, main disadvantage being increased risk of perforation of the uterus

at the time of instrumentation.

Symptoms which can be seen are :

• Spasmodic dysmenorrheaQ

• Pelvic congestion syndrome causing :

– Congestive dysmenorrhea

– Polymenorrhagia

– Premenstrual low backache

– Dyspareunia (it is the most specific and genuine complain in case of retroversion)

– Leucorrhoea

• Infertility : as cervix is directed forward away from the seminal pool and the ejaculation of semen directly into the

external os.

• Abortion : can cause abortion between 10th to 14th week.

Treatment :

• If retroversion is mobile no treatment is required.

• In patient complaining of dyspareunia backache with retroverted uterus : Hodge pessary may be used to keep

uterus in anteverted position.

• Surgical management : – Modified Gilliams operation – Plication of round ligament Q

– Baldy webster operationQ

25. Ans. is c i.e. In a setting of antibiotic treatment Ref. Ananthnarayan 7/e, p 275 - 276

The concept of significant bacteriuria is given by Kass.

Significant bacteriuria refers to bacterial count more than 105/ml of urine

Prerequisite for collection of urine for culture.

• Clean voided mid stream samples of urine are employed for culture. Normal urine is sterile but during voiding

may become contaminated with genital commensals.

• Even under ideal conditions (urine collected by catheterisation), rate of urinary infection is 2%.

• In men, it is sufficient, if mid stream urine is collected after the prepuce is retracted and the glans penis

cleaned with wet cotton.• In women, anogenital toilet is more important and should consist of careful cleaning with soap and water.

Results :

– When bacterial count are more than 105/ml of urine, it is called Significant bacteriuria.

– Counts of 104/ml of urine are due to contamination during voiding and are of no significance.

– In a patient on antibiotic treatment with some bacteria like staph. aureus, even low counts i.e. < 10 5 /ml may be

significant.


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R E V I E W Q U E S T I O NS

1. Which of the following is the site of bladder injury

in abdominal hysterectomy is : (UP 01)

a. Anterior wall

b. Posterior wall

c. Medial wall

d. Lateral wall

Note : Posterior wall of bladder is in relation to the

anterior wall of vagina, therefore it is most likely to

be damaged

2. Commonest cause of genital fistulae in India :

a. Obstructed labour (UP 05)

b. Operation therapy

c. Radiotherapy

d. Laparoscopic injuries

[Ref. Shaw 15/e pg -183; Williams Gynae. 1/e,

p 573]

3. Vesicovaginal fistula repair surgery, the bladder

drainage should be done for : (UP 06)

a. 6 days

b. 10 days

c. 12 days

d. 14 days

[Ref. Shaw 15/e pg 187]

4. A 70 year old female pat ient presents with

recurrent dysuria, with urine routine microscopy

normal and urine culture negative. Treatment that

should be given is : (Delhi 99)

a. Local antifungal cream

b. Antibacterial chemotherapy

c. Hormone replacement therapy

d. None of the above

[Ref. Shaw 15/e pg -64]

5. Most common type of urinary fistula is :

a. Uterovaginal (Delhi 01)

b. Vesicovaginal

c. Urethrovaginal



6. Clinically vesicovaginal and ureterovaginal fistula

are differentiated by : (Delhi 04)

a. USG

b. IVP

c. Cystoscopy with dye

d. Methylene blue three swab test


7. Following procedure is used to differentiate

between vesicovaginal and ureterovaginal fistula:(Karnataka 2008)

a. IVP

b. Three swab methylene test

c. Micturating cystourethrography

d. Idigocarmine test

[Ref Smith urology 17/e, p 583, Shaw 15/e pg -186]

8. Commonest cause of VVF in India is :

a. Obstetric causes (DNB 06, 00)

b. Carcinoma cervix

c. Gynae. operations

d. Bladder stone[Ref. Shaw 15/e pg -184]

9. Vesicovagina l fistula by obstructed labour

manifests .......... of delivery : (DNB 00)

a. Within 24 hours

b. Within 72 hours

c. Within 1st week

d. After 1st week

[Ref. Jeffcoate 7/e, p 264]

10. Bonney’s test is used to demonstrate :

(DNB 99, 91)

a. Stress incontinence


c. Fibroidsd. True incontinence


Answer 1. b. Posterior ... 2. a. Obstructed ... 3. d. 14 days 4. c. Hormone ... 5. b. Vesicovaginal

6. d. Methylene ... 7. b. Three ... 8. a. Obstetric ... 9. d. After ... 10. a. Stress ...


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11. Stress incontinence is best corrected by :

a. Colpo-suspension (AI 94)

b. Hysterectomy

c. Bladder neck repair

d. Bladder exercise

[Ref. Dutta Gynae 5/e, p 387]

Note : It is the basis of treatment in kelley’s repair.

12. Important post operative management of a case

of VVF is : (AIIMS 84)

a. Continuous bladder drainage

b. Antibiotics

c. Complete bed rest

d. Early ambulation


13. Stress incontinence is repaired by ..... repair :

a. Manchester (DNB 95, PGI 88; UPSC 85 )

b. Fothergill’s

c. Marshall Marchatti Krantz

d. Bonney’s

[Ref. Dutta Gynae. 5/e, p 387; Shaw 15/e pg -193]

14. The causes of retention of urine in obstetrics and

gynaecology is / are : (PGI 85)

a. Impacted ovarian tumour

b. Retroversion

c. Hemotocolps

d. Cervical fibroid

e. All

[Ref. Shaw 15/e pg -175-176]

15. Manifestation of uretero vaginal fistula is :

a. Overflow incontinence (PGI 96)

b. Hydronephrosis

c. Continuous incontinence

d. Stress incontinence


Note : Patient will have continuous incontinence

+ urge to void normally. This is because the

opposite ureter is intact.

16. Commonest cause of rectovaginal fistula in India

is : (PGI 88)

a. Carcinoma cervix

b. Carcinoma vaginac. Crohn’s disease

d. Internal malignancy

[Ref. Shaw 13/e, p 162 - 163]

Note : Majority of rectovaginal fistulas result from

obstretic injuries, usually a complete tear of perineum

which has been imperfectly repaired.

17. Stress incontinence is a common symptom in :

a. Prolapse uterus (Kerala 95)

b. Fibroid

c. Adenomyosis

d. VVF

[Ref. Shaw 15/e pg -336, Dutta Gyane 5/e p 382]

18. Marshall-Marchetti-Krantz surgery is done for :

a. Stress incontinence (Karn. 96)


c. Vesico vaginal fistula

d. Bladder obstruction

[Ref. Dutta Gynae 5/e, p 387; Shaw 15/e pg -193]

19. Which causes stress incontinence?: (RJ 2009)

a. VVF

b. RVF

c. Ureterovatinal fistula

d. Procidentia


20. Incontinence in elderly female is most commonly

due to : (CUPGEE 99)

a. Detrusor instability

b. True stress incontinence

c. Vesicovaginal fistule

d. Outlet obstruction

[Ref. Dutta Gynae 5/e, p 389;Shaw 15/e pg -195]

Note : “Urge incontinence due to deterusor

instabality (DI) is the second most common cause of

urinary incontinence in an adult female. The first

being GSI (Geniune stress incontinence) However,

in the elderly group, DI is the commonest.”

... Dutta Gynae 5/e, p 389

21. Commonest cause of recto vaginal fistula is :

a. Following Wertheim’s operation (TN 90)

b. Pressure necrosis during labour

c. Improper repair of perineal tear

d. Abnormal presentation

[Ref. Shaw 13/e, p 162 - 163]

Answer 11. a. Colpo-sus.... 12. a. Continuous ... 13. c. Marshall ... 14. e. All 15. c. Continuous ...

16. None 17. a. Prolapse ... 18. a. Stress ... 19. d. Procidentia 20. a. Detrusor ...

21. c. Improper ...


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121

22. One week after an extended hysterectomy, the

patient leaks urine per vaginum. In spite of the

leakage, she has to pass urine from time to time.

The most likely cause is : (UPSC 97)

a. Vesico-vaginal fistula

b. Ureterovaginal fistula

c. Stress incontinence

d. Overflow incontinence

[Ref. Jeffcoate 7/e, p 265]

23. A primipara who had a prolonged labour and

difficult vaginal delivery three months ago

presents with complains of incontinence of loose

stools and flatus from the day of delivery. The

most likely diagnosis : (UPSC 99)

a. Chronic diarrhoea

b. Recto-vaginal fistula

c. Haemorrhoids

d. Complete perineal tear [Ref. Shaw 15/e pg -166-167]

24. ‘Boari’s Operation’ is : (AP 97)

a. Renal pelvic flap

b. Urinary diversion

c. Bladder flap

d. Uretero- rectal anastanosis

[Ref. Bailey & Love 24/e, p 1313]

25. Chassar Moir technique is used in : (AMU 05)

a. Vesico vaginal fistula

b. Stress incontinence

c. Urethrocoele

d. Enterocoele repair

[Ref. Shaw 15/e pg -187] 26. Kelly’s suture is done in : (Calcutta 00;

a. Stress incontinence CUPGEE 06)

b. Cervical incontinence

c. Genito-urinary prolapse

d. Vaginoplasty


27. Commonest s ite of injury of the ure ter in

hysterectomy : (UPSC 85; PGI 88)

a. Where it enters the bladder

b. Crossing by uterine artery

c. Where it enters the pelvis


[Ref. Telinde Operative Gynae 9/e, p 1084]

28. Vesicovaginal fistula by obstetric labour manifests

at after .............. delivery: (DNB 2008)

a. Within 24 hours

b. Within 72 hoursc. Within 1st week

d. After 1st week

(Ref: Jeffcoates, 7/e, 263)

Note: If the fistulas are a result of direct injury e.g.-

cuts, then they manifest immediately. If they are a

result of pressure necrosis they manifest after 7-14

days. In case of obstructed labour–mechanism of

injury is pressure necrosis hence it will manifest after

1st week.

29. Which is not seen in ureteric fistulas: (AP 2008)

a. Pyelonephritis

b. Amenorrheac. Repair is done by fascial split

d. Hydronephrosis

[Ref Shaw 15/e pg -185]

Note : If the fistula develops as a result of ligation of

one or both ureters patient may develop

hydronephrosis and pyelonephritis.

30. Dye test for fistula all true except: (Kolkata2009)

a. If the middle swab is stained with dye, the

diagnosis is vesicovaginal fistula

b. If the lower swab is stained with dye the diagnosis

is urethrovaginal fistula

c. Upper most swab stained with urine but not with

dye and lower two swabs are dry, diagnosis is

ureterovaginal fistula.

d. If the middle swab is stained with dye, the

diagnosis is genuine stress incontinence.


Note : In case of stress urine incontinence also, the

lower swab well get the stain with dye ... Smith urology

17/e, p 583.

Answer 22. b. Ureterovaginal ... 23. d. Complete ... 24. c. Bladder ... 25. a. Vesico ... 26. a. Stress ...

27. c. Where it ... 28. d. After 1st week 29. b. Amenorrhea 30. d. If the middle ...

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