Fistulas

Urinary fistulas may be ureterovaginal, vesicovaginal, urethrovaginal or complex, and can occur following pelvic surgery or in cases of advanced pelvic malignancy, especially when there has been radiotherapy. The most common varieties in the UK are lower ureteric or bladder fistulas occurring after an abdominal hysterectomy. In developing countries, poor obstetrics with obstructed labour resulting in ischaemic necrosis of the bladder base is more likely to be the cause of a vesico- or urethrovaginal fistula.

Fistulas give rise to incontinence which is continuous, occurring both day and night. They are usually visible on speculum examination but cystoscopy and intravenous urography may be required to confirm the diagnosis.

Treatment is surgical. Ureterovaginal fistulas should be repaired as quickly as possible to prevent upper urinary tract damage. Vesicovaginal fistulas are usually treated conservatively initially with bladder drainage and antibiotics, during which time some will close spontaneously. Abdominal or vaginal repair is normally performed 2 or

3 months after the initial injury, although there is now a trend towards earlier repair; if a fistula is detected within a very short period of time after the initial operation, it can often be closed immediately.

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