Vesicovaginal fistulae

Abstract

The aetiology, methods of repair and results are described in 616 patients with vesicovaginal fistulae (26 also had rectovaginal fistulae). The cure rate was 81%.

PIP: 161 Ethiopian and 33 British women with vesicovaginal fistulae, of which 26 also had rectovaginal fistulae, are presented with an introduction on patient management. The most common cause was pressure necrosis in obstructed labor, or injury during operative deliver (128). There were a few cases caused by incisions done locally. 28 were secondary to gynecological surgery. Repairs were done after a waiting period of 8-12 weeks for antibiotic therapy and resolution of edema. Methods included deep episiotomy, incision of fibrotic bands, scar tissue and vaginal stenosis, and reconstruction of the urethra. The ureters were catheterized if necessary to prevent injury. Repairs were done in 2 layers with 2/0 atraumatic catgut or 3.0 atraumatic polyglycolic acid interrupted inverting sutures. Many African cases with fixation to the pubic bone were repaired with an atraumatic needle to penetrate the periosteum. The Martius procedure of grafting a pedicle from the labium majus was used when there was a large fistula or extensive scarring. Transplantation of the gracilis muscle subcutaneously to the lower vagina for support was also employed. The vaginal skin was closed with interrupted everting non-absorbable sutures. In extensive stenosis, flaps of vulval skin were used to close the vaginal defect. Bladder catheters were kept in place for 3 weeks. 131 patients were cured on the 1st attempt (81.4%). 7 of the 17 who still had stress incontinence improved with exercises. 33 women subsequently became pregnant, with 12 vaginal deliveries, and 3 stillbirths and fistula breakdowns.