URINARY INCONTINENCE AND GENITAL FISTULA

Question 1

Types of urinary incontinence

Answer 1

1. Stress urinary incontinence- Involuntary leakage of urine in response to physical exertion, sneezing, or
   coughing
2. . Overactive Bladder / urge urinary incontinence- describe a problem with bladder control that is associated
   with a strong desire to pass urine with a decreased ability to control it.
    Associated with detrusor muscle instability, defined as “urgency, usually with but sometimes
   without urge incontinence and with frequency and nocturia.”
    Classically, women with OAB describe a sudden, strong urge to urinate with an inability to suppress feeling,
   rushing to urinate, and experience leaking before making it to the toilet and nocturia prominent feature
3. Overflow Incontinence - urinary retention and overflow incontinence may result from detrusor areflexia or a
   hypotonic bladder, as in pts with lower motor neuron dx, spinal cord injuries, or autonomic neuropathy (DM). .
    Overflow incontinence may also occur when there is an outflow obstruction.
    Outflow obstruction will result in bladder over filling and distending and later leakage of urine
    Obstructive disorder features incl: Straining to void, poor stream, retention of urine, & incomplete emptying
    Best managed with intermittent self-catheterization
4. True incontinence- caused by fistulas. Fistulas are an uncommon cause of urinary incontinence in developed
   countries

Question 2

Tx of overactive bladder incontinence

Answer 2

 Behavior modification- reducing fluid intake and avoiding liquids in the evening hours, gradually increasing
voidings intervals, and pelvic floor muscle strengthening exercises, such as Kegel exercises
 Electrical stimulation- used when other treatments fail. Electrical stimulation to pelvic floor muscles or their
nerves- afferent fibers of pudendal nerve, to improve their tone and function
 Antimuscarinics, or anticholinergics, the mainstay of drug treatment for OAB- include
a) Oxybutynin chloride (Ditropan) and tolterodine (Detrol).
b) Tolterodine also has anticholinergic activity and its bladder specific
c) Imipramine hydrochloride- a tricyclic antidepressant that acts via its anticholinergic properties to
increase bladder storage & improve compliance rather than counteracting uninhibited detrusor contractions
 Identify any dietary triggers, such as caffeine, alcohol, acidic or spicy foods, or carbonated beverages

Question 2

causes of Stress urinary incontinence

Answer 2

 Etiology:
a) Urethral hypermobility due to vaginal wall relaxation displacing bladder neck & proximal urethra
downward; causing unequal transmission of increased intraabdominal pressure to the bladder & proximal
urethra. Normal urethral resistance is overcomed by this increased bladder pressure, & leakage of urine results
b) Intrinsic sphincter deficiency (leak valve)- urethra fails to close in response to increases in
intraabdominal pressure
 Contributing factors include: childbearing, previous urogenital surgery, trauma, pelvic radiation, estrogen
deficiency, and medications (e.g., diuretics and α-adrenergic blockers)

Question 2

fistula

Answer 2

A fistula is abnormal communication between two or more epithelial surfaces /body cavities.
 Genitourinary fistula is an abnormal communication between the urinary and genital tract either acquired or
congenital with involuntary escape of urine into the vagina.

Question 3

Causes of fistulae

Answer 3

1. Iatrogenic
2. Radiation therapy
3. Surgery
4. Trauma
5. Malignance
6. Old age
7. Child birth

Question 4

Types of obstetric Fistulae

Answer 4

1. Bladder
    Vesicovaginal (commonest)- communication between the bladder and the vagina and the urine escapes
   into the vagina causing true incontinence
    Vesicourethrovaginal
    Vesicouterine
    Vesicocervical.
2. Urethra
    Urethrovaginal.
3. Ureter
    Ureterovagina

Question 5

Classification of fistula

Answer 5

Simple (Healthy tissues with good access) or
 Complicated (tissue loss, scarring, difficult access, associated with RVF)

Question 6

Cassification based on the site of VesicoVaginal Fistula

Answer 6

1. Juxtacervical (close to cervix)- connection is betwn supratrigonal region of the bladder & vagina (vault fistula)
2. Midvaginal- communication is between the base (trigone) of bladder and vagina.
3. Juxtaurethral- communication is between neck of bladder and vagina (may involve upper urethra as well).
4. Subsymphysial- Circumferential loss of tissue in region of bladder neck & urethra. Fistula margin is fixed to bone.

Question 7

Causes of vesicovaginal fistula (VVF)

Answer 7

1. Obstetrical- due to obstructed labour, traumatic: instrumental vaginal deliver, abdominal operations such as
   hysterectomy for rupture uterus or Cesarean section specially a repeat one or for cesarean hysterectomy.
2. Gynecological: Operative injury, traumatic, malignancy, radiation and infective- (Chronic granulomatous
   lesions such as vaginal TB, lymphogranuloma venereum)

Question 8

Pathophysiology of fistula due to obstructed labour

Answer 8

Sustained pressure of the fetal head against the back of the pubic bone produces
ischaemic necrosis of the intervening soft tissue of the genital tract and bladder
 It results from prolonged compression effect on the bladder base between the
head and symphysis pubis in obstructed labor ischemic necrosis
infection sloughing fistula.
 Necrotic tissue subsequently sloughs off leaving a hole.
 It takes few days (3–5) following delivery to produce such type of fistula.

Question 9

Clinical features of fistula from obstructed labour

Answer 9

Usually pts are young primiparous with H/O difficult labor or instrumental
delivery in recent past or related event
Symptoms
 Continuous escape of urine per vaginum (true incontinence)
 No urge to pass urine
 For small fistula, urine escapes in certain positions & pt can also pass urine normally.
 For vesicocervical or vesicouterine fistulae, pt may hold urine at level of uterine isthmus and may remain
continent but C/O
 Cyclical hematuria during menstruation (menouria).
 At times pt may C/O intermittent leakage of urine.
Signs: Vulval Inspection
 Watery discharge per vaginum of ammoniacal smell is characteristic.
 Evidence of sudden and excoriation of the vulval skin.
 Varying degrees of perineal tear may be present.
 Internal examination:
 Note position, size and tissues at the margins for big fistula
 Vaginal atresia can make the fistula inaccessible.
 Speculum examination:
 Allows good view of anterior vaginal wall
 Note the size, site and number of fistula.
 A tiny fistula is evidenced by a puckered area of vaginal mucosa
 Other associated clinical features
1) Secondary amenorrhea of hypothalamic origin (Menstruation resumes after repair).
2) Foot-drop due to prolonged compression of sacral nerve roots by fetal head during labor.
3) Complete perineal tear or rectovaginal fistula

Question 10

Confirmation of fistula diagnosis

Answer 10

Clinically diagnosis is made from typical history and local examination.
* Tiny fistula may be confused with stress incontinence, ureterovaginal and
urethrovaginal fistula and so additional methods are required
1) EUA- using a sims speculum and pt in knee chest position, ask pt to cough, bubbles of air are seen through
the small tiny fistula
2) Dye test- introduce speculum and swab dry anterior vaginal wall. Introduce methylene blue solution into
the bladder by a catheter, the dye will be seen coming out via the opening.
3) Use of metal catheter passed via external urethral meatus into the bladder and out via the fistula confirms
VVF and patency of the urethra.
4) Three-swab test- differentiates VVF from ureterovaginal and urethrovaginal
fistula. 3 cotton swabs are placed in the vagina- at the vault, middle and last
just above the introitus. Methylene blue is instilled into bladder via a rubber
catheter and pt is asked to walk for about 5 min and then swabs are inspected
5) Imaging studies
a) Intravenous urography: for dsis of ureterovaginal fistula
b) Retrograde pyelography: for diagnosis of exact site of ureterovaginal fistula
c) Cystography: not done in cases with VVf. it may be done in a complex fistula or vesicouterine fistula
where uterine cavity
d) Hysterosalpingography- for dsis of vesicouterine fistula when there is H/O hematuria (youssef’s
syndrome).
e) Ultrasound, CT and MRI are done for evaluation of complex fistulae, involving of ureter or intestines

Question 11

Consequences of obstructed labour

Answer 11

Extent of injury depends on duration of prolonged labour.
 Severe exhaustion
 Dehydration and hunger
 Sepsis
 Anaemia
 Fetal death
 Maternal morbidity/death

Question 12

obstetric fistula Predominant lesion (primary)

Answer 12

1. Communication between bladder/vagina or the rectum or both (5-10%) but RVF is rare
2. Renal Damage (P) - A few pts develop a stricture on distal ureter leading to hydronephrosis & nephropathy
3. Genital tract injuries- Destruction of the soft tissues of the birth canal with subsequent vaginal stenosis
4. Nerve Damage: Compression damage to the lumbar-sacral plexus. Foot drop from involvement of L5 root.
   Severe form of pelvic ischemia leads to paraplegia.
5. Muscle and fascial damage- Lavator muscles, pubal –coccygeus, pelvis fascial support
6. Bone Damage- 30% cases, X ray shows bone damage to the pubic symphysis.
7. Social Consequences- Loss of self esteem and human dignity, divorce, loss of ability to earn an income,
   rejection, misery, depression and solitary life.
8. Limb contractures: Patients often lie curled in bed
9. Malnutrition: Neglect and depression
10. Infertility: due to amenorrhea, evere mental stress, malnutrition, and Sheehans syndrome
11. Urine Dermatitis- Many patients restrict drinking and end up with concentrated urine. Phosphates and
    nitrates in urine irritate the skin  leading to local hyperkeratosis

Question 13

What are the consequences of fistula for a woman?

Answer 13

1. Leaking urine
2. Offensive smell
3. Infection
4. Genital sores
5. Foot drop

Question 14

Treatment of VVF

Answer 14

 Control infection
 Correct anaemia
 Improve nutrition
 Surgery- Fistulae repair
These socially ostracized women need realistic counseling.
Other-wise treatment failure may cause further devastation

Question 14

Prevention of obstetric fistula

Answer 14

Adequate antenatal care
* Anticipation, early detection (partograph) of obstructed labour
* Early intervention in obstructed labour and ideal approach of delivery to relieve the obstruction
* Continuous bladder drainage for a variable period of about 5–7 days following delivery of longstanding
obstructed labor.
* Care to be taken to avoid injury to the bladder during pelvic surgery