Archive for December, 2018

Vesico-Vaginal Fistula (VVF): What You Need to Know

December 8, 2018

Andrew Siegel MD 12/8/2018

The last few entries have been geared towards men.  This week’s and next week’s entries address female urogenital maladies.  Today I cover a specific type of fistula–an abnormal connection between two body parts that are normally not connected –specifically one that occurs between the bladder and the vagina and that often leads to miserable urinary leakage issues. 

Vesicovaginal_Fistula

By BruceBlaus [CC BY-SA 4.0  (https://creativecommons.org/licenses/by-sa/4.0)%5D, from Wikimedia Commons

A vesico-vaginal fistula (VVF) is an abnormal hole or connection between the bladder and the vagina that causes continuous and persistent urinary leakage. Urine from the bladder drains from the fistula into the vagina, resulting in high-volume, continuous urinary leakage out of the vagina.

In the USA the most common cause is gynecological surgery, with abdominal hysterectomy accounting for the majority.  Other causes are urological and pelvic surgery, pelvic cancers and radiation therapy. My most recent patient with a VVF had a retained (long forgotten about) pessary used to treat her pelvic organ prolapse, which eroded from the vagina into the urinary bladder creating the fistula.

However, on a worldwide basis, the most common cause of VVF is an obstetrical fistula that occurs in third-world nations, particularly in West Africa. This is the most extreme form of birth trauma, a not uncommon, horrific problem endemic in poverty-stricken countries where pregnant women have poor access to obstetric care. It happens after enduring days of “obstructed” labor, with the baby’s head persistently pushing against the mother’s pelvic bones during labor contractions. This prevents pelvic blood flow and causes tissue death, resulting in a fistula between the vagina and the bladder and/or vagina and rectum. These fistulas are often huge and are totally different entities compared to the fistulas resulting from hysterectomies that are seen in first-world nations. When birth finally occurs, the baby is often stillborn.  The long-term consequences for the mother are severe urinary and bowel incontinence, shame and social isolation.

Fistulas can vary in size from tiny, pinpoint fistulas to those that are several centimeters in diameter.  A simple fistula is solitary and small in diameter; complex fistulas include those that are large, multiple, recurrent after previous repairs and those associated with pelvic radiation.  Most fistulas occur because of tissue “necrosis” (tissue death) and do not cause symptoms for several days to several weeks following the initial instigating surgery. The tissue necrosis is often caused by sutures inadvertently placed in the bladder wall in an effort to control pelvic bleeding.

The classic presentation of a VVF is urinary leakage from the vagina that occurs a few days to a few weeks following a hysterectomy. Evaluation is via pelvic examination in conjunction with cystoscopy (using a small lighted instrument to visualize the bladder) and vaginoscopy (using a small lighted instrument to visualize the vagina).  The location, size and number of fistulas present are determined as well as the extent of inflammation associated with the VVF.

Small fistulas may occasionally heal spontaneously with prolonged urinary catheter drainage.  Tiny fistulas can sometimes be dealt with via cauterization (searing them with electrical current), although most fistulas will be need to be repaired with surgery.

Surgical repair of a VVF can be via a vaginal or abdominal approach depending on circumstances and surgeon preference. In general, simple fistulas involving the more superficial vagina can be treated using vaginal approaches. Advantages of the vaginal approach are avoiding opening the bladder, minimal blood loss and less post-operative discomfort and the ability to do the procedure on an outpatient basis.

Complex fistulas that involve the deeper vagina can be repaired vaginally, although the abdominal approach is often preferred.  Vaginal repair can be facilitated with the use of either a flap of the labial fat pad (Martius repair) or alternatively, with the use of a flap of muscle tissue attached to its blood supply (often gracilis muscle).  Nowadays, the abdominal approach is often a robotic-assisted laparoscopic technique that has numerous advantages over the older, open technique.

In either case, important principles of surgical repair of a VVF are the following:

  • Waiting a sufficient time period after diagnosis to allow the inflammation and tissue swelling to subside to optimize tissue health and suppleness. The repair should not be attempted if devitalized tissues, infection, inflammation or encrusted deposits on the tissues are present. The timing needs to find middle ground between optimal conditions for closure and the desire to minimize the duration of the annoying and distressing constant urinary leakage.
  • Any urinary infection needs to be treated with antibiotics in advance of the surgery
  • Topical estrogen can be used to optimize vaginal tissue integrity
  • Careful tension-free closure of the VVF in several non-overlapping suture lines (bladder layer and vaginal layer) often with interposition of additional tissue (interposition flaps include omentum or peritoneum for abdominal repairs; peritoneum or labial fat for vaginal repairs) between the bladder and vaginal walls to buttress the repair. A flap of vaginal wall is advanced to cover the repair.
  • Urinary catheter for several weeks after the repair for purposes of continuous urinary drainage to facilitate the healing process by keeping the bladder decompressed of urine
  • Bladder relaxant medication post-operatively to minimize involuntary bladder contractions
  • Post-operative antibiotics

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

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Medical “Urban” Myths in Urology

December 1, 2018

Andrew Siegel MD  12/1/2018

I am pleased to announce that with this entry I have surpassed 400 blogs composed over the past seven years.

Myth:  a widely held but false belief or idea; a misrepresentation of the truth; a fictitious or imaginary thing; exaggerated or idealized conception

thank you Pixabay for image above

Part I of today’s entry confronts widely held but false medical concepts that run rampant in the general population. Part II addresses widely held but false medical concepts that run rampant within the medical field. The medical mythology I attempt to debunk is largely urological in nature.

General population medical myths: Some myths are perpetuated by the general (non-medical) community, consisting of erroneous beliefs and inaccurate presumptions. These falsehoods often require a great deal of physician time in an effort to disabuse patients of them. 

Medical community medical myths: Some aspects of the practice of medicine are on the basis of customs perpetuated by medical personnel (most often not physicians) that seem logical or justified and ultimately become accepted dogma. However, they often do not hold muster, crumble under scientific scrutiny and can be categorized as medical myths.   

GENERAL POPULATION MEDICAL MYTHS

“A vaccine caused my child’s autism.”

(This is a non-urological myth, but nonetheless needs to be addressed.)

Myth: Vaccines, particularly MMR (measles, mumps, rubella) cause neurological injuries including autism spectrum disorder.

Reality: Scientific evidence overwhelmingly shows no correlation between vaccines in general, MMR vaccine in specific, and thimerosal (a mercury-based preservative) in vaccines with autism spectrum disorders or other neuro-developmental issues. 

We have come a long way on the immunization and vaccination front, wiping out a significant number of diseases completely.  In children, vaccines have been among our most effective interventions to protect individual as well as public health. What a great means of reducing  risk for certain infections that are potentially lethal, if not capable of incurring significant morbidity.  Vaccinations are now available for hepatitis A and B, diphtheria, tetanus, pertusis, polio, hemophilus, measles, mumps, rubella, varicella, meningitis, cervical cancer/human papilloma virus, influenza and pneumococcal pneumonia and herpes zoster (shingles).

“Doing a prostate biopsy will spread any cancer that may be present.”

Myth: Using a needle to obtain tissue samples of the prostate allows cancer cells to seed and implant along the needle track, or alternatively, into blood or lymphatic vessels. 

Reality: Although this is a theoretical consideration, the truth of the matter is that based upon millions of prostate biopsies performed annually in the USA, the incidence of seeding is virtually non-existent and the potential risk can be thought of as being negligible at best.

“Cancer spreads when exposed to oxygen.”

Myth: When a body is opened up and exposed to oxygen any cancer present can readily spread.

Reality: There is no scientific evidence that supports cancer advancing because of exposure to air/oxygen.  At times, upon doing an exploratory surgery, more cancer is discovered than was anticipated based upon imaging studies. This has nothing to do with the surgical incision nor exposure to air/oxygen, but is simply on the basis of cancer that did not show up on the diagnostic evaluation.

“All prostate cancer is slow growing and can be ignored.”

Myth: Prostate cancer grows so slowly that it can be disregarded. 

Reality:  Every case of prostate cancer is unique and has a variable biological behavior.

Yes, some are so unaggressive that no cure is necessary and can be managed with surveillance; however, others are so aggressive that no treatment is curative, and many are in between these two extremes, being moderately aggressive and highly curable. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.

Those who feel that prostate cancer should not be sought out and treated should be attentive to the fact that it is the second leading cause of cancer death, with an estimated 30,000 deaths in 2018, and furthermore, that death from prostate cancer is typically an unpleasant one

MEDICAL COMMUNITY MEDICAL MYTHS

“Drink lots of fluids to flush out kidney stones.”

Myth: Drinking copiously will help promote passage of kidney and ureteral stones. The rationale of this advice is that by hydrating massively, a head of pressure will be created to help passage of a stone present in the kidney or ureter.

Reality: The presence of a stone often causes urinary tract obstruction.  Over-hydration in the presence of obstruction will further distend the already bloated and inflated portion of the urinary collecting system located above the stone. This increased distension can exacerbate pain and nausea that are often symptoms of colic. The collecting system of the kidney and the ureter have natural peristalsis—similar to that of the intestine—and over-hydration has no physiological basis in terms of helping this process along, being pointless and perhaps even dangerous.  Drinking moderately in the face of a kidney or ureteral stone is sound advice.

“Everyone must drink 8-12 glasses of water a day.”

Myth: Many sources of information (mostly non-medical and of dubious reliability) dogmatically assert that humans need 8-12 glasses of water daily to stay well hydrated and thrive.

Reality: Many people take the 8-12 glass/day rule literally and as a result end up in urologists’ offices with urinary urgency, frequency and often urinary leakage. The truth of the matter is that although some urinary issues are brought on or worsened by insufficient fluid intake–including kidney stones and urinary infections–other urinary woes are brought on or worsened by excessive fluid intake, including the aforementioned “overactive bladder” symptoms.  Water requirements are based upon ambient temperature and activity level. If you are sedentary and in a cool environment, your water requirements are significantly less than when exercising vigorously in 90-degree temperatures.

Humans are extraordinarily sophisticated and well-engineered “machines” and your body lets you know when you are hungry, ill, sleepy, thirsty, etc.  Heeding your thirst is one of the best ways of maintaining good hydration status, in other words, drinking when thirsty and not otherwise. Another method of maintaining good hydration status is to pay attention to your urine color.  Urine color can vary from deep amber to as clear as water.  If your urine is dark amber, you need to drink more as a lighter color is ideal and indicative of satisfactory hydration

“When a patient needs to have a catheter placed because he or she is unable to urinate, clamp the catheter intermittently to allow for gradual drainage instead of allowing it to drain at once.”

Myth: Rapid bladder decompression with a catheter can cause problems including bleeding that may require intervention, kidney failure and circulatory collapse. 

Reality: Science has clearly shown that concerns for kidney failure and circulatory collapse due to rapid bladder decompression are untruths.  Yes, on occasion some bleeding can occur (with or without) rapid decompression, but it is usually self-limited and inconsequential.

“A patient is experiencing leakage around a urinary catheter, so it must be too small and replaced with a larger one.”

Myth: A catheter that leaks needs to be replaced with a larger bore catheter so as to provide a better seal and reduce the leakage. This practice is commonly applied in nursing homes where many patients have long-term indwelling catheters for a variety of reasons.

Reality:  Leakage of urine around indwelling catheters is a common scenario. Although it can be due to a blocked catheter, most often the cause is bladder spasms induced by the catheter or catheter balloon irritating the bladder. The sensible management is to irrigate the catheter to ensure no obstruction, deflate the balloon to some extent, and thereafter consider the use of a bladder relaxant medication to minimize the bladder spasms.  The best practice is always to use the smallest catheter that is effective and remove it as soon as feasible. The longer a catheter stays in, the greater the chance for infections and long-term catheters that are upsized are clearly associated with urethral erosion and urethral stricture (scarring).

“If a patient has bacteria in the urine they must have a urinary infection that needs to be treated.”

Myth: There are bacteria present in the urine on urinalysis, so there must be an underlying infection that demands antibiotic treatment.  This is one of the medical myths perpetuated by internists and general practitioners.

Reality: The thought process that the presence of bacteria in the urine without symptoms means an infection is erroneous. It is vital to distinguish a symptomatic urinary infection from asymptomatic bacteriuria. Asymptomatic bacteriuria, common in elderly and diabetics, is the presence of bacteria within the bladder without causing an infection. This does not require treatment, which is futile and promotes selection of resistant bacteria.  Asymptomatic bacteriuria should be treated only in select circumstances:  pregnant women; in patients undergoing urological-gynecological surgical procedures; and in those undergoing prosthetic surgery (total knee replacement, etc.).

An extension of this myth is that bacteria in the urine in the face of an indwelling catheter is an infection that must be treated. The reality is that in the vast amount of cases, this is bacterial colonization without infection.

Bottom Line: Lay and even medical populations are subject to medical myths—mistaken beliefs that are often passed down like memes with little to no basis in fact. These myths have no place in the art and craft of medicine and need to be challenged with real science.  

“What is dogma today is dog crap tomorrow.”

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area,Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor