Posts Tagged ‘fistula’

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

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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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Female Genital Mutilation (FGM): Why??

March 1, 2014

Blog # 143   Andrew Siegel MD

The juxtaposition of the words “genital” and “mutilation” disturbs me greatly. Regardless of gender, the concept of inflicting serious damage on a person’s genitals or, for that matter any body part, conflicts strongly with the Hippocratic oath that physicians pledge, and is incompatible with the tacit oath of humanity that each of us incorporates during our actualization process as human beings.

You probably cannot imagine the scenario of having non-medical personnel come into your home and use crude and unsterile equipment to cut off some or all of the penis and scrotum of your young sons, on the basis of tradition and ritual.  Sadly, however, the practice of the female equivalent of this is precisely what happens to young girls in many African nations.

Female Genital Mutilation (FGM) is an ancient cultural ritual currently practiced in 28 African nations, Yemen, Iraqi Kurdistan, and within immigrant communities. Certain countries have an extremely high prevalence of this, involving more than 90% of their female population: Djibouti; Egypt; Eritrea; Guinea; Mali; and Somalia.

It is thought that FGM originated millenniums ago in ancient Egypt and thereafter became an entrenched social-cultural-religious tradition. Religion is most often invoked as the underlying explanation for this practice; however, cleanliness and “improved” health are other justifications that are often touted. Additionally, removing the clitoris is seen to be a means of curbing a woman’s libido. The most extreme form of FGM, infibulation (see below), is seen as proof of virginity, the presence of which is of significant importance in many of the countries where FGM is practiced.

The practice was known as female circumcision until the 1980s and gradually the more appropriate term female genital mutilation took hold—a descriptive moniker—because it is truly a genital-deforming “operation.”  Because of emigration to Western nations in Europe and the USA, physicians are now confronting women who have undergone these ritual procedures and suffer with medical complications.

FGM is defined by the World Health Organization (WHO) as “a procedure that involves partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons.”

FGM is classified into 4 types:

(In boldface I have delineated the male equivalent of the FGM procedures—can you imagine for one moment these being cultural norms?)

Type Ia-removal of clitoral hood (Male equivalent is a circumcision.)

Type Ib-partial or total removal of the clitoris and hood (Male equivalent is partial or total removal of the penis.)

Type II: in addition to the type I surgery on the clitoris, parts of the labia minora  (inner lips) or the entire labia minora are removed. At times, this involves removing all of the labia majora  (outer lips).  (Male equivalent is removal of the penis and partial removal of the scrotum.)

Type III: This is known as infibulation—cutting the labia minora and majora and sewing them together with or without removal of the clitoris, thereby sealing the vulva, leaving only a tiny opening for urination/menstruation. (Male equivalent is total removal of the penis and total removal of the scrotum.)

When infibulation is performed, the closure must ultimately be re-opened to allow for sexual intercourse and for childbirth. Pregnancy in women who have undergone infibulation represents a difficult challenge.

Type IV: this includes all other kinds of female genital circumcision done for nonmedical reasons including pricking, piercing, scraping, and burning the labia or the vagina.

FGM is most often carried out by nonmedical staff and occurs outside the confines of a hospital setting without anesthesia or hygienic conditions. The procedure is typically performed in the home setting by a village elder experienced in performing the procedure. Most of the time, it is done in early childhood, commonly before age 5. Unsterile, crude objects are routinely used as cutting implements. Wounds are often closed with thread or with agave or acacia thorns. Uniquely, medical professionals most commonly perform the procedure in Egypt, the country that has the highest prevalence of FGM.

In 2012, the U.N. General Assembly voted unanimously to condemn this practice. It is actually outlawed in most of the countries in which it is practiced, but the laws are poorly enforced. Fortunately, there has been a gradual but steady movement to stop this practice in many countries, but the procedure is far from being extinct. The most common reason given for continuing the practice today is for purposes of “social acceptance.”

The medical complications of FGM include recurrent urinary infections; difficulties with urination, menstruation and possibly pregnancy; and abnormal, debilitating connections between the vagina and the urinary bladder (fistula). FGM can lead to heavy bleeding, severe pain, painful sexual intercourse and the potential for transmission of infections, hepatitis, and HIV. Psychological problems are another major potential consequence of FGM.

If one objectively considers male circumcision, it is nothing other than a form of male genital mutilation (Yes, I have been mutilated). It is well adopted among the Jewish and Muslim populations for religious/cultural reasons and has been practiced for so many generations such that it is considered a meme and a cultural norm, and for many an aesthetic necessity with the natural, uncircumcised penis appearing unattractive to those whom accept circumcision as a convention (however, it is worth mentioning that there are some true, significant health benefits to circumcision, which is not the case with FGM). My point is that I can come to understand “strange” ritual practices that we are socialized to accept; however, my limit of tolerance is at circumcision. I might, perhaps, be able to accept circumcision’s female equivalent—removal of the clitoral foreskin—if it was a time-honored societal norm. That stated, any form of FGM beyond this should never be condoned by society—it is nothing short of assault and battery with potentially horrific physical and psychological consequences.

References: Female Genital Circumcision/Mutilations: Implications For Female Uro-Gynecological Health.   International Uro-gynecological Journal “2013” 24:2021–2027

Andrew Siegel, MD

For more info on Dr. Siegel: http://www.about.me/asiegel913

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in April 2014.

www.MalePelvicFitness.com