Thread by @Jasonphilip8

This is a Vesico-Vaginal fistula a condition that devastates d life of lacs of women, in India & in d west. VVF is an abnormal communication btw the bladder & d vagina, leading 2 continuous leak of urine without control. It often coexists with a ureterovaginal fistula.A thread🧵;

https://twitter.com/Jasonphilip8/status/1591703314907140096

A fistula is an abnormal pathway btw 2 body cavities, lined by epithelium. In this case, it is between the Vagina & the Urinary Bladder. It can be caused by;
1.Pelvic Surgery
2.Obstructed Labour
3. Radiation treatment
4. Cancer
5.Trauma including sexual assault
6.Miscellaneous

Obstructed Labour used 2 be d most common cause in India,while in the west,it ws Pelvic Surgery. Today even in India,Pelvic Surgery is d most common cause.
Hw does d pt present?- Constant Urine leak frm d Vagina. When a large fistula is present, d pt may not visit d toilet at all

The condition has 2 be distinguished frm incontinence& ureterovaginal fistula. Methylene Blue is infused into d bladder & a tampon placed in d vagina. If the tampon is stained blue at its top,a VVF may be suspected. If there is no stain, IV Indigo Carmine is given& test repeated.

If now the tampon is stained blue at the top,a Ureterovaginal fistula can be diagnosed. If the bottom end of the tampon is stained blue in the 1st test, urinary incontinence can be suspected. Ureterovaginal combined with Vesicovaginal fistulae occur in around 10% of cases.

A cystogram or a voiding cystourethrogram(filing d bladder with contrast & taking an Xray while d pt urinates)is necessary fr diagnosis. CT urogram is necessary 2 diagnose ureterovaginal fistula. In addition,a cystoscopy (looking at d inside of d bladder through a scope) is done.

The goal of treatment of VVF is rapid cessation of urine leak with normal return to Urinary & Genital function. For small, recent fistulae a trial of Urinary Catheter insertion can be done fr 2-3 weeks. Sometimes, the fistula MIGHT close. Most pts will need surgery.

A VVF can be closed either through the abdomen(O' Connor's repair), or the Vagina with equal success rates. A uretero vaginal fistula will need reimplantation of the ureter into the bladder. Both might co-exist requiring both surgeries. Obstetric fistulae might warrant a waiting

period of 3-6: months before surgery to allow damaged tissues 2 heal. Radiation induced fistulae might need a delay of 6-12 months. Uncomplicated gynaec fistulae r closed as soon as identified.
Here is an algorithm for diagnosing a Vesico-Vaginal fistula.

And here is an algorithm for treating uretero-vaginal fistula (abnormal connection btw the Ureter & d Vagina). Successful treatment of small UVFs can be hoped by inserting a stent(a synthetic tube) in d ureter for 4-6 weeks. If it doesn't heal after this period, Sx is warranted.

Here is the algorithm to diagnose and treat Ureterovaginal Fistulae.

This is an intravenous urogram of a typical ureterovaginal fistula. Note how the opacification of the ureter ends before entering the bladder. This is a typical finding in this condition along with Dilatations of the ureter upto the injured spot+Renal pelvis + Renal calices.

Here in d image posted in d morning, U can see d Urinary Bladder anteriorly, the fistulous track at the top, and the Vagina at the posterior aspect. So contrast given into the bladder, which shd remain in the bladder is seen passing through the abnormal fistula into the Vagina.

To conclude, Vesicovaginal Fistula is a devastating experience for d patient, which seriously affects her body& her dignity. It is extremely common in society. Prevention shd be the goal, failing which expeditious diagnosis& wherever possible early corrective treatment is needed.

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