CASE –URINARY FISTULA

History

Details of Incontinence - true or false, associated presence of urinary stream Previous obstretric history including

(a )details of labour

(b )mode of delivery

(c )interval between delivery and leakage Previous gynae operative history Type of surgery performed

Interval between surgery and leakage

Clinical examination

Inspection of Vulva with special reference to excoriation

PIS to demonstrate site and size of Fistula

PN to confirm above and to comment on extent of scaring I fibrosis

Further information on PN to assess regarding uterine and adnexal pathology

Urinary examination for microscopy and culture Methylene blue test Cystoscopy.

IVP in selected cases

Examination under anaesthesia especially if clinical examination is not infonnative enough

- Must distinguish between ureterovaginal and vesicovaginal fistulae

Managment

Non - Surgical management - Role of prolonged catheterization Pre Operative management - Elimination of urinary tract infection

- Treatment of external excoriations

Surgical management

Various techniques of repair

- Special reference to postoperative management - Prophylactic measures for both obstetric and gynae urinary fistulae

FAECAL FISTULAE

Histroy - Similar to urinary fistulae. Special importance to intermittent  incontinence with reference to consistency of faecal matter

-Vulval examination

- PIS and P/V to determine details of fistula and especially to assess distance of fistula from anal verge and introitus

- Tone of external anal sphincter

Investigations - Routine - Special - proctoscopy I sigmoidoscopy

- Examination under anesthesia if required - Fistulogram

Differential diagnosis - Distinguish between RVF and 3^rd degree perineal tear

Management

- Local hygiene

- Various kinds of repair and their approaches

- Prophylactic measures during episiotomy, Perineorrhaphy suturing and hysterectomy