Editing Urinary fistulas


Fistula: communication between two epithelium-lined surfaces

== Vesicocutaneous fistulae: ==

* Congenital:
** Ectopia vesicae
** Patent urachus - urine leakage from umbilicus
** In a/w imperforate anus
* Traumatic
** Perforating wounds
** Radiotherapy - avascular necrosis
** Damage during surgery

== Vesicovaginal fistulae: ==

* Aetiology:
** Obstetric - ischaemia due to prolonged pressure from fetal head
** Gynaecologic - hysterectomy/anterior colporrhaphy
*** Grasping bladder wall with artery forceps
*** Including bladder in a suture
*** Local oedema/haematoma
** Radiotherapy
** Direct neoplastic infiltration (cervical cancer)
* Clinical features
** Leakage of urine from vagina and excoriation of the vulva
** Check for localised thickening on anterior wall or in the vault
** Urine may be seen escaping from an opening in the anterior vaginal wall with a speculum
* Examination
** Three-swab test - place a swab in the vagina and inject methylene blue into the urethra. Obviously if the swab turns blue there is a vesicovaginal fistula.
** Cystogram should demonstrate too
* Management
** Most will require surgical repair
** Low fistula (subtrigonal): best repaired per vagina in multiple layers of absorbable sutures, leaving a catheter in for at least 10 days.
** High fistula: suprapubic is often the best method

== Colovesical fistula ==

* Aetiology
** Diverticulitis
** Crohn's
** Appendiceal abscess
** Pelvic surgery
** Carcinoma - locally advanced, may still be operable
* Presentation
** Pneumaturia
* Workup
** Exclude UTI with gas-forming organism in a diabetic
** Cystogram likely to show the fistula
* Treatment
** Surgery
*** Separate communication
*** Resect bowel
*** Debride bladder hole, close, patch with omentum
*** Drain bladder as usual post-op

== Urethral fistulae in men ==

* Infection above a stricture produces a paraurethral abscess that ruptures into the urethra, allowing extravasation into scrotum and perineum to occur
* Urine and infection extend into the upper 2.5cm of the thigh and lower abdominal wall
* Widespread cellulitis and tissue necrosis may occur (can lead to Fournier's)
* Drain urine via suprapubic cystotomy and drain/debride tissue planes

[[Category:Urology]]