Urinary fistulas
Fistula: communication between two epithelium-lined surfaces
Vesicocutaneous fistulae:
[edit | edit source]- 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:
[edit | edit source]- 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
[edit | edit source]- 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
- Surgery
Urethral fistulae in men
[edit | edit source]- 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