Genital Tract Injuries, U-V Prolapse, Vesico-Vaginal Fistula, Recto-Vaginal Fistula, Complete Perineal Tear & Vaginal Stenosis

1. GENITAL TRACT INJURIES

Causes

• Obstetric: Precipitate or prolonged labor, instrumental delivery (forceps, vacuum), large fetus (macrosomia), malposition, shoulder dystocia
• Surgical: Hysterectomy, anterior colporrhaphy, pelvic surgery
• Traumatic: Sexual assault, pelvic fractures, foreign body
• Congenital: Abnormal tissue

Types / Classification

Management

• Vaginal lacerations: Inspect fully, repair primarily. Ensure apex is incorporated to prevent ongoing hemorrhage. Close in layers.
• Cervical lacerations: Running locking suture from apex downward. If apex is high, use distal suture for traction first.
• Hematoma: Small ones - conservative (observe, monitor). Expanding or patient-unstable - surgical incision and drainage; hemostasis with electrosurgery or fine absorbable sutures; packing if needed. Vaginal pack placed and removed at 24 hours.

2. UTEROVAGINAL (U-V) PROLAPSE

Anatomical Types

Risk Factors / Causes

• Older age, multiparity, prolonged or difficult vaginal labors
• Obesity, chronic constipation, heavy lifting occupations
• Estrogen deficiency (postmenopause - reduced tissue elasticity)
• Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome
• Family history / genetic predisposition

Grading - POP-Q System (Pelvic Organ Prolapse Quantification)

• Grade 0: No prolapse
• Grade 1: Distal portion of prolapse is >1 cm above the hymen
• Grade 2: Distal portion is ≤1 cm above or below the hymen
• Grade 3: Distal portion is >1 cm below the hymen but < (total vaginal length - 2 cm)
• Grade 4: Maximal descent - complete prolapse (procidentia)

Treatment

• Lifestyle modification: avoid constipation, reduce weight, avoid heavy lifting
• Pelvic floor physiotherapy for at least 16 weeks
• Topical estrogen (if estrogen deficient) - increases tissue strength
• Ring pessary: Most commonly used. Inserted between posterior fornix and pubic bone. Replaced every 3-6 months. Complications: vaginal ulceration, infection, discharge/bleeding.

Note: ~30% of women experience recurrence of symptoms after surgical treatment.

3. VESICO-VAGINAL FISTULA (VVF)

Causes / Etiology

• Failure to identify proper plane between bladder and cervix
• Blunt rather than sharp bladder dissection
• Incorrect clamping/suturing of vaginal cuff
• Unrecognized bladder laceration

• Radiation therapy (for pelvic malignancy)
• Advanced pelvic malignancy
• Forceps laceration, uterine rupture, Cesarean section injury
• Anti-incontinence surgery, anterior colporrhaphy
• Infectious/inflammatory causes, foreign body

Types (Anatomical)

Goh Classification (most widely used)

• Type 1: Distal edge >3.5 cm from meatus (good prognosis)
• Type 2: 2.5-3.5 cm
• Type 3: 1.5-2.5 cm
• Type 4: <1.5 cm (worst prognosis - near/at bladder neck)

• Simple: <2-3 cm, supratrigonal, no radiation/malignancy, normal vaginal length
• Complicated: Previous radiation, malignancy present, shortened vagina, >3 cm, trigonal involvement

Clinical Features

• Continuous involuntary leakage of urine from vagina (most characteristic)
• Watery vaginal discharge appearing 10-14 days post-surgery (or 48-72 hours in early cases)
• Excoriation of vulva and thighs
• Recurrent UTIs, dyspareunia

Diagnosis

1. Dye test (Double Dye test): Insert cotton tampon vaginally + instill methylene blue via urethral catheter. Blue staining = VVF confirmed.
2. If no blue staining, give oral pyridium: orange staining within 20 minutes = ureterovaginal fistula
3. CT urogram: Evaluates ureteral integrity, rules out obstruction
4. Cystoscopy, vaginoscopy

Treatment

• Conservative (early): Insert Foley catheter for prolonged continuous bladder drainage. Up to 15% close spontaneously with 4-6 weeks of drainage.
• If no closure by 6 weeks: Surgical repair required
• Timing of surgery: Wait 3-4 months from diagnosis to allow inflammation to subside and improve vascular supply.
• Surgical approach: Vaginal repair for most post-hysterectomy fistulas (fistula site is above bladder trigone, away from ureters). Four-layer closure: (1) bladder mucosa, (2) seromuscular layer, (3) endopelvic fascia, (4) vaginal epithelium.
• Abdominal (O'Connor) or laparoscopic approach for complex/high fistulas.
• Martius flap (labial fat pad) used as interposing layer for complex cases.

4. RECTO-VAGINAL FISTULA (RVF)

Types / Classification (by Location)

• Low RVF: Between lower rectum/anus and posterior vaginal wall near fourchette (most common obstetric type)
• Mid RVF: Mid-rectum to mid-vagina
• High RVF: High rectum or sigmoid to posterior vaginal fornix (usually related to Crohn's, diverticular disease, malignancy)

Goh Classification (anorectal-vaginal fistulas):

• Type 1: Distal edge >3 cm from hymen
• Type 2: 2.5-3 cm from hymen
• Type 3: 1.5-2.5 cm from hymen

Causes

• Obstetric (most common low RVF): Third or fourth-degree perineal tear with defect between the two viscera; unrecognized or improperly repaired sphincter injury
• Cryptoglandular infection: Anorectal abscess/fistula
• Iatrogenic: Previous surgical procedures
• Crohn's disease (perianal Crohn's)
• Diverticular disease, rectal malignancy, radiation injury (Fischer's Mastery of Surgery, p. 4304)

Clinical Features

• Passage of flatus and/or feces through vagina
• Fecal incontinence (large fistulas)
• Excoriation of perianal skin, raw red vagina
• Recurrent vaginal infections, dyspareunia

Diagnosis

• Vaginal speculum examination - identifies vaginal opening
• Proctoscopy/proctosigmoidoscopy - excludes malignancy, Crohn's, radiation damage; identifies dentate line opening (cryptoglandular origin)
• MRI perineum - most helpful for complex/obscure fistulas; almost always diagnostic
• Examination under anesthesia with fistula probes and dye injection
• Biopsy of any suspicious fistula to exclude malignancy
• Colonoscopy to identify inflammatory/malignant bowel disease

Treatment

• Severe fecal incontinence
• Fistula complicated by pelvic sepsis
• Fistulas occurring within 2 weeks of vaginal birth

• High RVF (pouch of Douglas / posterior fornix): Resection when possible. For Crohn's, diverticular disease, or malignancy - bowel resection ± radical hysterectomy + partial vaginectomy
• Carcinoma of middle third rectum: Abdominoperineal excision + hysterectomy + partial vaginectomy; occasionally sphincter-saving procedures with coloanal anastomosis
• Low obstetric RVF: Direct layered perineal repair after adequate preparation (endorectal advancement flap, perineoproctotomy + layered closure, sphincteroplasty if sphincter defect present)
• Interposing tissue (Martius flap, gracilis muscle) for complex recurrent fistulas

5. COMPLETE PERINEAL TEAR (4th Degree)

Classification of Perineal Lacerations

In 4-5% of vaginal deliveries, the anal sphincter or anorectal mucosa is involved (3rd/4th degree tear).

Causes / Risk Factors

• Precipitate labor
• Large baby (macrosomia), occiput posterior position
• Instrumental delivery (forceps > vacuum)
• Shoulder dystocia
• Previous 3rd/4th degree tear
• Midline episiotomy (increases risk; mediolateral episiotomy is protective)
• Nulliparity, shorter perineum

Clinical Features

• Visible defect in perineum extending to anus
• Immediate postpartum bleeding
• If unrecognized/improperly repaired: fecal incontinence, RVF, perineal pain, dyspareunia

Repair (Surgical)

1. Close anorectal mucosa first (interrupted 2-0 or 3-0 absorbable suture in submucosal layer)
2. Close Internal Anal Sphincter (IAS) as a separate layer
3. Reconstruct External Anal Sphincter (EAS): Identify severed ends and reconstruct using:
   • End-to-end technique (approximation), OR
   • Overlapping technique (preferred for EAS, better long-term continence)
4. Then proceed with 2nd-degree repair: Approximate perineal body, vaginal epithelium from apex down, perineal skin closed subcuticularly.

Incomplete reconstruction of 3rd/4th-degree tears leads to pelvic floor disorders, fecal incontinence, and future fistula formation.

Follow-up

• Stool softeners, laxatives
• Broad-spectrum antibiotics (to prevent infection of repair)
• Pelvic floor physiotherapy postoperatively
• Long-term follow-up for continence assessment

6. VAGINAL STENOSIS

Causes

• Post-radiation therapy (most common acquired cause for gynecologic malignancy) - fibrosis and scarring
• Post-surgical: After colpocleisis, vaginoplasty, fistula repair, or radical surgery
• Post-obstetric: Poorly repaired perineal tears, excessive tissue excision during episiotomy repair
• Inflammatory: Lichen sclerosus, lichen planus, pemphigoid
• Congenital: Imperforate hymen, transverse vaginal septum, vaginal agenesis (Mayer-Rokitansky syndrome)
• Infections: Severe chronic infections, tropical infections

Types / Classification (by site)

• Distal (introital) stenosis: Near vaginal opening - most common post-obstetric or post-surgical
• Mid-vaginal stenosis: Most common site after radiation
• Proximal stenosis: Near vault - post-hysterectomy, radiation
• Complete stenosis: Entire vaginal canal obliterated (severe radiation damage)

Clinical Features

• Dyspareunia (painful intercourse) or inability to have intercourse
• Difficulty with vaginal examination and speculum insertion
• Difficulty with vault smear follow-up after cervical cancer treatment
• Urinary symptoms if involving anterior wall

Treatment

• Vaginal dilators: Progressive dilation using vaginal trainers/dilators, starting from smallest size; combined with topical estrogen cream. First-line treatment after radiation therapy.
• Surgical: Incision/excision of scar tissue; vaginal reconstruction with skin grafts (McIndoe procedure for vaginal agenesis) or flaps (gracilis, pudendal thigh flap) for severe cases
• Topical estrogen: Improves tissue quality and elasticity
• Postoperative dilation is mandatory after surgical repair to prevent re-stenosis

Summary Table