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Prolapse of the Uterus - Detailed Answer

Note on Sources: The medical library contains Berek & Novak's Gynecology (16th ed.), from which all textbook citations below are drawn. DC Dutta's Textbook of Gynecology and Shaw's Textbook of Operative Gynaecology are not available in the library, so content attributed to those sources is drawn from well-established teaching that appears consistently in those texts, supplemented by Berek & Novak's for the main evidence base.

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DEFINITION

• Berek & Novak: "Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus." (p. 1598)
• Procidentia = prolapse of the uterus and vagina; complete vaginal vault prolapse = eversion of the entire vagina after hysterectomy (p. 1598)

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CLASSIFICATION / DEGREES

Classical Grading (DC Dutta / Shaw System)

Berek & Novak / ICS: The Pelvic Organ Prolapse Quantification (POP-Q) System

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INCIDENCE & EPIDEMIOLOGY

• 11% of women up to age 80 years will undergo surgery for POP or urinary incontinence in the United States; nearly one-third are repeat procedures. (Berek & Novak, p. 1595)
• Women's Health Initiative data: anterior POP in 34.3%, posterior wall prolapse in 18.6%, uterine prolapse in 14.3% of women studied. (p. 1595)
• Women with at least one vaginal delivery were twice as likely as nulliparous women to have POP after adjusting for age, ethnicity, and BMI.
• Projected increases in surgical demand are expected given the ageing global population.

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ETIOLOGY & RISK FACTORS

Predisposing Factors (DC Dutta classification - widely taught)

• Congenital weakness of pelvic supporting ligaments
• Spina bifida / neurological conditions

• Prolonged/precipitate labour damaging levator ani
• Difficult forceps/instrumental delivery
• Large baby, bearing down before full dilatation
• Multiple pregnancies
• Poor perineal repair after episiotomy/lacerations
• Premature return to hard physical labour after delivery

• Raised intra-abdominal pressure: chronic cough, constipation, obesity
• Postmenopausal oestrogen deficiency - atrophy of support tissues
• Advancing age
• Race (more common in Caucasian women, less in Black/Asian women)
• Connective tissue disorders (Ehlers-Danlos syndrome)

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PATHOPHYSIOLOGY AND ANATOMY

Three Levels of Pelvic Support (DeLancey's Classification)

• "Birth-induced injury to the pubococcygeal portion of the levator ani muscles is seen in 55% of women with prolapse and 16% of women with normal support."
• Failure of the cardinal-uterosacral ligament complex allows downward descent of the cervix and uterus.
• Levator ani hiatus enlargement facilitates pelvic organ descent when muscle damage or neuromuscular dysfunction occurs.
• Damage to the pubocervical fascia (anterior) leads to cystocele; damage to Denonvilliers (pararectal) fascia (posterior) leads to rectocele.

Associated Defects in Procidentia

• Cystocele (anterior wall) - descent of bladder
• Rectocele (posterior wall) - rectum protrudes into vaginal lumen
• Enterocele - herniation of peritoneum + small bowel (the only true hernia)
• Cervical elongation
• Decubitus ulcer on the prolapsed cervix

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SYMPTOMS

Local Symptoms

• Feeling of "something coming down" or bearing down sensation - the classic symptom
• Dragging pain or discomfort in the lower abdomen/pelvis and back
• Visible mass at the vulva (3rd degree)
• Decubitus ulcer - ulceration on prolapsed cervix due to friction/drying; discharge, bleeding

Urinary Symptoms

• Stress urinary incontinence (common with cystocele)
• Urinary frequency, urgency, incomplete emptying
• Obstructive uropathy with severe prolapse - kinking of ureters causing hydroureter/hydronephrosis
• Need to digitally reduce the prolapse to void (advanced cases)
• Retention

Bowel Symptoms

• Constipation (with rectocele)
• Incomplete evacuation; need to splint vaginally or perineally to defaecate
• Tenesmus, fecal incontinence

Sexual Symptoms

• Dyspareunia
• Reduced sexual satisfaction

Important clinical note (Berek & Novak, p. 1609): "A retrospective study of 330 patients reported that women with more advanced prolapse were less likely to have symptoms of stress incontinence and more likely to use manual reduction of the prolapse to void." - i.e., severe prolapse may actually mask stress incontinence by urethral kinking.

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DIAGNOSIS & EXAMINATION

History

• Parity, obstetric history, menopausal status
• Urinary, bowel, and sexual symptoms
• Duration and progression

Physical Examination

• Patient examined in lithotomy position (and standing if lithotomy findings don't match symptoms)
• Sims speculum (univalve) used - placed posteriorly to examine anterior wall, anteriorly for posterior wall
• Graves speculum or Baden retractor for apical compartment
• Patient asked to Valsalva/bear down to demonstrate maximum extent of prolapse
• Rectovaginal examination to distinguish posterior vaginal wall defect from enterocele

• Stage of prolapse (POP-Q or traditional grading)
• Presence of cystocele, rectocele, enterocele
• Condition of cervix/vaginal epithelium (decubitus ulcer, leukoplakia)
• Pelvic floor muscle strength (4 and 8 o'clock palpation of puborectalis/pubococcygeus)
• Urethral mobility (Q-tip test, goniometer)

Investigations

• Urine analysis/culture - to exclude UTI
• Post-void residual (PVR) - urinary retention assessment
• Urodynamics - if urinary symptoms present
• Cystoscopy if bladder involvement suspected
• Pelvic ultrasound/MRI - in complex cases (MRI gold standard for dynamic pelvic floor assessment)
• Bowel function evaluation - colonoscopy, proctoscopy as needed

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TREATMENT

Conservative / Non-Surgical Management

• Mild prolapse (Stage I-II) without significant symptoms
• Patient unfit for surgery
• Patient during pregnancy or desiring future pregnancy
• Patient declining surgery
• As a temporizing measure

• Treat predisposing causes: constipation, chronic cough
• Weight reduction
• HRT/local oestrogen therapy (postmenopausal women) - improves tissue quality

• Berek & Novak (p. 1616): "Pelvic floor muscle exercises may limit the progression of mild prolapse and related symptoms; however, a lower response rate has been noted when prolapse extends beyond the vaginal introitus."
• A RCT showed fewer prolapse symptoms at 12 months with one-to-one PFMT vs. lifestyle advice alone (Stages I-III).

• The pessary should be retained during Valsalva/cough when fitted
• Patient should void with pessary in place before leaving
• Ring pessary: can stay for 4-12 weeks; follow-up at 1-2 weeks, then 4-6 weeks, then 6-12 monthly
• Complications: erosion, discharge, ulceration, fistula (if neglected)

Surgical Management

• Symptomatic prolapse that has failed conservative therapy
• Stage II or above with apparent progression
• Patient preference

1. Reconstructive - uses patient's own (native) tissue support
2. Compensatory/augmentation - permanent graft material to replace deficient support
3. Obliterative - closes/partially closes the vagina (for women who do not desire sexual function)

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VAGINAL PROCEDURES

A. Apical Compartment Repairs (Most Important)

"Apical support is the key to a successful prolapse repair." - Berek & Novak (p. 1621)

• Amputation of the elongated cervix + anterior and posterior colporrhaphy + reconstruction of the cardinal ligaments in front of the cervical stump
• Indications: 1st and 2nd degree prolapse with cervical elongation; patient wants to retain uterus
• Not used when procidentia or 3rd degree due to risk of cervical stenosis blocking future pregnancy
• Steps: Anterior colporrhaphy + Fothergill stitch (cardinal ligament plication) + cervical amputation + posterior colporrhaphy + perineorrhaphy

• Standard treatment for 2nd and 3rd degree uterovaginal prolapse when childbearing is complete
• Combined with anterior and/or posterior colporrhaphy
• Must suspend the vault - Berek & Novak: "Following hysterectomy for prolapse, the vaginal apex must be suspended or the patient will likely have posthysterectomy prolapse." (p. 2368)

• Extraperitoneal transvaginal procedure
• Vaginal cuff/cervix attached to the sacrospinous ligament (usually right-sided)
• Good for vault prolapse after hysterectomy
• Risk: pudendal neurovascular injury, buttock pain

• High bilateral uterosacral ligament plication to support the vaginal apex
• Intraperitoneal approach
• Risk of ureteral kinking (ureteral stenting/cystoscopy mandatory)

• Vaginal apex sutured to the iliococcygeus muscle/fascia above the ischial spine

B. Uterine Preservation (Hysteropexy) - Modern Trend

• The SUPeR trial (Study of Uterine Prolapse Procedures - Randomized Trial): compared uterine preservation (sacrospinous hysteropexy) vs. vaginal hysterectomy + uterosacral ligament suspension - no significant difference in outcomes at 2 years
• Sacrospinous hysteropexy - uterus preserved; cervix sutured to sacrospinous ligament
• Contraindicated if: cervical pathology, abnormal uterine bleeding, unresolved uterine/cervical pathology, perimenopausal women (surveillance concerns)

C. Anterior Compartment (Cystocele Repair)

• Midline plication of the pubocervical fascia
• Most common; anatomic cure rates 57-83% (less durable for lateral defects)

• Reattaches the detached lateral pubocervical fascia to the arcus tendineus fascia pelvis
• Vaginal or abdominal approach; indicated for lateral/paravaginal defect type cystocele

D. Posterior Compartment (Rectocele/Enterocele Repair)

• Berek & Novak (p. 1631): anatomic cure rates 76-90%; however de novo dyspareunia in 8-26%
• Plication of the fibromuscular layer of the posterior vaginal wall

• Identifies and closes specific fibromuscular tears; aims to minimize dyspareunia
• Anatomical cure rates 82-100% in case series; lower de novo dyspareunia (2-7%)

• Excision of hernial sac, high ligation of peritoneum
• McCall culdoplasty, Halban, Moschowitz procedures

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ABDOMINAL PROCEDURES

• Graft (polypropylene mesh or biological graft) attached from the vaginal vault to the sacral promontory (S1-S2)
• Berek & Novak: best long-term durability for vault prolapse; 78-100% anatomical cure
• FDA mesh warning: must use only in sacrocolpopexy (abdominal route); vaginal mesh augmentation now largely abandoned due to complications

• Same principle as open; shorter hospital stay, less blood loss
• Increasingly preferred over open abdominal approach

• High sutures placed in the uterosacral ligaments transabdominally

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OBLITERATIVE PROCEDURES

• Strips of anterior and posterior vaginal mucosa are removed and raw surfaces approximated to partially close the vaginal canal
• Creates lateral channels for cervical drainage
• Indications: elderly, medically unfit patients with procidentia who do not desire sexual intercourse
• High success rate with low morbidity
• Contraindicated if cervical/uterine pathology is suspected (as access is lost)

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COMPLICATIONS OF UTERINE PROLAPSE

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MANAGEMENT IN SPECIAL SITUATIONS

Prolapse in Pregnancy

• Usually first trimester, regresses spontaneously after 12-14 weeks as uterus rises out of pelvis
• Conservative management: rest, pelvic floor exercises, pessary if necessary
• Rare cases may require surgical intervention

Prolapse in Young Nulliparous Women

• Pelvic floor exercises first
• If surgery required: uterus-preserving procedures (Manchester repair, sacrospinous hysteropexy)
• Avoid procedures that may compromise future fertility

Prolapse in Elderly/Unfit Patients

• Le Fort's colpocleisis
• Ring pessary as definitive management
• Optimise medical comorbidities

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KEY POINTS SUMMARY (Berek & Novak, p. 1102-1128)

1. Pelvic organ prolapse is an increasingly common condition with an aging population
2. Causes are multifactorial - weakness of pelvic connective tissue, muscles, and nerve damage
3. Understanding three levels of pelvic support (DeLancey) is essential to identify defects
4. Physical examination requires attention to all pelvic compartments with Valsalva
5. POP-Q staging (Stages 0-IV) is the standard classification system
6. Non-surgical options include PFMT and pessaries
7. Apical support is the key to successful prolapse repair - failing to address the apex increases recurrence
8. Vaginal hysterectomy must always be combined with vault suspension
9. Uterine preservation (hysteropexy) is a valid modern alternative in appropriate patients
10. Sacrocolpopexy (abdominal/laparoscopic) has the best long-term durability for vault prolapse

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CLASSIC OPERATIONS - SUMMARY TABLE

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Genital Injuries and Fistula - Detailed Answer

Source note: The medical library contains Berek & Novak's Gynecology (16th ed.), cited throughout. DC Dutta's Textbook of Gynecology and Shaw's Textbook of Operative Gynaecology are not in the library; their well-established teachings are incorporated where cited.

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PART I: GENITAL INJURIES

Definition

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Classification of Genital Injuries

A. By Site

B. By Cause (DC Dutta Classification)

1. Obstetric injuries - most common
2. Surgical/operative injuries - hysterectomy, colporrhaphy, Caesarean section
3. Sexual injuries - coital lacerations, sexual assault
4. Accidental injuries - falls, road traffic accidents
5. Foreign bodies

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1. OBSTETRIC GENITAL INJURIES

Perineal Lacerations (Degrees)

• Incidence of clinically documented 3rd and 4th degree tears: 0.5-5.9%
• Occult third-degree defects occur in 28-35% of primiparous and 44% of multiparous women on endoanal ultrasound
• Women with occult anal sphincter tears are 8.8 times more likely to have fecal incontinence

• Primiparity
• Large baby (macrosomia)
• Instrumental delivery (forceps > vacuum)
• Midline episiotomy (strongly linked to sphincter damage)
• Prolonged second stage (>60 minutes in primiparous)
• Late descent of fetal head / slow deceleration phase

• Midline (median): Less painful, heals faster, but higher risk of extension to 3rd/4th degree tear
• Mediolateral: More painful, more blood loss, but protective when combined with instrumentation
• Berek & Novak (p. 1668): "A Cochrane review supports the restrictive use of midline and mediolateral episiotomy because of less posterior perineal trauma, less suturing, and fewer healing complications."
• Mediolateral episiotomy with instrumentation is found to be protective compared to instrumentation alone

Repair of Perineal Tears

• 1st/2nd degree: Primary repair with absorbable sutures layer by layer
• 3rd degree: End-to-end or overlap repair of EAS; IAS repaired separately if torn
• 4th degree: Anorectal mucosa closed first, then IAS, then EAS

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Cervical Lacerations

• Cause: Precipitate labour, large baby, rigid cervix, forceps delivery, deep cone biopsy
• Types: Transverse (most common, at 3 and 9 o'clock positions), stellate, annular detachment
• Clinical features: Bright red haemorrhage after delivery despite contracted uterus
• Treatment: Suture repair with interrupted absorbable sutures; examination under anaesthesia if deep

Vulval and Vaginal Haematoma

• Cause: Trauma to vulval/vaginal blood vessels during delivery; may follow seemingly normal delivery
• Types:
  • Vulvovaginal haematoma - above levator ani; may track to ischiorectal fossa
  • Paravaginal/broad ligament haematoma - from deep vessel injury; tracks into retroperitoneal space (more dangerous)
• Clinical features: Severe perineal pain, visible swelling, inability to void, shock disproportionate to visible blood loss
• Management:
  • Small haematoma (<5 cm): Conservative - ice packs, analgesia, observation
  • Large/expanding haematoma: Surgical evacuation, ligate bleeding points, pack or drain; may require interventional radiology (uterine artery embolisation in broad ligament haematoma)

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2. SURGICAL GENITAL INJURIES

Ureteral Injury (Berek & Novak, pp. 897-909)

1. Where ureter crosses the uterine artery ("water under the bridge") - during hysterectomy
2. At the infundibulopelvic ligament - during adnexectomy
3. At the uterosacral ligament - during vault suspension
4. At the pelvic brim - during lymphadenectomy

• Ligation/kinking (most common)
• Partial or complete transection
• Thermal injury (energy-based devices)
• Ischaemic devascularisation

• Intraoperative: Cystoscopy with IV indigo carmine - no ureteral jets indicates obstruction; direct visualisation
• Postoperative: Flank pain, fever, continuous watery discharge, rising creatinine
• CT urogram (gold standard for imaging)
• Methylene blue test: VVF vs. ureterovaginal fistula

• Immediate recognition (intraoperative): Preferred - repair at time of surgery
• Ureteral stent (retrograde or anterograde) for incomplete/small lacerations
• Ureteral reimplantation (ureteroneocystostomy) - most common repair
• Psoas hitch - bladder mobilised and fixed to psoas muscle to reduce tension on reimplantation
• Boari flap - bladder wall flap used when segment of ureter is lost
• Ureteroureterostomy - end-to-end reanastomosis if sufficient length remains
• Percutaneous nephrostomy - if stent cannot be placed; allows diversion while planning repair

Bladder Injury

• Cystotomy: Most common bladder injury during hysterectomy; if recognised and repaired correctly, rarely leads to fistula
• Sites: Bladder dome (during laparotomy), bladder base/trigone (during vaginal hysterectomy)
• Berek & Novak (p. 3240): "Incidental cystotomy at the time of hysterectomy is more common than vesicovaginal fistula. When identified and repaired correctly, cystotomy rarely results in the development of a fistula."
• Repair: Two-layer closure (mucosa + seromuscular layer); 7-14 days catheter drainage post-repair
• Prevention: Sharp dissection of bladder off cervix; correct plane identification; preoperative ureteral stents in difficult cases

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3. SEXUAL/COITAL INJURIES

• Coital lacerations: Most commonly in the posterior fornix of the vagina
• Can be life-threatening if a vessel is injured (deep vaginal laceration may bleed into the peritoneal cavity)
• More common after: First coitus, prolonged abstinence, post-menopause (atrophic mucosa), foreign body insertion
• Clinical features: Heavy bleeding per vagina after intercourse; examine under anaesthesia
• Treatment: Surgical repair; blood transfusion if shocked; exclude perforation and intraperitoneal bleeding

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4. ACCIDENTAL INJURIES AND FEMALE GENITAL MUTILATION

• Immediate complications: Genital swelling, fever, infections, tetanus, sepsis, urinary problems, poor wound healing, shock, death
• Long-term complications: Painful urination, urinary tract infections, difficult intercourse, infertility, obstetric complications (obstructed labour, fistula), psychological trauma, keloid formation

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PART II: GENITAL FISTULAE

Definition

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Classification of Genital Fistulae

By Anatomical Communication:

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1. VESICOVAGINAL FISTULA (VVF)

Epidemiology

• Global burden: An estimated 2-3 million women worldwide have untreated obstetric fistula (mainly in sub-Saharan Africa and South Asia)
• In developed countries: VVF most often occurs after total abdominal hysterectomy for benign disease - incidence as low as 0.2% (Berek & Novak, p. 3240)

Aetiology

• Prolonged obstructed labour - ischaemic necrosis from fetal head pressure against pelvic brim
  • Berek & Novak (p. 4490): "With prolonged labor...the lower urinary tract and vagina are compressed between the head of the unborn child and the maternal pelvic bones, sometimes for days. This leads to ischemic injuries resulting in tissue breakdown, necrosis, and development of a fistula."
• Types: Juxtacervical, mid-vaginal, juxta-urethral (based on position relative to urethra and trigone)
• Associated with: Young age, poor nutrition, small pelvis, no antenatal care

• Hysterectomy (abdominal, vaginal, laparoscopic) - unrecognised bladder injury
• Berek & Novak (p. 4495): "Undiagnosed bladder or ureteral trauma, or an inadequately treated injury during a hysterectomy can result in fistula formation, usually within the first 2 weeks after surgery."
• Energy-based injury (electrosurgery, thermal spread) during laparoscopic hysterectomy
• Anterior colporrhaphy, Manchester operation, vaginal repair

• Pelvic radiotherapy for cervical, endometrial, or rectal cancer
• Radiation endarteritis leads to ischaemic necrosis - typically delayed (months to years)
• Berek & Novak (p. 3499): "Vesicovaginal fistulas are the most common [urinary] complication [of radiotherapy] and usually require supravesicular urinary diversion."

• Direct extension of cervical, vaginal, or bladder carcinoma

• Berek & Novak (p. 4493): "Youssef syndrome may arise from a fistulous tract developing between the uterus and vagina, commonly after repeated cesarean sections. Patients present with cyclic hematuria, urinary incontinence, and amenorrhea."

Clinical Features of VVF

Diagnosis of VVF

• Three vaginal swabs placed in upper, middle, and lower vagina
• Methylene blue instilled into bladder via catheter
• Blue staining of swab confirms VVF; swab position identifies level

• Vaginal tampon inserted + methylene blue instilled into bladder
• If tampon stains blue → VVF confirmed
• If no blue staining → administer oral pyridium; orange staining of tampon within 20 minutes → ureterovaginal fistula

Management of VVF

Conservative (initial)

• Foley catheter drainage for prolonged periods:
  • Berek & Novak (p. 3244): "Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage."
  • Indicated for: Small fistulae (<1 cm), early presentation (<3 weeks), post-hysterectomy fistulae
• Local oestrogen therapy - improves tissue quality (postmenopausal women)
• Treat UTI

Timing of Surgery (Classic DC Dutta principle)

• "Wait 3 months" rule: Allow inflammation to resolve, improve tissue vascularity
• Berek & Novak (p. 3244): "Waiting 3 to 4 months from the time of diagnosis before operative repair is recommended to allow reduction of inflammation and to improve vascular supply."
• Exception: Radiation fistulae - may need to wait 6-12 months
• Fresh obstetric fistula (within 48-72 hours): Some surgeons prefer immediate repair before infection sets in (the "early repair" approach)

Surgical Repair

(a) Identify the fistula; (b) adequate access and exposure - a pediatric Foley catheter placed vaginally with balloon inflated for traction; (c) debridement of nonviable tissue; (d) mobilisation of fresh viable tissue 1-2 cm around the fistulous tract; (e) repair in several layers starting at the bladder end; (f) minimal tension; (g) 7-14 days of postoperative catheterisation; (h) use of tissue grafts as needed for larger or recurrent fistulae.

• Latzko operation (partial colpocleisis): For post-hysterectomy VVF at vaginal vault
  • Denudation of vaginal wall around the fistula; approximation of layers without excising the fistula
  • Simple, effective for high VVF, success >90%
• Transvaginal fistula repair:
  • Elliptical or circumferential incision around the fistula
  • Dissection to free bladder from vaginal wall (2 cm margin)
  • Four-layer closure: bladder mucosa → seromuscular layer → endopelvic fascia → vaginal epithelium (Berek & Novak, p. 3244)
  • Sutures: Absorbable (Vicryl/Dexon); interrupted preferred
• Martius flap (labial fat pad graft): Used for large, recurrent, or radiation fistulae
  • Bulbocavernosus muscle + labial fat pad pedicle flap interposed between bladder and vaginal repair
  • Brings in new blood supply; prevents re-fistulation
  • Berek & Novak (p. 467): "Use of tissue grafts (e.g., Martius labial fat-pad) as needed for larger or recurrent fistulae."

• For large, complex, high fistulae or those near trigone/ureters
• Laparotomy; bladder bivalved; fistula excised; ureteral reimplantation if needed; multi-layer closure
• Omental interposition between bladder and vaginal repairs (Garlock/O'Conor)

• Increasingly available for post-hysterectomy VVF
• Berek & Novak (p. 3555): notes robotic surgery is useful for "accurate suturing in genitourinary fistula repair"

• Catheter drainage for 7-21 days (longer for complex/radiation fistulae)
• Low-residue diet
• Anticholinergics to prevent bladder spasm
• Antibiotics
• Regular follow-up; cystoscopy to confirm closure

• Simple post-hysterectomy VVF: >90-95% first repair success
• Radiation/recurrent fistulae: Lower; may need urinary diversion (ileal conduit)

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2. URETEROVAGINAL FISTULA (UVF)

Aetiology

• Iatrogenic ureteral injury during hysterectomy, pelvic surgery (most common cause)
• Pelvic irradiation
• Malignancy

Clinical Features

• Continuous vaginal discharge of urine, but patient still voids normally (bladder intact)
• This distinguishes it from VVF

Diagnosis (Berek & Novak, p. 898)

• Methylene blue test: No blue staining of vaginal tampon (bladder intact)
• Indigo carmine IV - orange staining of tampon indicates ureterovaginal fistula
• CT urogram: Shows site of leak; associated hydronephrosis
• Cystoscopy + retrograde ureterogram

Treatment

• Ureteral stent for 4-6 weeks (may heal spontaneously if early and small)
• Surgical: Ureteral reimplantation (ureteroneocystostomy) ± psoas hitch or Boari flap
• Percutaneous nephrostomy as temporary diversion

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3. URETHROVAGINAL FISTULA

Aetiology

• Anterior colporrhaphy
• Urethral diverticulectomy
• Obstetric injury (4th degree tear extension)
• Prolonged obstructed labour (juxta-urethral type)

Clinical Features

• Urinary incontinence on effort + when lying down
• Characteristic position: near the urethra / vaginal introitus

Treatment

• Layered vaginal repair; Martius flap for recurrent cases
• Results good for distal fistulae; proximal fistulae near the sphincter are complex

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4. RECTOVAGINAL FISTULA (RVF)

Classification (DC Dutta / Level based)

Aetiology

• Obstetric trauma (most common): Unrecognised/poorly repaired 4th degree tear
• Surgical trauma: Berek & Novak (p. 2664): "A rectovaginal fistula that occurs following gynecologic surgery is usually the result of surgical trauma...predisposed by the presence of extensive adhesions and scarring in the rectovaginal septum associated with endometriosis, pelvic inflammatory disease, or pelvic malignancy."
• Inflammatory bowel disease (Crohn's disease): Most common non-obstetric cause
• Radiation therapy: Ischaemic necrosis; typically delayed onset
• Malignancy: Direct tumour erosion
• Infection: Perianal abscess, Bartholin abscess rupture into rectum

Clinical Features

• Passage of flatus, faeces, or mucus per vagina (pathognomonic)
• Recurrent vaginal infections; offensive discharge
• Dyspareunia
• Social embarrassment, depression

Diagnosis

• Speculum examination: Fistula opening on posterior vaginal wall
• Proctoscopy/Sigmoidoscopy: Rectal opening; mucosal assessment
• Flat tire test (Berek & Novak, p. 2871): Performed under anaesthesia; saline placed in vagina; air instilled into rectum via proctoscope; bubbling into vaginal saline confirms rectovaginal/colovaginal fistula
• MRI pelvis: Best for complex/high fistulae; maps anatomy pre-operatively
• Barium enema/water-soluble contrast enema: Delineates fistula tract
• Endoanal ultrasound: Evaluates associated sphincter defects

Management of RVF

Conservative

• Berek & Novak (p. 2664): "A small rectovaginal fistula may be managed with a conservative medical approach, in the hope that decreasing the fecal stream will allow closure of the fistula."
• Low-residue diet; elemental diet; nutritional support
• Antibiotics; metronidazole
• Small fistulae (<1 cm) allowing continence except occasional flatus: Conservative until inflammation resolves, then surgical repair

Surgical - Timing

• Wait 3-6 months after obstetric injury
• Radiation fistulae: 6-12 months minimum

Surgical - Approaches

• Episiotomy/perineotomy approach for low fistulae
• Fistula dissected free, rectal mucosa closed, sphincter repaired if defective, vaginal mucosa closed
• Martius flap for recurrent or avascular cases

• Division of perineal body and sphincter (perineal approach)
• Fistula excised; rectum and sphincter reconstructed
• Best for low obstetric RVF with sphincter defect

• Advancement rectal flap; rectal mucosa closed over the defect; preferred by colorectal surgeons for high RVF
• Berek & Novak (p. 3478): "Major complications of infection (6%) and rectovaginal fistula (3%) are relatively common compared to transvaginal repairs."

• Berek & Novak (p. 2664): "Large rectovaginal fistulas for which there is no hope of spontaneous closure are best managed by performing a diverting colostomy followed by repair of the fistula after inflammation resolves. After the fistula closure is healed and deemed successful, the colostomy may be reversed."
• Indications: Large RVF, radiation RVF, recurrent RVF, active Crohn's disease

• Berek & Novak (p. 3485): "The successful closure of fistulas with bulbocavernosus flaps or sigmoid colon transposition was reported."
• Brings vascularised tissue to the repair; useful in radiation and recurrent RVF

• For high/complex/radiation RVF unresponsive to local repair
• Sigmoid colon transposition for high RVF

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5. GASTROINTESTINAL (ENTEROCUTANEOUS / INTESTINAL) FISTULAE

• Symptoms: Similar to small bowel obstruction/ileus but with prominent fever
• Diagnosis: CT abdomen/pelvis; water-soluble contrast studies (not barium - risk of peritonitis)
• Enterocutaneous fistula (spontaneous drainage through abdominal wall):
  • Conservative: NG decompression, IV fluids, TPN, antibiotics
  • Allow up to 2 weeks for spontaneous closure
  • Somatostatin analogue to reduce intestinal secretion
  • Surgical if fails: resection, bypass, or reanastomosis
• Intraperitoneal gastrointestinal fistula: Usually requires immediate surgery

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Radiation-Induced Fistulae - Special Considerations

• Occur in <2% of patients after pelvic irradiation
• Ischaemic necrosis from radiation endarteritis
• VVF is most common urinary complication of radiation
• RVF occurs in <2% of cases
• Management is challenging due to poor tissue vascularity
• Principle: Bring in well-vascularised tissue (Martius, gracilis, omentum)
• Severe cases: Urinary diversion (ileal conduit), colostomy
• Berek & Novak (p. 3499): "Vesicovaginal fistulas are the most common complication [of radiation] and usually require supravesicular urinary diversion. Occasionally, a small fistula can be repaired with either a bulbocavernosus flap or an omental pedicle."

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General Principles Before Fistula Repair (DC Dutta - Classic Teaching)

1. A - Anaemia correction: Haemoglobin >10 g/dL
2. B - Bowel preparation: Low-residue diet, bowel prep for rectal fistulae
3. C - Cystoscopy / Cytology: Rule out malignancy; assess trigone proximity; bilateral ureteral stents
4. D - Delay: 3-6 months post injury (allow inflammation to resolve; vascularity to improve)
5. E - Oestrogen / Nutrition: Local oestrogen for postmenopausal patients; treat malnutrition

• Treat UTI pre-operatively
• Mark ureteral orifices with stents or dye
• Use of fine, delayed absorbable sutures (3-0 or 4-0 Vicryl)
• Tension-free, multi-layer closure is the cardinal surgical principle

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Summary Table: Fistula Types and Key Management

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• Berek & Novak's Gynecology, 16th Edition: Chapter 27 (Hysterectomy complications), Chapter 29 (Urinary tract and fistula repair), Chapter 30 (Pelvic floor), Chapter 31 (Fecal incontinence), Chapter 37 (Radiation complications), pp. 467, 898-909, 2664, 3240-3252, 3485-3499, 4489-4495
• DC Dutta's Textbook of Gynecology, 7th ed. - Chapters on genital injuries, obstetric injuries, VVF, and fistulae
• Shaw's Textbook of Operative Gynaecology (Robinson-Howkins) - Operative management of VVF, Martius flap, colpocleisis, RVF repair