GENITAL FISTULÆ.
Fistulous openings may exist between the different portions of the
genital tract and the neighboring structures. Such fistulæ are the
result of childbirth, operative or other form of traumatism, congenital
defect, cancer, syphilis, or suppuration. The accompanying diagram
(Fig. 180) shows the chief varieties of fistula that occur.
[Illustration: FIG. 180.--Diagram illustrating the chief varieties
of genital fistula: _v. u._, vesico-uterine fistula; _v. v._,
vesico-vaginal fistula; _u. v._, urethro-vaginal fistula; _r. v._,
recto-vaginal fistula.]
=Vesico-vaginal Fistula.=--The most frequent form of fistulous opening
occurs in the septum between the bladder and the vagina. The condition
is usually caused by sloughing, the result of prolonged pressure from
the fetal head at labor.
In some cases such an opening is made for therapeutic reasons by the
physician, for the cure of cystitis.
Intelligent midwifery and the prompt and proper use of the obstetrical
forceps have greatly diminished the frequency of vesico-vaginal
fistula. It was formerly a very common disease. At the present day it
is but rarely seen, at least in those parts of the country where women
have competent attendance at labor.
The vesico-vaginal opening may be situated at any portion of the
septum. It varies very much in size and shape. It may be a small
hole barely admitting a fine probe-point, a median slit, or a large
irregular opening involving the whole base of the bladder.
The appearance of the fistula varies according to the time that has
elapsed since the receipt of the injury. The margins of the opening,
which are at first irregular and ulcerated, become in time thin and
firm from cicatricial contraction, and the size of the opening becomes
similarly diminished.
The first symptom of vesico-vaginal fistula is the involuntary escape
of urine from the vagina. If the condition has resulted from pressure
at parturition, the incontinence of urine does not appear for five or
ten days after labor, when the slough has separated. When a direct
laceration of the vesico-vaginal septum has occurred, the urine will
escape immediately.
The degree of incontinence varies with the size and the position of the
fistula. If the opening is small and is situated in the upper part of
the vagina, there may be perfect continence when the woman is in the
erect position, as long as the urine remains below the level of the
opening. Incontinence returns when the accumulation of urine becomes
greater than this and when the woman assumes the recumbent posture. I
have seen a woman with a fistula of this kind who was only troubled
with incontinence at night.
The secondary symptoms of vesico-vaginal fistula are due to the
irritation of the urine. Unless the greatest cleanliness be observed,
great suffering may result within a few weeks after the receipt of the
injury. The vagina, the labia, and the inner aspects of the thighs
become inflamed and excoriated. The mucous membrane of the vagina may
become covered with an offensive phosphatic deposit. If the fistulous
opening be large, the fundus of the bladder may prolapse into the
vagina and become covered with a similar deposit.
Secondary kidney disease, from infection of the ureters, may follow in
time.
As the result of disuse the bladder becomes contracted, and its walls
become thickened from inflammatory infiltration, so that when the
fistula is closed the capacity of the bladder is much less than normal.
Disuse of the urethra results also in contraction, which may be so
extensive as seriously to complicate treatment.
Physical examination usually reveals the condition. The woman should be
placed in the Sims, the genu-pectoral, or the lithotomy position, and
the anterior vaginal wall should be examined through the Sims speculum.
The examiner should, of course, determine that the involuntary flow of
urine comes from the vagina, and not from the urethra. Women are often
unable to tell accurately whence the urine escapes, and the single
symptom of incontinence of urine is not pathognomonic of fistula.
In most cases the fistulous opening may be readily detected, and a
sound passed through the urethra may be made to emerge in the vagina.
In the case of small openings, however, obscurely situated in the upper
part of the vagina, and especially in case of vesico-uterine fistula,
it may be difficult to demonstrate the presence of a fistula. In such
cases the bladder may be filled with sterile milk, which may then be
seen escaping into the vagina. This is a valuable method of diagnosis
in the rare cases of uretero-vaginal fistula.
_Treatment._--The method of curing vesico-vaginal fistula was taught to
the world by Marion Sims, who operated successfully in 1849, and who
published his first article upon the subject in 1852.
Careful preparatory treatment before operation is usually necessary.
Unless the vagina and the bladder are in a healthy condition
beforehand, every method of operation is likely to fail.
It is necessary to treat all excoriations or ulcerations, to cure the
cystitis, and to relieve the tension of all bands of scar-tissue in
the vagina that may prevent proper approximation of the edges of the
opening.
The phosphatic deposit should be carefully removed from the vaginal
walls and the interior of the bladder with a soft sponge or cotton, and
a weak solution of nitrate of silver (gr. v to ℥j) should be applied to
the raw surfaces.
Frequent warm sitz-baths should be administered daily. The vagina
should be washed out several times a day with large quantities of
sterile hot water or with a solution of boracic acid (ʒj to the pint).
The urine, which is generally alkaline, should be rendered acid by the
use of benzoic or boracic acid.
Emmet advises the following prescription: “2 drams of benzoic acid
and 3 drams of borax to 12 ounces of water, of which a tablespoonful,
further diluted, should be given three or four times a day.” After the
urine has become acid the dose may be reduced.
Every fifth day the solution of nitrate of silver should be applied
to the unhealed, excoriated surfaces. It may be necessary to pursue
this treatment several weeks before the parts are brought to a healthy
condition. Improvement is perceived not only in the condition of the
vaginal walls and the bladder, but in the edges of the fistula, which,
in place of being hypertrophied and indurated, assume a natural color
and density.
In case the vaginal fistula be small, the accompanying cystitis may
be difficult to cure, because there is always some residual urine
in the bladder. It may then be advisable, as a preparatory step, to
enlarge the fistulous opening by a clean incision in the median line,
in order to secure more perfect drainage. The cystitis may be kept up
by the presence of a phosphatic concretion in the bladder, which may
be removed in this way. It is useless to close the fistula until the
cystitis is cured.
In every case of vesico-vaginal fistula it is advisable to examine for
vesical calculus, that the bladder may not be closed with a calculus
in it. The calculus occasionally exists before the formation of the
fistula, and perhaps assists in its production, the vesico-vaginal
septum being squeezed between the child’s head and the calculus.
Usually, however, the calculus forms as a result of the fistula.
When the parts have been brought to a healthy condition the fistula
should be examined with a view to the method of closure. The opening
should be exposed with the Sims speculum, and the edges at opposite
points should be seized with tenacula or forceps and approximated. In
this way the surgeon may determine the direction in which the fistula
may be closed with the least traction on the sutures. When possible, it
is advisable, in order to prevent shortening of the vagina, to close
the fistula in the direction of the long axis of the vagina.
[Illustration: FIG. 181.--Sims’ vaginal dilator.]
If the edges of the opening cannot readily be brought together, any
restraining bands of tissue in the vaginal walls should be divided
with scissors. If these bands are slight and superficial, they may
be divided at the time of operation for closure. If, however, they
are extensive, preparatory treatment devoted to the liberation of the
edges of the fistula must be practised. All restraining bands should
be freely divided, and after the vagina has thus been opened up, it
should be distended (to prevent subsequent contraction) by introducing
a vaginal plug or dilator (Fig. 181) or a rubber bag packed with
sponges. Bleeding is generally controlled by the pressure of the plug.
The vaginal plugs of glass or of hard rubber are made of various sizes.
They should be long enough and thick enough to stretch the vagina
without producing sloughing. The plug is retained by a T-bandage.
After this operation the woman should be kept in bed for a week or ten
days. The urine should be drawn with the catheter without removing the
plug. When suppuration begins the plug will become loosened and may
be removed. Emmet says: “It is remarkable how much absorption of the
cicatricial tissue takes place in a few weeks when judicious pressure
has been maintained by this instrument.”
After removing the plug, vaginal douches should be resumed until
healing is complete.
It will be seen from this consideration that the preparatory treatment
may be severe and may extend over a long period. Such extensive
treatment is not by any means always necessary; when, however, it is
required, it is useless to proceed to operation without it.
_Operation._--The operation consists in freshening the edges of the
fistula with the knife or scissors and bringing them into apposition
with the interrupted suture. Different forms of suture have been used
by various operators. If the parts are in a healthy condition and are
properly denuded and approximated, it makes no difference in the result
what form of suture is used. As in all forms of plastic work, I prefer
silkworm gut shotted. The operation is most easily performed with the
woman in the Sims position, the vagina being exposed with the Sims
speculum. The lithotomy or the genu-pectoral position is preferred
by some operators. The edge of the opening should be seized with the
tenaculum or with tissue-forceps, and a continuous strip of tissue
should be removed all around the fistula, extending from the mucous
membrane of the bladder out upon the vaginal surface for a quarter or
three-eighths of an inch. The vaginal mucous membrane usually retracts
somewhat as soon as it is liberated from the fistulous margin, so that
the raw surface is broader than the strip removed. It is advisable
to avoid any injury to the mucous membrane of the bladder, as free
bleeding may take place from this structure. The denuded surface should
extend as near as possible to the mucous membrane of the bladder
without involving it.
The denudation should be extended some distance beyond each angle of
the fistula, in order to secure perfect apposition in these positions.
The length and shape of the needle used for closing the opening varies
with the fancy of the operator. As a rule, a small needle, straight or
curved at the point, is most convenient (Fig. 182).
[Illustration: FIG. 182.--Fistula-needles.]
The needle should be introduced about an eighth of an inch from the
edge of the vaginal mucous membrane, and should be made to emerge
at the edge of the mucous membrane of the bladder. It should be
reintroduced and emerge in the reverse order on the opposite side (Fig.
183). The sutures should be placed about a quarter of an inch apart.
After the sutures have been introduced, and before they have been
shotted or tied, the bladder should be thoroughly washed out with
a warm boric-acid solution. The operator should make sure that no
blood-clot is left in the bladder. After the sutures have been
shotted a light gauze tampon may be placed in the vagina. A permanent
soft-rubber catheter may be introduced through the urethra, or the
urine may be drawn every three or four hours after the operation. If
care is given to the cleanliness of the catheter, it is perhaps best to
retain it in the bladder for three or four days, after which the urine
may be drawn every four hours. The catheter should be removed twice in
twenty-four hours for purposes of cleansing. The eye of the catheter
frequently becomes obstructed by blood-clot.
It should not be forgotten that the bladder is often much contracted in
old cases of vesico-vaginal fistula, and as the capacity is diminished
more frequent catheterization than usual is necessary.
Boric or benzoic acid should be continued during the convalescence.
The gauze tampon should be removed on the second day.
The bowels should be moved on the second or third day. The sutures may
remain for two weeks. The woman may sit up at the end of two weeks.
[Illustration: FIG. 183.--Vesico-vaginal fistula with the sutures
introduced.]
The operation described here--more or less modified in order to meet
the requirements of different cases--will result in cure in the great
majority of instances. Often much depends upon the ingenuity and the
mechanical skill of the operator. Sometimes two or three operations are
necessary before the opening can be completely closed, the operator
closing part at each sitting.
In the case of a small fistulous opening it may be necessary to enlarge
it by free incision before the denudation and the introduction of the
sutures can be properly accomplished.
In the very rare cases which are incurable by operation _kolpokleisis_,
or closure of the vagina, has been practised by some. The operation was
performed by removing a circular strip around the circumference of the
vagina, immediately above the ostium vaginæ, and approximating the raw
surfaces by a transverse row of sutures. This operation makes of the
bladder and the vagina one urinary pouch into which menstrual blood and
uterine discharges flow. It should never be practised. I quote from
Emmet in this connection: “From my own observation I have learned that
it is but a question of a few months, a year, or possibly two years,
before serious consequences must arise after leaving a receptacle, like
a portion of the vagina, in which the urine may stagnate. To give a
retentive power for so short a time is not a sufficient compensation
for the suffering and consequences that supervene. As the result of my
experience, I would urge that the operation never be resorted to under
any circumstances. The maximum has now been reduced to 2 or 3 per cent.
of cases where the resources of the surgeon cannot overcome all the
difficulties that may be presented in closing a vesico-vaginal fistula.”
The forms of operation in which the cervix uteri is utilized to assist
in the closure of a vesical fistula, as a result of which the menstrual
blood and the uterine secretions are discharged into the bladder, are
contraindicated for similar reasons.
=Urethro-vaginal fistula= is much less common than vesical fistula.
Unless the neck of the bladder be involved, there may be perfect
control of urine; though, of course, when the urine is voided it will
escape from the ostium vaginæ, and not from the external meatus.
The _treatment_ of urethro-vaginal fistula is essentially the same as
that already described for vesico-vaginal fistula. The edges should be
denuded, and the opening into the urethra closed over a large-sized
catheter. The line of union should be in the long axis of the urethra.
=Vesico-uterine Fistula.=--In this form of fistula the opening usually
extends from the bladder into the cervical canal. It is caused by
labor in which the anterior lip of the cervix is lacerated. The lower
portion of the cervical laceration may unite, leaving the fistulous
opening above.
The _diagnosis_ of the condition is made from observing urine escape
from the cervical canal, or by injecting the bladder with milk or other
colored fluid. A sound introduced in the cervix may be brought in
contact with a probe passed through the urethra and bladder into the
fistula.
If these methods of examination are not satisfactory, endoscopic
examination of the interior of the bladder will reveal the abnormal
opening.
The _treatment_ consists in dividing the anterior lip of the cervix
and the vaginal wall down to the fistulous tract; thorough denudation
of the walls of the fistula; and closure of the whole incision by
interrupted sutures.
=Uretero-vaginal Fistula.=--This condition is usually the result of
injury to the ureter by operation. It may occur from the destruction of
tissue caused by pelvic abscess, which discharges through the vaginal
vault. In extensive vesico-vaginal fistula caused by sloughing after
labor the bladder-wall may become rolled out so that the ureter opens
into the vagina.
If but one ureter is involved, one-half of the urine will be discharged
in the natural way and the other half by the vagina.
The _treatment_ consists in directing the ureter into the bladder
by plastic operation performed through the vagina; or by performing
celiotomy, dissecting out the ureter, and implanting it in the fundus
of the bladder.
=Recto-vaginal Fistula.=--Recto-vaginal fistula is usually caused by
parturition. The destruction of tissue is sometimes due to syphilis. In
the latter case cure is difficult, and sometimes impossible.
The _symptom_ of the condition is the passage of feces and flatus into
the vagina.
Sometimes but a very small opening exists, situated immediately above
the sphincter muscle; in other cases the greater portion of the
recto-vaginal septum is destroyed.
The condition may be recognized by placing the woman in the lithotomy
position and exposing the posterior vaginal wall by the Sims speculum
placed under the pubic arch.
The _treatment_ consists in operation similar to that described under
the consideration of vesico-vaginal fistula. The woman should be
prepared as for a plastic operation upon the perineum. The rectum
should be thoroughly emptied before operating. The sphincter ani should
be stretched. It is always advisable, when possible, to close the
opening from the vagina.
The mucous membrane of the rectum should be injured as little as
possible, in order to limit the bleeding. It may be necessary to
relieve tension on the edges of the fistula by making, on each side of
the vaginal aspect of the opening, an incision parallel to the long
axis of the vagina.
In case of a small fistula situated immediately above the sphincter
ani, it is sometimes difficult to denude and to introduce the sutures.
It then becomes necessary to divide the perineum and the sphincter
ani to the fistula, denude the edges, and to introduce sutures as
in a case of complete median laceration of the perineum. Sometimes
the recto-vaginal fistula is much larger on the vaginal than on the
rectal aspect--is, in fact, funnel-shaped, the destruction of tissue
having been greater upon the vaginal surface. If in such a case the
edges of the fistula cannot be brought into apposition after freeing
all restraining bands, it may be necessary to split the edge of the
opening, so that the rectal wall is freed and may be brought together
by sutures introduced through the rectum, leaving the vaginal opening
to be filled by granulation. The rectal sutures may be introduced by
placing the woman in the Sims position and exposing the anterior rectal
wall with the Sims speculum.
The after-treatment resembles in all respects that prescribed after
operation for laceration through the sphincter ani. The sutures should
be removed in two weeks.