Vesicovaginal fistula

　　Vesicovaginal fistula is usually divided into various symptoms, mainly manifested as vesicointestinal fistula, vesicovaginal fistula, and vesicopelvic fistula, and other symptoms. Then, what are the etiological factors of vesicovaginal fistula? Common causes are as follows:

　　1. Primary intestinal diseases

　　Diverticulitis accounts for 50% to 60%; colon cancer 20% to 25%, Crohn's disease 10%.

　　2. Primary gynecological diseases

　　Obstructed labor-induced pressure necrosis, advanced cervical cancer.

　　3. Gynecological surgery

　　After hysterectomy, low transverse cesarean section, or after tumor radiotherapy.

　　4. Injury

　　Malignant necrosis and erosion of the colon, small intestine, vagina, and cervical canal, severe bladder injury leading to the formation of perivesical abscesses, which can溃溃 into the perineum or abdominal cavity. Accidental bladder injury may occur during gynecological vaginal surgery.

　　In addition, cystolithotomy, and after transurethral resection of the prostate, can also lead to long-standing fistula formation. There are also reports that vesicovaginal fistula disease is caused by intestinal diseases, accounting for about 60%. Caused by colorectal cancer, about 20%. The proportion caused by Crohn's disease is about 10%.

　　Vesicovaginal fistula is relatively common in clinical practice and can communicate with the skin, intestines, and female reproductive organs. The etiology of vesicovaginal fistula is often an extrarenal urological disease. Therefore, the treatment of vesicovaginal fistula should focus on symptomatic treatment based on the specific etiology. If not treated in a timely manner or treated improperly, it is prone to other complications.

　　Common complications of vesicovaginal fistula in clinical practice include:

　　1. Hemorrhage and Hematoma

　　Various vaginal repair surgeries are due to small surgical fields, heavy adhesions, difficulties in exposure, accidental injury to surrounding larger blood vessels, or due to harder scar tissue around the area, making hemostasis difficult, leading to continuous bleeding in the pelvis or postoperative渗血forming hematomas. Therefore, the stripping of tissues must be cautious and meticulous, and should not be done in large areas. Any bleeding points should be hemostatized thoroughly. If there is oozing blood that cannot be stopped from above, saline pads with pressure, hemostatic sponges, or Monsel's solution can be used to help stop the bleeding. Suturing should be done carefully to avoid leaving any gaps to prevent oozing blood.

　　2, Infection

　　Patients with vesicovaginal fistula all have varying degrees of urinary tract infection. After fistula repair, the wound still contacts contaminated urine, and the surgical injury to the tissue increases the amount of non-vital tissue, or using multiple strands of silk thread to suture can cause foreign bodies to remain in the wound. All these factors can cause the repaired scar to become infected and suppurate, leading to poor healing and the reformation of the disease orifice. The operation must meet sterile requirements, and tissue damage should be minimized. The use of monofilament atraumatic suture thread, good drainage, and maintaining the bladder in a voided state are the main measures to prevent the failure of fistula repair.

　　3, Urinary incontinence

　　Vesical neck fistula is extremely difficult to repair due to tissue defects, and even if the repair is successful, urinary incontinence is likely to occur postoperatively. However, the surgical reconstruction of bladder and urethral continuity by repairing vaginal defects is more likely to be successful. For cases without vesical neck defects, urinary incontinence due to long-term disuse of the internal sphincter, relaxation of the vesical neck, or short urethra can occur after surgery. To prevent stress urinary incontinence, the vesical neck can be fixed to the pubic periosteum at the same time as the urethral elongation procedure.

　　4, Ureteral injury

　　Because the distal ends of both ureters enter the bladder through the vaginal fornix, they are very close to the superior aperture of the vagina, especially in giant disease holes, which are often connected with one or even both ureteral orifices. Especially when the bladder mucosa is edematous, the ureteral orifices are not easily seen, and slight carelessness during surgery can easily cause injury.

　　The clinical manifestations of vesicofistula vary depending on the involved site, and the clinical manifestations are:

　　(1) Bladder intestinal fistula

　　Vesicointestinal fistula can present with symptoms such as bladder irritation, fecal leakage, and urethral exhaust, often accompanied by changes in defecation habits caused by primary intestinal diseases, and physical examination may reveal signs of intestinal obstruction. If it is caused by inflammatory diseases, abdominal muscle tenderness may be observed. Urinalysis often suggests concurrent infection. Barium enema and sigmoidoscopy can show the presence of fistula, and usually after barium enema, urine samples are centrifuged and X-ray examination is performed to find non-transparent barium to confirm the presence of vesicocolonic fistula. Cystoscopy has important diagnostic value, helping to locate the fistula, and under the microscope, it can be seen that the bladder wall shows obvious inflammatory changes. Catheterization through the fistula and injection of contrast agent can often help with definitive diagnosis.

　　(2) Bladder vaginal fistula

　　Vesicovaginal fistula is relatively common, often secondary to obstetric, surgical, or radiotherapy injuries or cervical cancer. Under cystoscopy, the catheter can be directly inserted through the fistula orifice to communicate with the vagina, and vaginal radiography can often well display vesicovaginal fistula, ureterovaginal fistula, and rectovaginal fistula. Another method is to insert a Foley catheter into the vagina, fill the water balloon after inflation, and inject a moderate amount of contrast agent to help with diagnosis. It has been reported that for some patients with small vesicovaginal fistula, scraping the fistula orifice with a metal spatula to promote closure can achieve good results after 3 weeks of catheter indwelling postoperatively.

　　(3) Bladder peritoneal fistula

　　This rare bladder fistula can be diagnosed through vaginal examination and detected through cystoscopy to find the fistula opening.

　　Bladder fistula patients should establish a normal dietary habit in their daily life, as the occurrence of bladder fistula is related to damp-heat. For greasy foods, they can produce damp-heat internally and should not be eaten too much. Therefore, it is recommended to eat more light and vitamin-rich foods, such as fresh vegetables and fruits like mung beans, radish, and winter melon.

　　The occurrence of bladder fistula is closely related to damp-heat, so it is necessary to limit the intake of greasy and damp-heat-producing foods. At the same time, it is important to quit smoking, drinking, and tea addiction. It is recommended to eat more light and vitamin-rich foods, such as winter melon, luffa, mung beans, and radish.

　　The chronic bladder fistula mostly belongs to the deficiency type, and it is advisable to consume foods rich in protein and other nutrients, such as lean meat, beef, mushrooms, jujube, and sesame. In addition, other foods for the prevention and treatment of deficiency include black fungus, yam, coriander, chive, eggplant, coix seed, lotus root, fennel, litchi, chicken, mutton, and figs.

　　Attention should be paid to the prevention and treatment of constipation and diarrhea, which is of great significance for preventing bladder-rectal abscesses. Because dry stools are prone to scratch the anal sinus, and combined with bacterial invasion, it can lead to infection. If not treated actively, it may cause systemic diseases such as ulcerative colitis and Crohn's disease. It is important to develop good defecation habits, take a sitz bath after defecation to keep the perineum clean, which has a positive effect on preventing infection.

　　The diagnosis of bladder fistula requires the combination of relevant examinations to be confirmed. Physical examination may reveal signs of intestinal obstruction, and if it is caused by inflammatory diseases, there may be signs of abdominal muscle tension. Urinalysis often suggests the presence of infection. Barium enema and sigmoidoscopy can show the presence of fistula, usually after barium enema, urine samples are centrifuged and then X-ray examination is performed to detect non-transparent barium, which can confirm the presence of bladder-colon fistula. Cystoscopy has important diagnostic value and can help locate the fistula. Under the microscope, the bladder wall shows obvious inflammatory changes, and injecting contrast agent through the fistula tube often helps to confirm the diagnosis.

　　The occurrence of bladder fistula is closely related to damp-heat, so it is necessary to limit the intake of greasy and damp-heat-producing foods. At the same time, it is important to quit smoking, drinking, and tea addiction. It is recommended to eat more light and vitamin-rich foods, such as winter melon, luffa, mung beans, and radish.

　　The chronic anal fistula mostly belongs to the deficiency type, and it is advisable to consume foods rich in protein and other nutrients, such as lean meat, beef, mushrooms, jujube, and sesame. Establishing a normal dietary habit is important. For greasy foods, they can produce damp-heat internally, so it is not recommended to eat too much and instead, more light and vitamin-rich foods such as mung beans, radish, and winter melon should be consumed.

　　The chronic bladder fistula is mostly due to deficiency, and it is recommended to consume more protein-rich foods in diet, such as lean meat, beef, mushrooms, black fungus, yam, coriander, chive, eggplant, coix seed, water chestnut, lotus root, fennel, litchi, chicken, mutton, and figs.

　　Common diet therapy:

　　(1) Boil 1 eel, 100 grams of lean pork, and 25 grams of Astragalus membranaceus together, add appropriate amounts of salt, sugar, and huangjiu, and eat after removing the Astragalus membranaceus. It is suitable for patients with bladder fistula of the deficiency type.

　　(2) Wash 100 grams of rice and 100 grams of millet, put them in a pot with enough water, bring to a boil, and then cook the porridge until it is half done. Add 500 grams of soy milk and stir well, then cook until done. It is suitable for patients with deficiency and can be eaten by the elderly and children.

　　(3) Add 6 grams of chrysanthemum, 6 grams of white sugar, and 3 grams of green tea leaves to a teacup, pour boiling water over them, let it steep for a moment, and it will have a light, fragrant and elegant taste. It can clear heat and detoxify, promote blood circulation, and relieve dampness and arthralgia.

　　The harm of bladder fistula is great and it is also common, so for the treatment of bladder fistula, it must be timely. Bladder fistula is mainly divided into three types: bladder intestinal fistula, bladder vaginal fistula, and bladder adnexal fistula. Here, I will introduce the treatment methods of these three types of bladder fistulas, hoping it will be helpful to you.

　　(1) Bladder intestinal fistula

　　If the lesion is located in the rectum or sigmoid colon, a proximal intestinal fistula can be performed first, and the fistula orifice can be closed after the inflammation subsides and the lesion segment of the intestine is resected. After that, the colonic fistula orifice can be closed. Some scholars propose that the entire operation should be completed in one stage, and partial resection of the intestinal segment or ileocecal resection is required for small intestinal or ileocecal bladder fistula, and the bladder fistula orifice should be closed.

　　(2) Bladder vaginal fistula

　　Smaller bladder vaginal fistulas can be treated with electrocautery, and the catheter should be left in place for at least 2 weeks after surgery. Aycinena (1977) reported that for some patients with small bladder vaginal fistulas, the fistula orifice was scraped with a metal spatula through the vaginal fistula orifice to promote closure, and the catheter was left in place for 3 weeks after surgery, which can achieve better efficacy.

　　Large bladder vaginal fistulas secondary to obstetric or surgical injuries can be surgically repaired through vaginal or bladder routes. Bladder vaginal fistulas caused by radiotherapy for cervical cancer are difficult to repair due to poor local tissue blood supply. For bladder vaginal fistulas caused by direct invasion of cervical cancer into the bladder, surgical repair is impossible, so urinary diversion surgery is often required, such as ureterosigmoidostomy.

　　(3) Bladder peritoneal fistula

　　Bladder peritoneal fistula can be cured by resection of the involved female reproductive organs and closure of the bladder fistula.