Female urinary fistula

　　First, causes of disease

　　Common causes of female urinary fistulas include:

　　1. Gynecological surgical injury: During surgeries for cervical cancer, retroperitoneal tumors, and other conditions, bladder and ureteral injuries may occur, leading to urinary fistulas.

　　2. Delivery injury.

　　3. Trauma, such as pelvic fracture, rough coitus, etc.

　　4. Urogenital malformations, such as congenital ectopic ureteral orifice.

　　5. Late-stage bladder tuberculosis, tumors, etc.

　　Second, pathogenesis

　　The vast majority of urinary fistulas are caused by injury. In China, dystocia-induced injury is the main cause, followed by surgical injury, and less frequently by other injuries or infections. With the strengthening of maternal and child health care and perinatal health care in China, urinary fistulas caused by delivery injuries have been greatly reduced, while injuries from gynecological surgery have increased relatively.

　　1. Delivery injuries are mostly caused by prolonged labor and dystocia. They can be divided into necrotic and traumatic types.

　　(1) Necrotic urinary fistula: Due to malpresentation, abnormal fetal position, and pelvic inlet stenosis, the descent of the presenting part is obstructed, leading to dystocia. If the presenting part is incarcerated in the pelvic cavity for a long time, the soft tissues such as the bladder, urethra, and vaginal wall are compressed between the presenting part and the mother's pubic symphysis, causing ischemic necrosis and shedding of the soft tissues, forming fistulas. If obstruction occurs at the pelvic inlet plane, it often involves the cervix, bladder trigone, or upper part of the ureter, causing vesicocervical fistula, vesicovaginal fistula, or vesicoureterovaginal fistula. If the presenting part is incarcerated in the middle pelvis, it often involves the bladder trigone and bladder neck, leading to vesicovaginal fistula or vesicourethrovaginal fistula. If the presenting part remains in the pelvic outlet for a long time, it often involves the urethra, causing urethrovaginal fistula and vaginal annular scar stenosis.

　　(2) Traumatic urinary fistula: Performing forceps delivery when the cervix is not fully dilated and the bladder is not empty, and performing other obstetric surgeries such as craniotomy, feticide, vacuum extraction, internal version, etc., not according to the standard operation procedures, rough surgery can cause injury to the vaginal wall, bladder, and urethra. Rupture and extension of the uterine incision during cesarean section can damage the bladder, or the ureter can be ligated and the bladder wall pierced during suture, without discovery and treatment during surgery, resulting in urinary fistula.

　　2. Gynecological surgery injury: Gynecological surgeries performed through the abdomen or vagina, such as radical cervical cancer surgery, adnexectomy, total hysterectomy, etc., can cause injury to urinary system organs and lead to urinary fistula.

　　3. Chemical corrosion injury: The placement of corrosive substances such as alum in the vagina can corrode local tissue, causing necrosis, ulceration, and ultimately forming a urinary fistula.

　　4. Cancer erosion or injury after radiotherapy: Advanced cervical cancer or vaginal cancer can directly invade the bladder wall and urethra, or local tissue necrosis and shedding can occur after radiotherapy, resulting in urinary fistula. Urinary fistula after radiotherapy can occur 1 to 2 years after radiotherapy, or it may appear 10 years later. Other gynecological tumors such as trophoblastic tumors, ovarian cancer, corpus cancer, etc., can also directly invade the ureter and bladder, causing urinary fistula.

　　5. Other factors: Genital trauma or pelvic fracture can damage the urethra and bladder, resulting in urinary fistula. Bladder tuberculosis and bladder calculi can also induce urinary fistula. Long-term placement of a pessary in the vagina can cause impaction, tissue compression, ischemia, and necrosis, leading to urinary fistula.

　　According to the standards specified by the Scientific Research Cooperation Group on the Prevention and Treatment of Urinary Fistula at the Hengyang Conference in 1979, urinary fistulas can be classified into two categories according to anatomical site and fistula nature:

　　(1) Classification according to anatomical site:

　　①Urethra-vaginal fistula: The urethra fistula is connected to the vagina.

　　②Bladder-vaginal fistula: The bladder fistula is connected to the vagina.

　　③Bladder-urethra-vaginal fistula: The fistula involves the bladder neck, urethra, and vagina, with the remaining urethra shorter than 3cm.

　　④Bladder-cervical-vaginal fistula: The fistula involves the cervix, bladder, and vagina, the upper edge of the fistula is located higher, and the anterior lip of the cervix often shows severe laceration or defect.

　　⑤Ureterovaginal fistula: The fistula communicates between the ureter and the vagina.

　　⑥Urinary fistula with rectovaginal fistula: Also known as urinary-fecal combined fistula or mixed fistula. The fistula involves the urinary system, vagina, and rectum.

　　(2) Classification according to the nature of the fistula:

　　①Simple urinary fistula: The bladder-vaginal fistula is located lower, and the fistula aperture is less than 3cm. The urethra-vaginal fistula aperture is less than 1cm. The bladder-cervical-vaginal fistula, the cervix is active, and the fistula is easily exposed.

　　②Complex urinary fistula: The bladder-vaginal fistula aperture exceeds 3cm or the fistula is not easily exposed. The urethra-vaginal fistula aperture exceeds 1cm, or there are transverse, longitudinal or partial defects. Mixed fistula. Multiple urinary fistulas. Urinary fistulas that have failed multiple repairs.

　　③The most complex urinary fistula; complete absence of the urethra, complex mixed fistula, large fistula, high fistula location difficult to expose, urinary fistula with severe scarring stenosis or closure of the vagina.

　　I. Secondary infection

　　The skin of the vulva, buttocks, and inner side of the thigh is affected by the long-term soaking of urine, causing varying degrees of dermatitis, rash, and eczema, causing local itching and burning pain. If scratched, it can cause secondary infection and form boils. Urinary fistula patients may sometimes have symptoms of urinary tract infection. If there is a ureteral fistula with local ureteral stenosis leading to renal pelvis dilatation and hydrops, it is more likely to cause infection. Some first form retroperitoneal urine extrusion, complicated with infection, and then develop vaginal urine leakage, which occasionally occurs after radical hysterectomy for cervical cancer.

　　II. Secondary amenorrhea, infertility

　　About 1/2 to 1/3 of urinary fistula patients have secondary amenorrhea, but the cause is not yet clear. Some believe it is due to ovarian dysfunction caused by mental factors, anovulation during urine leakage, and ovulation and menstruation can be restored after repair and cure. About 40% of urinary fistula patients have secondary infertility, and related factors include:

　　1. Pelvic infection during delivery, residual chronic pelvic inflammation, affecting fallopian tube function.

　　2. Secondary amenorrhea, anovulation.

　　3. Urine continuously flowing out from the vagina hinders the survival of sperm.

　　III. Mental and neurological symptoms

　　Whether it is day or night, in hot summer or cold winter, urinary fistula patients dribble urine all day long, wetting clothes and bedding, emitting the smell of urine, and some have feces leakage, making the smell even worse. They often dare not go out to participate in collective activities and labor, nor do they want to visit relatives and friends, which seriously affects work and study. Those with vaginal scar stenosis or closure lose sexual and reproductive ability, and it also affects the relationship between couples and the family. Some patients cannot bear the long-term mental and physical torment and even have thoughts of suicide.

　　1. Urinary incontinence:Urine continuously flows out through the vagina, in unilateral uretero-vaginal fistula, there is still spontaneous urination, but in bladder-vaginal fistula with a large fistula, there is no spontaneous urination, and urethra-vaginal fistula only has urine flowing out through the vagina during urination.

　　2. Urinary eczema:Due to long-term stimulation by urine, the perineal and perianal skin becomes red and swollen, thickened, and sometimes there are papules or superficial ulcers, with pruritus and burning pain of the vulva.

　　3. Menstrual disorders:10% to 15% of patients have long-term amenorrhea or reduced menstruation.

　　4. Depression:Due to long-term dribbling of urine, soiling of clothing and pants, the smell of urine spreading everywhere, it is difficult to live with others, the bedsheet is wet at night, sexual dysfunction, leading to depression and even a desire to end one's life.

　　5. Gynecological examination:Vaginal endoscopy, bimanual and trichoscopy examinations, to understand the condition of the vagina and uterus, while paying attention to the size, location, and extent of scarring around the fistula, inflammation, and to check the urethra with a metal catheter or uterine probe to understand the length of the urethra, whether there is an obstruction, stenosis, or rupture.

　　I. Treatment

　　Strengthening perinatal health care and continuously improving the quality of obstetric care and gynecological surgical techniques can largely prevent urinary fistula.

　　Birth injury is the main cause of urinary fistula in developing countries. In the prevention of birth injury urinary fistula, it should be emphasized to practice family planning, strengthen the systematic management of pregnant and postpartum women, regularly perform prenatal examinations, and detect early signs of pelvic narrowness, malformation, or abnormal fetal position, correct them in time, and admit to the hospital in advance for delivery. Strengthen the observation of the labor process for women, and timely handle any abnormal labor curve or prolonged second stage of labor to end labor as soon as possible to avoid dystocia. During vaginal surgery delivery, routine catheterization to empty the bladder before surgery, strictly follow the operation procedures during surgery, and carefully use various instruments. When sharp instruments or bone fragments from amputated limbs pass through the vagina, the vaginal wall must be protected. After surgery, routine examination of the reproductive and urinary tracts for injury should be performed, and immediate repair should be given if any injury is found. For those with a long labor, urinary retention, or a history of hematuria, a catheter should be left in place for about 10 days after delivery to prevent the formation of a urinary fistula.

　　Patients with urinary fistula who have been cured should undergo cesarean section during subsequent childbirth.

　　In terms of the prevention of gynecological surgery injury, fully estimate the difficulties in surgery, grasp the links that are easy to cause injury during surgery, be familiar with the anatomy and variations of pelvic organs, and improve the basic technical operation. When adhesions are severe in pelvic surgery, carefully separate the adhesions first and restore the normal anatomy of the organs. During total hysterectomy, the bladder is pushed down to the level of the external os of the cervix, especially 1cm outside the lateral margin of the cervix on both sides. Always pay attention to the course of the ureter, and it can be mobilized if necessary to trace the course of the pelvic segment and avoid injury.

　　Radiation therapy should avoid excessive dose. The use of pessaries should be consistent with daytime placement and nighttime removal, and should not be placed for a long time. Do not use corrosive drugs in the vagina.

　　Two, prognosis

　　1. Cured: There is no urine leakage after surgery.

　　2. Improved: The amount of urine leakage after surgery has decreased.

　　3. Unhealed: The amount of urine leakage after surgery has not decreased or has even increased.

　　Three, health care

　　1. Bladder drainage: It should be kept unobstructed to facilitate wound healing. Bladder distension can tear the sutured area, leading to surgical failure. If there is urine leakage in the early postoperative period, it may come from the urethra or small cracks. Do not give up hope of success and remove the catheter. Many cases can still heal, and it is not advisable to do a vaginal examination in a hurry. The time for placing the catheter can be determined according to the size of the fistula. If the fistula is very small, it can be removed 3-5 days after surgery, and a large fistula can be extended to 12-14 days. A few people believe that it is not necessary to place a catheter at all and to rely on postoperative spontaneous urination. The reason is that it is easy to cause ascending infection, the catheter directly stimulates the repaired wound in the bladder, and over time, urinary salts can solidify into stones, affecting the success of the surgery.

　　Currently, the引流method is still widely used, but regardless of the type of bladder drainage used, it is necessary to keep the drainage tube unobstructed. During the period of indwelling catheter, it is generally not necessary to irrigate the bladder. If there is hematuria or a large amount of sediment, and the catheter is not patent, a small amount (10-20ml each time) of sterile normal saline or 1:5000 furazolidone solution can be used for low-pressure irrigation until it is patent. Some routine administration of Chinese herbal medicine Xianzi, Shuanghua decoction for oral administration to clear heat and promote diuresis. Encourage patients to drink more water. The fluid replacement in the early postoperative period should be sufficient to 2500-3000ml/d, and then encourage patients to drink more water.

　　2, Keep the perineum clean: The perineum and external urethral orifice must be wiped twice a day with a 1:2000 solution of new chlorhexidine to prevent ascending infection.

　　3, Postoperative position: Try to take a prone or lateral position to reduce the infection of the fistula area due to urine soaking. However, if the patient finds it difficult to maintain a posture, lying flat is also fine. The key is to keep the catheter unobstructed.

　　4, Routine use of antibiotics for 2 to 3 weeks, estrogen can be added in the elderly.

　　5, Postoperative diet: Liquid and non-fiber semi-liquid diet for 5 days, liquid paraffin or lubricating pills can be given on the fourth day to ensure daily defecation.

　　5, At the time of discharge, it is prohibited to have sexual life and vaginal examination within 3 months, otherwise it may cause the repaired urinary fistula to rupture. If pregnancy occurs in the future, it is emphasized to be admitted to the hospital early and cesarean section should be performed. For those with children, especially those with difficult fistula repair, weak local tissue, and narrow pelvis, contraceptive measures should be taken or sterilization should be performed at the same time as repair.

　　1, Cystoscopy can understand the number, size, location of the fistula, the relationship between the fistula and the ureteral orifice, the internal urethral orifice, and understand the bladder capacity, inflammation, calculi, diverticula, etc.

　　2, Methylene blue test can distinguish between vesicovaginal fistula or ureterovaginal fistula. Inject diluted methylene blue into the bladder, if the cotton ball in the vagina turns blue, it suggests vesicovaginal fistula; if the cotton ball in the vagina does not turn blue, and there is a small fistula, it suggests ureterovaginal fistula.

　　3, Indigo carmine test intravenously with 5ml of indigo carmine, after 5 to 7 minutes, blue liquid can be seen oozing out of the fistula, suitable for the diagnosis of congenital ureteral orifice ectopia or ureteral fistula.

　　4, Intravenous urography can understand the condition of the upper urinary tract, determine the location of the ureteral fistula and the renal function.

　　1, Persimmon and Lampbrush Grass Soup

　　2 persimmons, 6 grams of lampbrush grass, appropriate amount of sugar, boil into soup for drinking. Has the effects of clearing heat, promoting urination, and stopping bleeding in stranguria.

　　2, Mung Bean and Plantago Herb Soup

　　60 grams of mung beans, 30 grams of red beans, plantago herb, appropriate amount of sugar, boil and take. Clears heat and detoxifies, promotes urination and relieves stranguria.

　　3, Plantago Seed and Bean Soup

　　50 grams of mung beans, 50 grams of black beans, 15 grams of plantago seed, 1 spoon of honey. Wrap the plantago seed in gauze, put the mung beans and black beans into the pot, add appropriate amount of water, boil until the beans are soft, turn off the heat, discard the medicine bag, mix in honey, eat the beans and drink the soup. Suitable for patients with difficult urination, short and urgent pain, lumbar pain and back pain.

　　4, Lonicera Tea

　　30 to 50 grams of lonicera japonica, 10 grams of licorice powder, soak in boiling water for 10 minutes, drink as tea. Clears heat and detoxifies, promotes urination and relieves stranguria. It can treat fever and dysuria.

　　5, Clam Meat Soup

　　20 grams of clam meat, 30 grams of begonia, appropriate amount of rock sugar, boil together with water, eat the meat and drink the soup. Clears heat and promotes urination, treats urinary tract infection.

　　6, Winter Melon and Mung Bean Soup

　　500 grams of fresh winter melon, 50 grams of mung beans, add appropriate amount of sugar, boil into soup and drink. It can clear heat and promote urination, and prevent summer heat and reduce temperature. It is the best beverage for preventing and treating urinary tract infections.

　　7, Sprout Juice

　　Mung bean sprouts 500 grams, sugar to taste. Clean the mung bean sprouts, crush them, squeeze the juice with gauze, and drink it as tea with sugar. It can treat urinary system infections, hematuria, frequent urination, turbid urine, and other symptoms.

　　8, Celery Juice

　　Celery 2500 grams. Clean the fresh celery, crush and squeeze the juice, heat to boiling, take 60 milliliters each time, three times a day. While the patient is recovering at home, it is necessary to maintain soft stools every day; if constipation occurs, take a mild laxative; drink plenty of water, and urinate frequently.

　　Most urinary fistulas can be prevented, and it is more important to prevent urinary fistulas caused by birth injuries. Carefully conduct prenatal examinations, observe the labor process in detail, properly handle abnormal deliveries, prevent the prolongation and dystocia of the second stage of labor. When assisting labor through vaginal surgery, it is necessary to catheterize first before the operation, use surgical instruments carefully, and conduct routine examinations of the reproductive and urinary tract for damage after the operation. For those with a long labor, prolonged compression of the bladder and vagina, and suspected injury, a catheter should be left in place for 10-14 days after delivery to keep the bladder empty, which is conducive to improving local blood circulation and preventing the formation of urinary fistulas. Urinary fistulas caused by gynecological surgery are mostly due to ureteral injury during total hysterectomy; for those with extensive adhesions in the pelvic cavity, the ureter should be fully exposed first, and the anatomical relationship should be clarified before the operation; if ureteral or bladder injury is found during the operation, it should be repaired immediately.

　　Thorough preoperative preparation is required, in addition to a detailed physical examination and psychological preparation for the patient's local and systemic condition, and also:

　　Most patients have dermatitis on the outer vulva and the inner side of the thigh, and it should be bathed in a 1:5000 potassium permanganate solution in advance, and the affected area should be coated with zinc oxide ointment after bathing. It is also advisable for those without inflammation to take a routine bath for 3 days.

　　For patients with concurrent cystitis, bladder mucosal inversion, or bladder stones, penicillin and streptomycin should be injected to control infection before surgery, and surgery should be performed 1-2 weeks after the inflammation subsides.

　　For elderly or amenorrheic patients, ethinyl estradiol 0.5mg/day or dienestrol 3mg/d should be administered for a total of 1 week to thicken the vaginal epithelium for easier separation and suture.

　　The application of cortisone: adrenal cortical hormones can reduce local inflammatory reactions, shrink the fistula and soften the scar, and at the same time, the application of antibiotics without controlling infection can promote the repair of the fistula in advance.

　　Before the operation, two days should be taken with a low-residue diet, and enema should be given the night before the operation and in the morning of the day of the operation.