Diagnostic workup and examination features
Disease diagnosis is based on a thorough medical history, analysis of the clinical course, and examination findings. Certain difficulties arise with high-positioned fistulas opening into the scarred vaginal vault.
The examination protocol includes:
- Medical history taking and gynecological examination.
- Performing the three-tampon test.
- Cystoscopy and vaginography.
- Ultrasound examination of the kidneys.
- According to indications: excretory urography, radioisotope renography, cystography in three projections.
Fistulas of inflammatory origin
Such formations can develop as a consequence of purulent-inflammatory diseases of the internal genitalia. Unlike traumatic fistulas, in which the general condition usually remains satisfactory, in inflammatory ones (vesico-appendicular, parametrial-appendicular, and complex), the patients' condition is impaired due to intoxication and destructive processes in the pelvis.
Clinical picture:
- Suprapubic pain of varying intensity radiating to the thigh and lower back.
- Dysuric symptoms.
- Symptoms of intoxication: fever, chills.
- Purulent discharge from the genital tract.
- Pyuria and rarely menouria (hematuria during menstruation).
Treatment strategy: from conservative measures to surgery
Spontaneous scarring of small fistulas during the administration of urinary antiseptics occurs extremely rarely—according to literature data, in only 2–3% of patients. The vast majority of patients require surgical intervention.
At the initial conservative stage, the following are used:
- Placement of an indwelling urinary catheter for 8–10 days.
- Bladder irrigation with antiseptics.
- Insertion of ointment-soaked tampons into the vagina.
- Antibiotic therapy.
Surgical approaches and treatment stages
Two main approaches are used for surgical treatment: vaginal and transabdominal. The selection criteria are the topographic location of the fistula and concomitant genital pathology.
When planning a vaginal approach, the surgeon addresses the following tasks:
- Complete mobilization of the fistulous tract.
- Radical excision of scar tissues.
- Adequate and complete restoration of the functional integrity of the affected organ.
Classic stages of surgical treatment include exposure of the fistula, probing of the fistulous tract, circumferential incision with tissue mobilization, and subsequent defect closure.
Class and exam questions
What percentage of patients are cured conservatively?
Spontaneous scarring and healing of small fistulas with conservative measures occurs extremely rarely—in only 2–3% of patients.
What are the main surgical approaches in treatment?
Two main approaches are used for surgical intervention: vaginal and transabdominal.
How do inflammatory fistulas differ from traumatic ones?
In traumatic fistulas, the patients' general condition is mostly satisfactory, whereas in inflammatory ones, it is severely impaired due to intoxication and destructive processes in the pelvis.
What else to study on this topic
- Three-tampon test and differential diagnosis
- Features of cystoscopy and vaginography
- Complex of laboratory and instrumental studies in inflammatory forms
- Criteria for choosing between vaginal and transabdominal approaches
- Detailed stages of fistulous tract mobilization and scar tissue excision
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