VESICO – UTERINE FISTULA – A COMPLICATION OF CAESAREAN SECTION

Vesico – Uterine Fistula

Abstract

INTRODUCTION

Caesarean section is the second commonest obstetric procedure after episiotomy [1,2]. Vesico – uterine fistula is one of the rare, but preventable, complications of caesarean section especially repeat surgery [3]. Prevention is possible by pushing the bladder away from the line of incision over the uterus during opening the uterus and then careful closure of uterine incision.

Repeated surgery can lead to fibrotic adhesions between urinary bladder and lower uterine segment leading to difficulty in separating urinary bladder away from uterine wall, hence increased danger of vesico-uterine fistula formation [4]. In the case reported, vesico uterine fistula followed second caesarean section. Vesico-uterine fistula typically presents 7-10 days post caesarean when sloughing of necrosed bladder and uterine walls occur. Urine leaks from cervical os when urinary bladder is full or intra-abdominal pressure rises such as on coughing-hence it is often mistaken as stress incontinence-as happened in this case.

Diagnosis is not difficult if condition is kept in mind and recommended examination is carried out. After ruling out stress incontinence by cough impulse, speculum examination is performed. Absence of urine leak from opening in anterior vaginal wall excludes vesico-vaginal fistula. Observing with patience urine can be seen escaping from cervical os. Methylene blue test confirms the diagnosis.

Careful preoperative evaluation and identification of fistula is very essential not forgetting that there maybe more than one fistula.

Cystoscopy is performed to demonstrate relationship of ureteric orifices to fistula. If fistula is found to be near ureteric orifice, the ureter should be catheterized.

Timing of operation is important. Usually 12 weeks time is given for local inflammation to be eradicated before repair operation. An indwelling catheter is used meanwhile for continuous drainage. Smaller fistulae might close spontaneously during this period.

Successful repair should be the aim on first attempt and surgery should be done by experienced surgeon. Failure rate is high hence repeated surgeries are common but it becomes more and more difficult due to fibrosis of previous operations. Golden principle of successful repair is good surgical technique. Wide separation of bladder wall from uterine wall and then closure of urinary bladder in two layers without tension over suture line. Uterine opening is closed separately Omentum is interposed between the two stitch lines to ensure separate healing of urinary bladder and uterus.

Post operatively continuous bladder drainage is ensured with an indwelling catheter for two to three weeks to enable repair to heal