Genital fistulas

A genital fistula is an abnormal opening between the genital tract and the urinary tract or bowel. Urine or stool leaks continuously through the vagina.

Causes

• Obstetric (worldwide the leading cause): prolonged obstructed labor — the fetal head presses the vaginal wall against the pubic bone for many hours, blood supply stops, and the tissue dies (ischemic necrosis) and sloughs days later. This occurs mainly where emergency cesarean birth is not available. Severe perineal tears (third- and fourth-degree) can cause rectovaginal fistula.
• Surgical (leading cause in high-income countries): injury during hysterectomy and other pelvic surgery; leakage often starts about 1–3 weeks after surgery
• Radiation therapy (e.g., for cervical cancer) — damages small blood vessels, causing tissue ischemia; fistulas may appear months to years later
• Pelvic malignancy, Crohn disease (rectovaginal), infection, trauma

Urinary incontinence (UI) in women

UI is involuntary loss of urine. Pregnancy, vaginal birth, menopause (estrogen loss), obesity, and aging weaken the pelvic floor and urethral support.

Transient (reversible) causes — DIAPPERS

• Delirium
• Infection (symptomatic UTI)
• Atrophic urethritis/vaginitis
• Pharmaceuticals (diuretics, anticholinergics, sedatives, alpha blockers, opioids)
• Psychological (depression)
• Excess urine output (hyperglycemia, heart failure, high fluid intake)
• Restricted mobility
• Stool impaction

Fistula

• Continuous wetness, need for pads day and night, odor
• History: recent hysterectomy or pelvic surgery, radiation, prolonged labor, severe perineal tear
• Perineal skin irritation, excoriation, dermatitis, yeast infection from constant moisture
• Recurrent vaginal or urinary infections; gas or stool from the vagina (RVF)
• Psychosocial: shame, social isolation, depression, relationship problems

Incontinence

• Pattern: when leakage occurs (with effort, with urgency, constantly), volume, frequency, nocturia
• Bladder diary (usually 3 days): fluid intake, voids, leaks, triggers
• Medications, fluid and caffeine intake, bowel habits, mobility, cognition, toilet access
• Pelvic exam: atrophy, prolapse, pelvic floor strength
• Skin: incontinence-associated dermatitis, pressure injury risk

Fistula

• Speculum examination — may directly show the opening or pooling of urine or stool
• Dye test ("tampon test") — the bladder is filled with dilute blue dye (e.g., methylene blue) and a tampon is placed in the vagina
  • Blue staining → vesicovaginal fistula
  • Tampon wet but not blue (especially if orange after oral phenazopyridine) → ureterovaginal fistula
• Cystoscopy — location and size of VVF
• CT urography (now preferred over the older intravenous pyelogram) and retrograde pyelography — identify ureteral involvement
• Rectovaginal: rectal exam, anoscopy/proctoscopy, contrast studies, MRI or endoanal ultrasound
• Biopsy if cancer recurrence is possible (post-radiation)

Incontinence

• Urinalysis (rule out infection, hematuria, glycosuria)
• Post-void residual (PVR) — high PVR suggests overflow
• Cough stress test — leakage with cough confirms stress UI
• Urodynamic studies for complex cases or before surgery

Fistula

• Small, fresh vesicovaginal fistula: continuous bladder drainage with an indwelling catheter for several weeks may allow spontaneous closure
• Surgical repair — transvaginal or abdominal; tissue interposition flaps for radiation fistulas; ureteral stent or reimplantation for ureterovaginal fistula
• Rectovaginal fistula: surgical repair; a temporary diverting colostomy for complex, radiation-related, or recurrent fistulas
• Treat infection, correct nutrition, and use vaginal estrogen in atrophic tissue before repair as ordered

Incontinence — start with behavioral measures; most women improve without surgery.

• Pelvic floor muscle training — first-line for stress and mixed UI
• Bladder training — first-line for urge UI
• Timed (scheduled) voiding — for overflow from reduced bladder sensation (e.g., diabetic neuropathy) and for functional UI; prompted voiding for cognitive impairment
• Weight loss; limit caffeine and alcohol; manage constipation
• Devices: incontinence pessary; vaginal estrogen for atrophy
• Intermittent catheterization for overflow with high PVR

Procedures for stress UI

• Midurethral sling — retropubic (TVT) or transobturator (TOT); most common operation
• Burch colposuspension, autologous fascial sling, urethral bulking injections

Listed in priority order.

1. Protect skin integrity
   • Cleanse gently after each episode with pH-balanced cleanser, pat dry, apply moisture barrier (zinc oxide or dimethicone)
   • Use absorbent, breathable pads; change promptly; sitz baths for comfort
   • Constant moisture → dermatitis, fungal infection, pressure injury
2. After fistula repair
   • Keep the catheter patent — check for kinks and clots; a blocked catheter lets the bladder distend and stresses the repair. Report decreased drainage immediately
   • Strict intake and output; encourage fluids (commonly 2–3 L/day unless restricted) to keep urine dilute
   • Give prescribed bladder antispasmodics; prevent constipation (stool softener) to avoid straining
3. After sling surgery — voiding trial and PVR; report retention, fever, groin or thigh pain, vaginal bleeding
4. Toileting program
   • Scheduled voiding (e.g., every 2–4 hours) for diabetic neuropathy or cognitive impairment
   • Functional UI: bedside commode, urinal, clear path, night light, call light in reach, easy-to-remove clothing
5. Identify and correct transient causes (DIAPPERS)
6. Psychosocial support — the most distressing aspects are odor, wetness, and stigma. Teach practical management of odor and leakage (absorbent products, hygiene, clothing choices), refer to counseling or support groups

Fistula

• After repair: no intercourse, tampons, or douching until the surgeon confirms healing (commonly about 2–3 months)
• Keep the catheter bag below bladder level; do not disconnect the system
• Drink plenty of fluids; report fever, flank pain, recurrence of leakage
• Rectovaginal fistula: drink adequate fluids and eat enough fiber to keep stools soft and avoid straining; stool softeners as prescribed; perineal hygiene after each bowel movement
• Future births after a repaired obstetric fistula are usually recommended by planned cesarean

Incontinence

• Kegel exercises daily; benefits take 8–12 weeks; do not use stopping the urine stream as routine exercise
• Bladder training: void on a schedule; when urgency comes, stop, stay still, contract the pelvic floor quickly several times, and wait for the urge to pass, then walk calmly to the toilet; gradually lengthen the interval between voids, increasing functional bladder capacity
• Do not restrict fluids (concentrated urine irritates the bladder); reduce caffeine, carbonated drinks, and alcohol; limit fluids 2–3 hours before bed
• Antimuscarinics: sip water or use sugar-free gum for dry mouth, prevent constipation, avoid overheating, avoid driving if vision is blurred
• Mirabegron: check BP regularly
• After sling surgery: take antibiotics only as prescribed (never self-start); use prescribed analgesics for pain; avoid heavy lifting and intercourse until cleared (often about 6 weeks)

• Vesicovaginal fistula = continuous painless urine leakage through the vagina
• Rectovaginal fistula = gas or stool through the vagina
• Ureterovaginal fistula = continuous leakage plus normal voiding
• Worldwide cause: prolonged obstructed labor (pressure necrosis); high-income countries: hysterectomy, radiation
• Dye (tampon) test distinguishes bladder from ureteral fistula; CT urography evaluates the ureters
• Priority nursing: perineal skin protection; after repair, keep the catheter patent
• Stress UI = leakage with cough/laugh → Kegel exercises first-line
• Urge UI = sudden urge → bladder training, antimuscarinics or beta-3 agonists
• Overflow from diabetic neuropathy → timed voiding, intermittent catheterization
• Functional UI → bedside commode, environment, prompted voiding
• DIAPPERS: D = delirium (depression is the "P" for psychological)
• Antimuscarinics: dry mouth, constipation, blurred vision, confusion in older adults