Urinary incontinence: ( UM 1, 1st bloc)
a. Def UI,
- Involuntary leakage of urine
- It is a social or hygienic problem & objectively demonstrable
b. classify different types of UI
- stress incontinence: involuntary escape of urine per urethra when there
is increased intra – abdominal pressure
- urge incontinence: incontinence due to hyperactive bladder following
infection, stones,etc
- overflow incontinence : due to overfilling of bladder as in case of atonic
bladder
- ture incontinence: due to urinary fistulae between genital & urinary
tracts
c. What are the different types of urinary fistulae?
- Uretero – uterine, Uretero- cervical, Uretero- vaginal
- Vesico- uterine, vesico- cervical , vesico – vaginal
- Urethro- vaginal fistula
d. Mention the obstetric and gynaecological causes of urinary fistulae
- Obstetric causes – 80% of cases in the developing countries
Prolong and obstructed labour
Difficult instrumental deliveries
Caesarean section
- Gynae causes – 80% of cases in the developed countries
Following radical hysterectomy for cancer cervix
Following operation for chroinic PID, endometriosis
Vaginal operative procedures such as VH & repair, Manchester
operation
- Direct trauma to genital tract
- RT for malignant d/s such as ca cervix, ca vg
- Chemical injury – irritant or corrosive chemicals
- Infection – TB , syphilis, schistosomiasis
- Congenital abnormalities
e. Outline the management of vesico-vaginal fistula
- Conservative tx: for recent onset fistula
6/2018 Gynaecology Bloc Q&A Page 42
Method: continuous drainage by urinary catheter for at least 2 weeks (
about 6-8wks) with patient in prone or semi-prone position under aseptic
precautions
Skin care to prevent vulval skin excoriation
If failed conservative treatment/ 3mths after injury, refer to tertiary
hospital
- Operative tx:
Vaginal approach
Sim’s saucerization
Sim’s flap splitting operation
Abdominal approach : Transperitoneally or transvesically , excision of
fistula tract and repair in 2 layers + pedicled omental graft
- Post op treatment
Continuous bladder drainage for 10-14 days
To check UO hourly
Antibiotics
Nothing into vagina for 3 mths
Pregnancy preferably after 1 year and next pregnancy s/b
delivered by elective CS
A 24 year old primipara was referred from a district hospital for continuous
leakage of urine per vagina for one week duration following a difficult forceps
delivery after a prolonged labour. Leakage occurred two weeks after delivery and
she did not need to void. ( UM Mgy, 2nd bloc and 3rd bloc, 2017-2018)
a. What is the possible diagnosis?
Vesico-vaginal fistula ( most probably due to ischemic necrosis & difficult
labour)
b. Give reasons for your diagnosis.
c. How would you confirm your diagnosis?
Physical examination
- Smell of urine, excoriation of vulva and perineum
- VE: demonstration of fistula with leakage of urine on Sim’s position
Investigation
- EUA and cystoscopy : site of fistula, no., area of fibrosis and fistula margin,
decision making for surgical approach ( vaginal or transabdominal)
- Hysterography
- CP, urine RE, urine for C&S if required
- IVU for upper urinary tract status
6/2018 Gynaecology Bloc Q&A Page 43
d. Outline your management.
Others to read
a. Name the position of patient to demonstrate urinary fistulae
- At left lateral position ( Sim’s position) or knee –chest position
b. Name one ivg for dx of GSI
- Urodynamic study (cystometry, urethrometry)
c. How will you (basic dr) manage the pt with UI?
o For UI: urine RE, urine C& S, antibiotics
o For Overflow I: catheterization & drill, referral to higher level care for
further investigation & management
o For ture I, & stress I: referral to higher level care for further ivg & mx
(How will you differentiate different types of UI on history taking?
True Incontinence:
- continuous leakage of urine,
- past history of obstetric prolonged labour , injuries, gynaecological
operation, TB , malignancy
over flow incontinence
- neurological symptoms, d/s, DM, h/o injury to spine
urge incontinence
- frequency, urgency, dysuria, h/o infection, stone
stress incontinence
- leakage of urine when intra abd pressure is increased.
- h/o prolong labour, multipartiy, associated UVP)
6/2018 Gynaecology Bloc Q&A Page 44
