Dr. Maswoodur Rahman Prince

Vesico-Vaginal Fistula and its sister ailment Vesico-Rectal fistula occur when, as a result of prolonged unrelieved obstructed labour, the baby's head tears through the orifice of the mother creating an opening between the bladder and the vagina, and sometimes, between the vagina and the rectum. This condition is most often associated with child-birth by young girls or small statured women when the pelvis is small and the baby is large. In other cases the baby may not be in the correct position when labour begins or other complications can arise. When the women can be taken to hospital quickly, doctors are usually able to aid the birth. But in remote communities with limited access to standard medical facilities, women can spend days in fruitless labour. In such cases, the baby is almost always still-born and the woman, if she survives, falls victim to VVF.
 The Vesico-Vaginal Fistula (VVF) sufferer loses control over her bodily functions and as a result has urine and sometimes-faceal matters, constantly trickling down her leg. Perhaps more damaging than the physical effects VVF is the social isolation that in many instances follows. Because of the offensiveness of the injury, many sufferers find them-selves abandoned by their husbands and families and shunned by their formal friends.
 It is estimated that there are more than two million VVF sufferers worldwide with a considerable proportion in sub-Sharan Africa, A large number of patients are also to be found in poor areas of Asia and south America where health facilities are inadequate, transportation systems are poor or absent, harmful traditions exist and women are accorded poor socio-economic status.
 Causes
1. Obstetrical trauma: by obstructed labour and obstetrical operations,
2. Gynaecological operative trauma,
3. Traumatic fistula,
4. Cancer fistula,
5. Inflammatory,
6. Radiation,
7..Congenital-very rare.

Signs and Symptoms:
Continous dribbling of urine per vagina is a characteristic symptom in a case of VVF of considerable size. In big fistula there is inability to pass urine per via naturalis. There is also offensive uriniferous odour emiting from the person of the patient. The patient with obstructive VVF is usually short statured. The patient becomes irritable due to insomnia and at times depressed for her social isolation.
Diagnosis
Inspection per vagina may reveal the patient with wet clothing and uriniferous odour emitting from her person.
The valval skin especially that of perineurn shows wetness with redness and marks of scratches; there may be ulceration and incrustations. In lying down position gushes of urine are found to be discharged per vagina when the fistula is big,
Vaginal speculum examination is an essential step for diagnosis. The patient is examined under general anesthesia in high lithotomy position retracting the perineurn by Sim's speculum.
The fistula, if big, can be easily seen with the prolapse of the red bladder mucsa through it. A metal female catheter is passed through the urethra.
In cases with patent uretura, the catheter can be passed inside the bladder and its tip projects out through the fistula into the vagina. The position of the fistula should thus be located especially that involving the bladder neck.
Through vaginal palpation a big fistula can be felt and one finger or more can be pushed through it inside the bladder.
In this examination, fistula's position, size, number scarring or any other abnormality at the margin, and that of the vagina are also carefully palpated. Moreover, condition of the cervix, body of the uterus, adclaxes are also palpated.
Cystoscopy is necessary to determine the urethral orfice in relation to the fistulas’ opening or for any intravesical abnormality. For Cystoscopy to fill up the bladder with water the fistula opening can be temporarily blocked by introducing a Foley's catheter through vagina and fistula opening into bladder or intravaginal block by a filled rubber finger stall.
Complications
Ascending infection of the urinary tract is important. Invalidism is the greatest menace. Very rarely, bladder stone may complicate VVF.
Treatment
prevention includes avoiding obstructive fistula by good obstructive care incidence of surgical fistula can also be minimized. Early diagnosis of carcinoma can avoid cancer fistula.
Radiation burn can also be minimized. Curative treatment of VVF maybe considered according to the clinical types as follows:
VVF of obstructive or operative origin:
Conservative treatment
After development of fistula especially small, spontaneous healing may be expected in some cases within a mooth or two. To help the healing, bladder by a catheter for about 10-14 days, semipro position, alkali mixture, chemotherapy and antibiotics should be provided. Surgical treatment, Local repair of VVF is the treatment of choice.  
The optimum time for repair is 2-3 months after the development of the fistula. The principles of local repair are :
a. Proper exposure by high lithotomy position for high up fistula; schuchardt's incision becomes helpful for better exposure in high up fistula;
b. Suture of the denuded fistulas walls of the bladder and vagina without tension
c. use of proper suture material
d. Drainage drayage of the bladder after repair J.M. Sims was pioneer to make the successful repair during 1845-49 through use of
(i) Sims speculum and in
(ii) Sims position with
(iii) silver urine situation.