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|Year : 1987 | Volume
| Issue : 2 | Page : 102-4
Conservative management of traumatic vesico-cervical fistula (a case report).
Varawalla NY, Krishna UR
|How to cite this article:|
Varawalla N Y, Krishna U R. Conservative management of traumatic vesico-cervical fistula (a case report). J Postgrad Med 1987;33:102
A case of traumatic vesico-cervical fistula occurred while performing a medical termination of pregnancy; it was conservatively managed with continuous bladder catheterisation, urinary antiseptics and complete suppression of the uterine endo-metrium with danazol. Fistulae do not close spontaneously as the fluids that flow through them inhibit the healing process. In this case, by preventing the passage of any fluids, the fistula healed and closed spontaneously. A detailed description of the management is presented.
Mrs. M.K., a 25 year old, married lady, gravida 3, para 2, presented with 12 weeks' amenorrhoea for medical termination of pregnancy. On examination, the uterus was found to be acutely retroverted and of a size corresponding to 12 weeks of gestation. The cervix was dilated with Hegars dilators upto No. 12. After suction evacuation of the products of conception, a currettage was done. A perforation was then suspected on the lower part of the anterior Uterine wall, probably caused while dilating the cervix. The bladder was catheterised with a self retaining Foley's catheter and the urine was found to be clear. On immediate diagnostic laparoscopy a perforation 0.5 cm in diameter was seen on the anterior aspect of the uterus at the level of the utero-vesical fold of the peritoneum. About 20 ml of blood was present at the utero-vesical peritoneal junction, but there was no active bleeding. It was decided not to undertake any immediate operative procedure. Three hours later, it was observed that in addition to passing adequate urine via the urethral catheter, the patient was incontinent. The urine remained clear except for a few red blood cells seen microscopically. During the next 5 days, the patient was intermittently incontinent. On per speculum examination done on the 6th day, clear urine was seen coming through the cervical os. The patient also complained of supra-pubic pain.
This traumatic vesico-cervical fistula was conservatively managed by suppression of the endo-metrium with danazol which caused amenorrhoea. Danazol was given orally in a dose of 200 mg three times a day for a total duration of 14 weeks. On the first two days of danazol administration, a testosterone preparation (Aqua-viron) was given intramuscularly in a dose of 50 mg daily to accelerate the endometrial suppression and stop the uterine bleeding. After 4 weeks of danazol therapy, the patient had spotting. Dexamethasone was then added in a single daily oral dose of 4 mg. Within two days, the spotting stopped. Dexamethasone was continued along with danazol for the remaining 10 weeks. Besides this, continuous bladder drainage with an indwelling Foley's catheter was maintained for 9 weeks. The catheter was changed at weekly intervals. Using alkaline mixtures and oral vitamin C, the urinary pH was altered weekly according to the antibiotic or antiseptic being administered. The following antibiotics and antiseptics were given in sequence for about seven days each-ampicillin and gentamicin, mandelamine, nitrofuran, nalidixic acid, cotrimoxazole and cefuroxime. The urine was cultured at weekly intervals. The second sample revealed an infection with E. coli, Klebsiella and Proteus organisms, which responded to the antibiotic regime. Five days after initiation of this therapy, no leak was seen on per speculum examination, but for the next 10 days, the patient was incontinent on straining. Following this, there was no leak at all, as demonstrated by the injection of 50 ml of dilute methylene blue via the urethral catheter. After a total of 9 weeks, the urinary catheter was removed and the patient discharged after bladder training. She continued to take danazol and dexamethasone in the same dosage for another 5 weeks. The patient was followed up for a further 8 weeks. She remained asymptomatic and was considered cured.
The clinical presentation of a vesico-uterine fistula would depend on whether it is located above or below the isthmus of the uterus. This is because of a functional sphincter at the isthmus as demonstrated by trans-abdominal, intra-uterine insufflation and manometric hysterography by Westman and Youssef.
The pressure to overcome resistance of this sphincter is about 98 mm of Hg, but is never less than 25-30 mm of Hg. If the fistula is present above the sphincter, the menstrual fluid enters the bladder causing cyclic haematuria or 'menouria'. Normal menses and leakage of urine per vagina are absent. Normally, menstrual blood distends the uterine cavity, causes relaxation of the sphincter and discharge through the cervical canal. But when a fistula is present, the blood directly passes into the bladder causing menouria. When a vesico-cervical fistula is present below the isthmic sphincter, there is complete urinary incontinence and the menstrual flow is through the cervix. This was present in the case under discussion. These fistulae usually occur following caesarean section and their spontaneous closure has been described. In fact, Rauch speculated whether vesico-uterine fistulae are really so rare. A brief episode of haematuria following caesarean section could be confused with lochia rubra, and early spontaneous closure might occur even before the fistula is recognised. To hasten closure of the fistula, beside sresting the bladder, the endometrium should also be suppressed. Thereby menstrual flow through the fistula is prevented and healing is faster. This has been achieved by amenorrhoea induced by contraceptive steroids. We suppressed the endometrium using danazol. Original pharmacological studies showed danazolto be a stronganti-gonadotropin with mild androgenic effects. Recent studies, emphasizing its molecular pharmacology, suggest that danazol has direct effect on hypothalamic-pitutary function, multiple steroid receptors; gonadal steroidogenesis and endogenous steroid metabolism.1By virtue of these various properties danazol suppresses the endometrium causing amenorrhoea. To assist this action, initially testesterone was also added and when the patient started spotting, oral corticosteroids in the form of dexamethasone tablets were supplemented. Urinary tract infection was treated with frequent change of urinary pH and urinary antibiotics and antiseptics.
We would like to thank:
(1) Dr. G. B. Parulkar, Dean, Seth G. S. Medical College, and K.E.M. Hospital for allowing us to publish the hospital data, (2) Dr. M. R. Narvekar, Hon. Professor, Department of Obstetrics & Gynaecology, K.E.M. Hospital, for his guidance in the management of this case, and (3) Winthrop-Win Medicare Ltd; and Cipla Ltd; for kindly supplying the Ladogal and Danogen capsules respectively.
|1.||Barbieri, R.L. and Ryan, K.J.: Danazol? Endocrine pharmacology and therapeutic applications. Amer. J. Obstet. Gynaecol, 141: 453-463, 1981. |
|2.||Rauch, R. J. and Rodgers, M. W.: Spotaneous closure of a vesico- uterine fistula following caesarean section. J. Arm Med. Assoc., 181: 997-999, 1962. |
|3.||Rubina, S. M.: Vesico-uterine fistula treated by amenorrhoea induced with contraceptive steroids-two cases report Brit. J. Obstet. & Gynaecol, 87: 343-341;1980. |
|4.||Westman, A.: Uber die sphinkperfunktion der muskulatur um die uterinen ostien Acta Obstet. Gynec. Scand., 22; 1-11, 1942. |
|5.||Youssef, A. F.: 'Menouria' following L.S.C.S. A syndrome. Amer. J. Obst & Gynaecol, 73: 759-767, 1957. |