Urinary fistula
Introduction
Introduction to urinary fistula The abnormal passage formed between the female reproductive tract and the urinary system or the intestine is called urogenitalfistula. The abnormal passage formed between the reproductive tract and the urinary tract is called urinary fistula, and urinary fistula or feces can occur separately. , can also be combined, or several exist at the same time. The genital fistula is incapable of controlling by the urine or feces and soaking the genitals and the skin on the inner side of the thigh for a long time. It brings great mental and physical pain to the patient. Those who are severely unable to participate in collective activities or productive labor, lose normal sexual life or childbearing. Bring misfortune to the family. Urogenital tract spasm is still the main cause of birth injury and gynecological surgery. As long as the perinatal health care is strengthened and the level of gynecological surgery is improved, it will help to reduce the incidence of genitourinary fistula in women. basic knowledge The proportion of illness: 0.004% Susceptible people: no special people Mode of infection: non-infectious Complications: dermatitis pelvic inflammatory disease
Cause
Urinary causes
Childbirth damage (12%):
1. Compression necrosis: due to the head basin not being called, the fetal position or fetal abnormality is delayed, especially the extension of the second stage of labor, so that the first exposure of the fetus (especially the first dew) stays in a certain part of the true pelvis for a long time. The soft tissues such as the bladder, urethra and vaginal wall are squeezed for a long time between the fetal first exposed and the maternal pubic symphysis. The urinary fistula is formed due to ischemia and necrosis. Tissue compression can occur in different planes of the pelvis to cause ischemic necrosis of the tissue. That is, "dry necrosis", 7 to 10 days postpartum tissue shedding to form pupils, if in the pelvic entrance plane, often involving the cervix, above the bladder triangle, or ureter, leading to bladder cervix, vaginal fistula or ureterovaginal fistula When squeezed in the middle pelvis plane, it involves the bladder triangle and bladder neck, resulting in low bladder vaginal fistula or bladder urethra vaginal fistula; extrusion occurs when the pelvic floor reaches the pelvic outlet plane, involving the urethra, leading to urethral fistula . 2. Torso of the birth canal: In the head basin, if the fetal position is abnormal (especially in the horizontal position), the irrational use of oxytocin (oxytocin) and prostaglandin may cause cervix, vaginal wall tear, and even uterine rupture. Involved in the urinary system to form urinary fistula, vaginal delivery after urinary fistula repair, the original mouth scar can be cracked due to excessive pressure, resulting in recurrence of urinary fistula. 3. Obstetrical surgery injury: the operator does not follow the operating procedures when dealing with dystocia, such as preoperative non-urinary catheterization, rough hip traction and internal reversal, when the forceps and fetal head aspirator are applied, the vaginal cervical tissue is not found in time. When the transcranial device is placed in the birth canal without finger protection, it can cause soft tissue damage. When the placenta is removed, the finger can break the uterus and the bladder can cause urinary fistula. In recent years, the cesarean section rate is abnormally high. If the preventive measures are not strengthened, The urinary fistula caused by such damage will also increase accordingly. Because the bladder adheres to the lower part of the uterus, or the bladder is not fully pushed, the uterine incision tears the bladder when the fetus is delivered, and it is not found in time to repair, or suture the uterine incision. Mis-sewing the bladder or ureter can cause urinary fistula.
Local treatment damage (6%):
1. uterine prolapse injection injury: the use of injectable drugs for the treatment of uterine prolapse such as anhydrous alcohol, alum and other injection into the uterine ligament, so that the tissue scar contracture, the prolapsed uterus, due to the wrong injection site, mistaken drugs Infused into the anterior wall of the vagina and the bladder, causing tissue necrosis and falling off to form urinary fistula. 2. Uterine incarceration: the pessary used by patients with uterine prolapse, indwelling the vagina for too long, forming incarceration, resulting in tissue compression, ischemia, necrosis and formation of urinary fistula. 3. Damage caused by radiation therapy: mainly caused by radiation therapy after cervical cancer and vaginal cancer, mostly due to excessive radiation dose, improper placement of the container or poor fixation.
Congenital malformation (8%):
It is rare in clinical practice, mainly ureteral ectopic and congenital hypospadias. The former is a ureteral opening in the vaginal canal or vestibular. The child has both leaking urine and some urine. The latter, the latter is the urethra opening in the vaginal opening or the vagina. The lighter one has no obvious symptoms. The severe urethral posterior wall is absent. The bladder directly opens into the vagina, so that the urination is completely uncontrollable. Some urethral openings are in the lower third of the urethra. In patients with hypospadias, prenatal control of urination, but postpartum due to pelvic floor muscle relaxation and vaginal anterior wall bulging and leakage of urine, clinically misdiagnosed as traumatic urinary fistula.
Disease damage (8%):
The urinary fistula caused by disease damage is more common in the following cases: 1. Bladder stones, due to stones compressing the bladder tissue, causing tissue ischemia and necrosis to form a fistula. 2. Urinary fistula caused by bladder tuberculosis is more common in young girls. The lesions often occur around the ureteral orifice, gradually spread to the bladder triangle, and then extend to the entire bladder. The bladder mucosa is edematous, congested, and later forms tuberculous nodules, cheese-like changes. And ulcers, and finally the lesion invades the muscle layer causing pupils. 3. Late cancer of the genitourinary genitalia, caused by infiltration of cancerous tissue and destruction of the vaginal wall.Gynecological surgical injury (10%):
The female reproductive system is closely related to the lower ureter, bladder and urethra. If the operator is not familiar with the local anatomy, the operation is not careful, or the anatomical position is mutated, adhesions, deformities can accidentally injure the ureter, bladder and urethra.
(1) Cervical cancer eradication: This surgery has a wide range of operations, involving the bladder and ureteral sites, which may cause ureteral fistula. This type of pupil usually appears 14 to 20 days after surgery, and the damage is likely to occur in the following Happening.
1 free ureter, damage to the ureter sheath, causing ischemia of the ureter, necrosis into a fistula.
2 In the surgical dissection, the nerve of the ureter is damaged, the ureter is weak, the lumen is dilated, and the internal pressure is increased, resulting in ischemia and urinary fistula.
3 When the uterine artery is cut off and separated from the ureter, it often causes bleeding due to damage to the venous plexus. At this time, if the blood is stopped, it is easy to accidentally clip the ureter.
4 Cervical cancer radiotherapy after radical surgery, often due to tissue fibrosis caused by ischemia and increased surgical difficulties, resulting in ischemic or ureteral vaginal fistula.
5 ureteral dissociation is too long, due to the lack of support tissue to the pelvic collapse and distortion, urine drainage is not induced into sputum.
(2) pelvic endometriosis surgery: endometriosis caused by pelvic organ adhesion, can cause the ureter and surrounding tissue unclear, if the surgery does not separate the adhesion to restore normal anatomical relationship, it is easy to damage the ureter With the bladder, and sometimes because the surgeon is not familiar enough with the anatomical relationship, although the ureter has been exposed but not recognized, "brightly daring" cuts off the ureter.
(3) Total hysterectomy: due to tight inflammatory adhesion between the bladder and cervix during surgery, injury when pushing the bladder, or insufficient separation of the bladder during the cutting or suturing, or mistakenly pinching the bladder or ureter during bleeding Damage, or bladder peeling surface electrosurgical injury; broad ligament and uterine neck fibroids make the distance between the ureter and the cervix closer. Therefore, if the fibroids are not removed beforehand, the ureter is easily damaged. When the cervical fibroids are used, the bladder is often Being pulled to a high position, the tissue is thinned, and the boundary between the bladder and the cervix should be carefully distinguished, and the separation should be carefully performed. Otherwise, the bladder may be easily damaged. If the above injury is not found and repaired in time, urinary fistula may be caused.
(4) vaginal surgery: vaginal angioplasty, transvaginal hysterectomy, tension urinary incontinence correction surgery, anterior and posterior vaginal wall repair, vaginal mediastinal or transverse incision and vaginal wall cystectomy have caused bladder, urethra and The possibility of ureteral injury, vaginal surgery may damage the bladder, the ureter is as follows:
1 When the vaginal wall is cut or peeled, the bladder is damaged. The thickness of the vaginal wall of the patient with uterine prolapse varies from person to person. If the anterior wall of the vagina is peeled off, if the thickness of the vaginal wall cannot be properly grasped, there is a possibility of injury to the bladder.
2 When the bladder gap is separated from the bladder, the bladder is damaged when the cervix is not leveled or clamped to cut the bladder ligament (bladder column).
3 When the bladder uterus reflexes the peritoneum, the bladder is mistakenly cut into the peritoneum.
4 The bladder bulges larger, the ureter has been bent on both sides of the vaginal wall of the bladder. When the vaginal wall is separated and removed, it is close to the lower ureter. Here, the venous plexus is more likely to bleed, such as with a large vascular clamp. Or too much suture tissue can hurt the ureter.
5 In the case of vaginal hysterectomy, when the vascular clamp clamps the uterine arteries and veins and the main ligament, too much tissue or farther from the uterus can damage the ureter.
(5) gynecological endoscopic surgery: laparoscopic, hysteroscopic surgery has increased significantly in recent years, occasionally after the occurrence of urinary fistula after surgery, laparoscopic mainly with the separation of bladder uterus reflexed peritoneum, treatment of uterine blood vessel injury, hysteroscopy mainly Associated with neglected bladder perforation.
Pathogenesis
The classification of urinary sputum is artificial, the damage is natural, irregular, especially the compression and necrosis caused by birth injury or the previous vaginal vaginal vaginal wall necrosis caused by the drug, not only the formation of complex, huge pupil, but also complete urethra Defect, vaginal scar adhesion, stenosis or bladder contracture, and even the ureter directly communicates with the vagina.
1. Classification Domestic and foreign scholars have a large number of classification methods for urinary fistula, which are classified according to the cause, and also according to the anatomical part of the pupil, and the acute urinary fistula (less than 8 weeks) and chronic urinary fistula according to the length of the leaking time. More than a month), most people advocate that the location and nature of the pupil are more reasonable, and the pupil condition can be understood at a glance, which is conducive to the development of treatment plans and estimation of prognosis.
(1) Classification by anatomical location:
1 urethral vaginal fistula: refers to the urethra has a fistula leading to the vagina, but the following forms of injury, statistics can also be included in the urethra vagina:
A. Complete urethral defect.
B. Longitudinal laceration of the urethra.
C. Transverse urethra.
2 vaginal fistula: refers to the fistula and the vagina in all parts of the bladder.
3 Bladder urethra vaginal fistula: refers to the fistula of the bladder neck and the urethra junction, the pupil involving the bladder and urethra, the residual urethra is shorter than 3cm.
4 bladder cervicovaginal fistula: refers to the fistula involving the cervix, but also damaged the vagina, the upper edge of the pupil is higher, the anterior lip of the cervix often severe tear or defect, involving the urinary fistula of the cervix, there is bladder urethra cervix vaginal fistula (often a huge pupil) and relatively rare bladder uterine fistula and bladder cervix.
5 ureteral fistula: fistula communication ureter and vagina.
6 urinary fistula combined with rectal vaginal fistula, can be called urinary feces combined with sputum or mixed sputum.
A. When vaginal atresia or severe stenosis is combined, the anatomical site is difficult to determine. It can be called urinary fistula unclassified. At the same time, there are multiple fistulas in the urethra, bladder and ureter, and the pupils are not connected together. In statistical analysis. It can be called multiple urinary fistula.
B. Pupil size: small pupil <1cm, middle pupil more than 1cm, large pupil more than 3cm.
(2) Classification according to the nature of the pupil: clinically, according to the anatomical location, size, combined scar degree and difficulty of surgical treatment, it is divided into simple urinary fistula, complicated urinary fistula and most complicated urinary fistula:
1 simple urinary fistula:
A. Bladder vaginal fistula, the position is not high, the pupil size is less than 3cm.
B. Urethral vaginal fistula, the pupil is less than 1cm.
C. Bladder cervix vaginal fistula, cervical activity, pupils are more likely to be exposed.
D. Vaginal scars are light and easy to expose.
E. Not repaired, no comorbidities.
2 complex urinary fistula:
A. Bladder vaginal fistula, the pupil size is more than 3cm, or the ureteral orifice is less than 0.5cm near the pupillary margin, or the pupil is not more than 3cm, but it is close to the pubic arch or deep into the lateral humerus.
B. Urethral vaginal fistula, the pupil is more than 1cm, or transverse, completely longitudinal or partial defect.
C. Bladder cervix vaginal fistula, deep cervical rupture, fixed position.
D. Urine and feces combined with sputum (small rectal pupil or low position scar), or multiple urinary fistula.
E. There is a moderate scar.
F. Once repair failed, or combined with bladder stones, severe perineal tears.
G. Urinary fistula caused by cancer, tuberculosis or radiotherapy damage.
3 most complicated urinary fistulas:
A. Complete urethral defect.
B. Urinary fistula combined with vaginal severe scar stenosis or atresia.
C. Urine and feces combined with phlegm, the rectal pupil is huge, or the position is high, and the scar is not easy to be exposed.
Prevention
Urinary fistula prevention
In the epidemiological investigation and etiology analysis of the etiology of genitourinary tract fistula, preventive measures are formulated. In China, prevention of birth injury is still the first priority, followed by improving the technical level of surgery for women (external). Most urinary fistula is avoidable.
1. Strengthening perinatal health care and continuously improving the quality of obstetrics At present, China is a relatively developed country in developing countries, and urinary fistula is still the main cause of urinary fistula in developing countries. In areas with developed economic and technological development in China, the production of urinary fistula has been greatly reduced. In the past 20 years, the urinary fistula admitted to Shandong Provincial Hospital mainly comes from rural areas or remote mountainous areas. Therefore, the focus of perinatal care is in rural areas, and the construction of three-level maternal and child health care network and maternal system management will continue to be strengthened, and scientific delivery will be promoted. On the basis of improving the hospital delivery rate, we should continuously improve the business level of maternity insurance personnel, especially the technical level of delivery or the level of dystocia treatment, timely discovering dystocia; avoiding the second stage of prolongation of delayed labor; strict indications for vaginal surgery Properly, avoid direct damage; pay attention to the lower uterus transverse incision cesarean section in the uterus, push the bladder, avoid the incision is too low and damage the uterine blood vessels and suture the ureter, if you want to remove the uterus after the fetus, it is feasible Total hysterectomy does not perform hysterectomy to reduce or avoid convulsions after bladder or ureteral injury, repaired urinary fistula, re-pregnancy Caesarean section should be performed during childbirth
2. Prevention of gynecological surgical injury should adhere to the preoperative discussion system, analyze the difficulties in the operation; grasp the link that is easy to cause injury during surgery; familiar with the anatomy and variation of pelvic organs: improve the basic technical skills of surgical operation, patiently and meticulously operate, In recent years, some scholars have emphasized the preoperative evaluation, according to the lesions and pelvic conditions, choose the best surgical approach and surgical procedures, such as surgical or vaginal or transabdominal, extrafascial hysterectomy or intrafascial hysterectomy, etc. In transabdominal hysterectomy, adhesions should be separated and adhesions can not be restored, normal anatomy of the organs can not be restored, benign lesions can be performed intrafascial hysterectomy, total uterine resection of the fascia is fully pushed away from the bladder and the sides, and the palace side Vaginal tissue, can help prevent bladder or ureteral injury caused by phlegm, such as wide ligament fibroids, cervical fibroids or bleeding in the treatment of the main ligament and other abnormal conditions, if improper treatment can often cause ureteral injury, it should touch the ureteral walking position, If necessary, the peritoneum is cut from the iliac crest and the bifurcation of the external artery to expose the ureter and follow down; the uterine ligament of the main ligament is treated. More bleeding may be the internal iliac artery ligation, help to stop bleeding to avoid ureteral injury, transvaginal hysterectomy, vaginal anterior wall bulging repair, and uterine prolapse bladder bulging with ureter position change, you must correctly dissect the bladder With the cervix space, urethral bladder and vaginal mucosal space, fully separate the paracervical tissue, congenital vaginal acupoints or partial vaginal incision, finding the urethra bladder and rectal space are the key to avoid bladder and rectal injury, extensive uterus Resection, separation of the bladder should be sufficient and no damage, correct ureteral tunnel opening treatment and avoid ureteral sheath injury is the key to prevent vaginal fistula and ureterovaginal fistula.
3. Pay attention to the timely and proper management of genitourinary tract trauma and postoperative management. Tumor radiotherapy should be routine, avoiding over-measurement, and using pessary on time.
4. Improve the accuracy of radiotherapy. Improper treatment during radiotherapy. If the dose is too large or the device is unstable, the bladder or rectum can receive more radiation than it can tolerate, which can often lead to the formation of urinary fistula. Therefore, in radiotherapy Before, we must fully understand the patient's condition, develop a treatment plan, accurately calculate the amount of radiation, properly place the device, and protect the healthy tissue, especially the bladder and rectum. Those who have had bladder or rectal metastasis should not use radiation therapy, radiation therapy. When the patient is undergoing surgery, the surgeon should pay attention to protect the blood supply of the ureter.
Complication
Urinary fistula complications Complications dermatitis pelvic inflammatory disease
Secondary infection
The genital area, buttocks, and inner thigh skin, due to long-term immersion by urine, different degrees of dermatitis, rash and eczema, causing local itching and burning pain. If it is smashed, it may cause secondary infection and bloated. Patients with urinary fistula may sometimes have different degrees of urinary tract infection symptoms, such as ureteral fistula with local ureteral stricture, resulting in pyelectasis and hydronephrosis, more likely to cause infection, and some form a retroperitoneal urinary extravasation, concurrent infection, and then vaginal leakage Urine, occasionally seen after radical resection of cervical cancer.
2. Secondary amenorrhea, infertility
1/2 to 1/3 of patients with urinary fistula have secondary amenorrhea, but there is no exact explanation for the cause. Some people think that the ovarian function caused by mental factors is low, there is no ovulation when leaking urine, and after repair and cure, There are ovulation, menstruation can be restored, urinary fistula patients have secondary infertility accounted for about 40%, related factors are:
(1) pelvic infection during childbirth injury, residual chronic pelvic inflammatory disease, affecting fallopian tube function.
(2) secondary amenorrhea, no ovulation.
(3) The continuous flow of urine from the vagina prevents sperm from living.
3. Neuropsychiatric symptoms
Urinary sputum patients, whether it is day or night or hot summer, the urine is not clean all day long, wet clothes, bedding, smell of urine, individual and leaking people, then urine manure doping, more stinking, often do not dare to go out Participate in group activities and labor, and do not want to visit relatives and friends, seriously affecting work and study, accompanied by vaginal scar stenosis or atresia, loss of sexual life and fertility, but also affect marital relationship and family relationship, individual patients can not bear the spirit of years And the torture of the body, and even suicidal thoughts.
Symptom
Urinary symptoms common symptoms urgency urgency pain urinary incontinence urinary frequency bloating
Leaking urine
The main symptom of urinary fistula is leakage of urine. The time to start leaking urine is closely related to the cause of urinary fistula. The compression of necrotic urinary fistula caused by delayed labor usually begins to leak urine about 1 week after delivery, and it also occurs several weeks later. Urinary fistula formed by poor delivery technology or direct damage to obstetric instruments, leakage of urine immediately after delivery, gynecological surgery injury, if not found in time and only simple suture, often 10 days after surgery, leakage occurs when the suture begins to fall off Symptoms, urinary fistula caused by radiation therapy injury occurs later, even after more than 10 years, due to the influence of radiation, causing arteritis is slow, progressive fibrosis, often accompanied by blood in the stool and anal stenosis, other Patients with diseases, trauma, etc. can be consulted for a more typical medical history.
The condition of leaking urine is different from the size and location of the pupil. The pupil is located in the triangle area or neck of the bladder. The urine overflows day and night and completely loses control. The pupil is located in the high bladder vaginal fistula or bladder above the triangle of the bladder. Cervical spasm, etc., when standing, there is no leakage of urine, but lying in the urine is not enough; the pupil in the bladder is very small, there is granulation tissue around, or the pupil remains after the repair, there are still twists and turns back to the small squat, often Involuntary leakage of urine only occurs when the bladder is full; the small pupil located on the side wall of the bladder can temporarily leak urine when the lateral position is taken, and the urine leaks when lying in the supine or lateral position; close to the bladder neck Urethral vaginal fistula, when lying flat and the bladder is not full, there is no leakage of urine, the urine is leaking when standing; the urethra vaginal fistula located in the lower third of the urethra can generally control urination, but when urinating, the urine is large Partial or total vaginal discharge; unilateral ureteral vaginal fistula, in addition to spontaneous urination, while urine involuntarily vaginal outflow; unmarried or vaginal delivery history of some urinary fistula patients, lying flat and tightly tied thighs Due to contraction of the levator ani muscle and bilateral labia minora The urine is temporarily stored in the dilated vagina, but when it is separated from the thigh or standing, the urine immediately overflows from the vagina.
2. Vulvar and hip dermatitis, caused by long-term stimulation of urine.
3. More associated with urinary tract infections.
4. Difficult sexual intercourse due to stenosis of the vagina.
5. Amenorrhea, about half of the patients of childbearing age have amenorrhea.
Examine
Urinary examination
[Laboratory Inspection]
Probe inspection
Use the uterine probe to gently insert from the urethra, measure the length of the urethra, understand the urethral stenosis or atresia, find a small pupil, the probe can enter the vagina through the pupil, the probe can also enter the bladder examination There are no stones.
2. Methylene blue test
This test can identify vesico-vaginal fistula or ureterovaginal fistula, and can also be used to identify the tiny vaginal vaginal pupil that is difficult to see by the naked eye. The method is as follows: the diluted methylene blue solution is injected into the bladder with a catheter, and then clamped. The urinary catheter, observing the leakage of the urine, helps the positioning of the small pupil. Anyone who sees the blue liquid flowing through the small hole of the vaginal wall is the vaginal vagina, and the cervix is the bladder cervix or the bladder uterus. If the effusion is clear urine, it is a ureteral vaginal fistula. When no liquid is vaginally discharged after injecting diluted methylene blue, the catheter can be removed, and the injected blue liquid overflows from the urethral orifice at this time. The possibility of stress urinary incontinence is large. If there is no fluid outflow, two dry cotton ball plugs can be placed in the vagina, let the patient drink water and walk out of bed for 15-20 minutes, and then check, such as the upper end of the vagina. The tampon blue dyeing is vaginal fistula of the bladder. When the cotton plug is wet but there is no blue, it is suggested to be ureterovaginal fistula.
3. Rouge test
When the methylene blue test is carried out, the pupils are clear liquid, so the vaginal fistula can be ruled out and the ureterovaginal fistula or congenital ureteral ectopic ectopic can be ruled out. The rouge test can be further confirmed. This method can help determine The position of the ureteral orifice and the side of the ureteral vaginal fistula can also understand the function of the kidney. The method is as follows: 5 ml of the rouge is injected intravenously, and after 5 to 7 minutes, the blue liquid is discharged from the fistula, and the blue liquid is discharged through the pupil. The longer the time from injection, the more severe the hydronephrosis on the side. For example, if there is no blue urine overflow in the ureteral orifice under the cystoscope, and there is blue urine in the vagina, it means that the ureterovaginal fistula is in the The side
Film degree exam
Cystoscopy
Cystoscopy can be used to observe the condition of the bladder under direct vision, with or without inflammation, tumor, tuberculosis, bladder stones, and can measure the bladder capacity, observe the relationship between the pupil and the ureteral orifice, the ureteral ejaculation, etc. Surgery provides a reliable basis, simple urinary fistula can not do cystoscopy, complex and most complicated urinary fistula can choose cystoscopy according to the situation, larger pupil of the bladder mucosa eversion can directly look at the bladder and ureteral opening , do not need cystoscopy, for the relationship between the ureteral orifice and the pupil, unclear ureteral stricture, obstruction or suspected lesions in the bladder, cystoscopy should be performed before surgery, such as diagnosis of ureterovaginal fistula, can be in the mirror Check the ureteral catheter, the general ureter can be placed into the catheter smoothly, and the diseased side is blocked. The blocked area is the location of the pupil. For example, due to edema of the bladder mucosa, it is difficult to find the ureteral orifice under the microscopic examination. Injecting the rouge, it can be seen that the blue urine overflows from the ureteral orifice. This method can help to determine the location of the ureteral orifice and the side of the fistula. Overflow of urine, urine and vaginal appear blue, then prove that the side of the ureteral fistula.
2. Urinary tract angiography
The most commonly used urinary fistula patients are excretory urography, X-ray film after intravenous injection of contrast agent, such as good renal function, no urinary tract obstruction, kidney, ureter, bladder are well developed, to understand the presence or absence of lesions in various parts and The degree of the lesion, if a certain side of the kidney is dysfunctional, the X-ray film is not developed or poorly developed. To determine the nature of the lesion, retrograde angiography can be performed to further confirm the diagnosis. If the bilateral kidney function is good, only one can be found. When the lateral ureteral opening is opened, it should be noted that the other side of the ureteral opening may be buried in the scar at the edge of the pupil. When the kidney is dysfunctional, the affected side often does not develop or develop poorly, so the nature of the lesion cannot be determined. Under the guidance, the ureteral catheter was inserted, and the urinary tract contrast agent was slowly injected for retrograde urography to observe the ureter and renal pelvis lesions. However, due to the presence of the pupil, the bladder could not be filled well, the intubation often failed, and the female ureteral orifice was ectopic. , can open in the cervix, vagina, urethra and vestibule, and often combined with repeated renal pelvis and repeated ureter, due to ureteral opening In addition to sphincter control, there are symptoms of leakage of urine, which is difficult to diagnose. It requires a rouge test, excretory or retrograde urography to confirm the diagnosis, suspected kidney damage, congenital polykiuosis, ureteral lesions and deformities. Renal pyelography can be diagnosed accurately.
3. Ultrasound Doppler examination
It is mainly used for the diagnosis of vesicovaginal fistula. The bladder is filled with saline. Ultrasound medium is perfused during ultrasound Doppler examination. The bladder wall can be seen in the presence of sputum. The sensitivity of diagnosis can be comparable to cystoscopy and urography. And no trauma, no radiation.
4. Kidney map
Through renal map analysis, you can understand the bilateral renal function and upper urinary tract patency, such as urinary fistula complicated with renal dysfunction and urinary tract excretion, which indicates that the ureteral vaginal fistula, such as kidney function is impaired Urinary tract tuberculosis may be.
Diagnosis
Urinary fistula diagnosis
diagnosis
Through medical history and gynaecological examinations and according to laboratory tests, other auxiliary examinations are generally not difficult to diagnose.
History
There are many reasons for the formation of urinary fistula. It is very important to ask for a detailed history before surgery. Generally, special medical history can be asked. Trauma of urinary fistula is often delayed, surgical midwifery and non-scientific delivery history, and leakage of urine after dystocia should be distinguished. Necrotic or traumatic type; caused by gynecological surgery, before urinary fistula has undergone some kind of gynecological surgery, such as extensive radical resection of cervical cancer and general vaginal or abdominal hysterectomy, etc., after extensive hysterectomy, due to ureteral defect Most of the urinary fistula caused by blood necrosis leaks urine around 14 days after surgery. Other gynecological surgery directly damages the ureter. Generally, there is leakage of urine within a few days after surgery. However, patients who have leaked urine often have abdominal pain, low back pain, abdominal mass. And fever and other symptoms of extraperitoneal urinary extravasation, when the leakage of urine, the above-mentioned pioneer symptoms can be gradually relieved and disappeared, young women, especially unmarried, unfertile people have leakage of urine, and have a longer-term fever before the onset, frequent urination , dysuria, urgency, accompanied by other areas of tuberculosis or a history of tuberculosis, generally tuberculous urinary fistula, urinary fistula formed by bladder stones, dysuria, dysuria, history of hematuria, Ministry The patient has a history of vaginal discharge; late stage cervical cancer or vaginal cancer forms a pupil, with irregular vaginal bleeding or drainage history; bladder or urethral cancer to the adjacent genital perforation formed by urinary fistula, bladder cancer with hematuria and bladder irritation, Urinary tract cancer has difficulty in urinating, bleeding and a large amount of odor secretion, and the cancer is often accompanied by pain in the late stage of the cancer, uterine prolapse and uterine ligament injection treatment, or the vaginal uterus is not removed for a long time. Asked about the history of the disease, congenital malformation caused by leakage of urine, ectopic ureteral ectopic is more common, in addition to normal urination, while leaking urine, congenital hypospadias, no urethra and bladder varus, etc., are extremely rare, And often combined with the genital tract and other parts of the deformity, generally speaking, these patients have symptoms of urinary incontinence since birth.
2. Physical examination
(1) Systemic examination: Most patients with birth defects and congenital malformations are short stature. Patients with chronic diseases suffer from depression, malnutrition or anemia due to long-term disease. For each urinary fistula, detailed physical examination should be carried out to assess the heart. Lung, liver, and kidney function to determine whether an anesthesia and tolerance surgery can be performed.
(2) gynecological examination: first take the bladder lithotomy position, use the speculum for examination, and then do double or triple examination, such as poor pupil exposure, unsatisfactory examination, can use the knee chest position, with a single The right vaginal retractor or the lower vaginal speculum of the leaf will lift the posterior wall of the vagina upwards. Generally, the pupil of the anterior wall of the vagina and the cervix can be exposed clearly. Even if it is located behind the pubic arch or the high pupil, it can be seen. The location, size and number of the pupil, the degree of vaginal scar, the presence or absence of damage to the urethral sphincter, the transverse or longitudinal rupture of the urethra, the smoothness of the urethra, the length of the urethra, the shape and mobility of the cervix, etc. Close to the pupil of the cervix and lateral pupil, pay special attention to the ureteral opening on the edge of the pupil or the eversion of the bladder mucosa, for some vaginal scar stenosis, or high, the pupil is small, can not pass the general examination Those who see it must be diagnosed with special examinations.
Differential diagnosis
Urine can not escape at any time, there are two possibilities, one of which has abnormal passages - sputum and deformity, and although urine flows out from the normal urethral orifice, it cannot be automatically controlled, and the symptoms are the same as sputum. Urinary fistula should be differentiated from urinary incontinence caused by various reasons. The main reason is that the former urine leaks from the pupil through the vagina, and the latter urine uncontrollably flows out from the urethra.
Stress urinary incontinence
The main pathological changes of stress urinary incontinence may be due to the urethral opening, urinary sphincter or pelvic floor muscle relaxation, short urethra or posterior urethral urethra disappearing, so when the abdominal pressure increases, the intravesical pressure is higher than the pressure in the urethra ( In normal women, when abdominal pressure increases, pressure can be transmitted to the bladder and urethra nearly 2/3 end). Stress urinary incontinence often occurs after delivery, after surgery, in old age (sex hormone deficiency, tissue relaxation) Every time after exertion, the clinical manifestation is that when the patient coughs, sneezes, laughs or stands, the urine immediately drains out, and in severe cases, there is also urine overflow in the supine, generally only seen in women with a history of vaginal delivery, but huge Bladder urethra vaginal fistula repair after recovery is often followed by this disease, check no pupils found, but the sputum patients see cough when the urine overflows from the urethra. At this time, if you eat, the two fingers into the vagina, placed separately On both sides of the urethra (not to pressurize the urethra), force the paraurethral tissue to the pubic direction to restore the normal angle between the bladder and the urethra and the resistance within the urethra, then sputum the patient cough, such as urine no longer Out, not only can be diagnosed as stress urinary incontinence, also suggesting the possibility of surgical cure must be carefully looking for fistula check, do methylene blue test are provided for identification, to avoid a small fistula mistaken for stress urinary incontinence if necessary.
2. Bladder contracture
Because tuberculosis causes bladder fibrosis to become hard and inelastic, the volume is very small, the number of urination is high, and the bladder neck loses contraction due to contracture, resulting in uncontrollable urine and continuous spillover. Symptoms are similar to urinary incontinence, and some are due to Bladder neck tuberculosis lesions invade the sphincter causing loss of urinary function. These patients have typical bladder irritation symptoms, hematuria and tuberculosis symptoms, cystoscopy, urography and urine culture can be further diagnosed, sometimes tuberculous contracture bladder Can be combined with urinary fistula
3. Neurogenic bladder dysfunction
Urinary dysfunction caused by damage to the central or peripheral nerves that regulate bladder function, more common in spinal cord diseases such as inflammation, tumors and recessive spina bifida; occasionally in bladder nerve injury after extensive radical resection of cervical cancer; also seen in Bladder paralysis after prolonged fetal head pressure during childbirth, clinical manifestations of detrusor contractility caused by urinary retention, when the bladder is overfilled, part of the urine involuntarily overflows through the urethra.
Urinary dysfunction is mainly characterized by urinary retention and overflow urinary incontinence. There is no pupil in the examination. The urine system overflows from the urethra. A large amount of urine can be exported from the bladder. According to the medical history, other primary disease clinical manifestations and related nervous system. Checking is not difficult to identify.
4. Detrusor incompatibility incontinence
Due to the involuntary paroxysmal contraction of the detrusor, such involuntary contractions can also be triggered by a sudden increase in intra-abdominal pressure, which is similar to stress urinary incontinence, but the patient has no organic lesions. Urine effluent does not appear immediately when the pressure increases, but only after a few seconds, and can continue to urinate for 10 to 20 s after the pressure is relieved. In addition to urinary incontinence, such patients still have normal urination function.
5. Pseudo urinary incontinence
Because of the serious urinary frequency caused by inflammation, urgency, and even unable to control urination, usually the symptoms of infection are obvious, there is a history of recurrent episodes, anti-infective treatment is effective.
