female urinary fistula
Introduction
Introduction to female urination Urinary fistula refers to the abnormal passage between the urinary system and other systems and organs. Here we mainly introduce urogenital spasm, including vesicovaginal fistula, urethral fistula, ureterovaginal fistula and so on. basic knowledge Prevalence ratio: 0.2% of specific population Susceptible people: women Mode of infection: non-infectious Complications: urinary tract infections bladder stones infertility
Cause
Female urinary causes
(1) Causes of the disease
Common causes of female urinary fistula: 1 gynecological surgical injury, cervical cancer, retroperitoneal tumors and other surgery may cause bladder, ureteral injury and urinary fistula; 2 childbirth injury; 3 trauma, such as pelvic fractures, rough sexual intercourse, etc.; 4 urinary Department of malformation, such as congenital ureteral ectopic opening; 5 late bladder tuberculosis, tumors and so on.
(two) pathogenesis
Most of the urinary fistula is caused by injury. In China, it is mainly dystocia injury, followed by surgical injury, less caused by other injuries or infections. With the maternal and child health care in China, the perinatal health care work is strengthened, and the urinary fistula caused by birth injury It has been greatly reduced, while gynecological surgery injuries have increased.
1. Childbirth injuries are caused by too long labor, difficult to produce, can be divided into necrotic and traumatic.
(1) Necrotic urinary fistula: due to the lack of head basin, abnormal fetal position, pelvic stenosis, the first exposure of the fetus is blocked and the production is delayed, the fetus is exposed in the pelvic cavity for too long, bladder, urethra, vaginal wall and other soft tissues Squeeze between the fetal first exposed and the maternal pubic symphysis, causing soft tissue ischemic necrosis, falling off and forming a fistula, such as obstruction occurring in the pelvic entrance plane, often involving the cervix, above the bladder triangle or ureter, causing bladder cervix, Bladder vaginal fistula or vesicoureteral vaginal fistula, such as fetal incarceration in the middle pelvis, often involving the bladder triangle and bladder neck, can cause bladder vaginal fistula or bladder urethra vaginal fistula, such as fetal stagnation stay in the pelvic outlet For a long time, it is more involved in the urethra and urethral fistula and vaginal ring scar stenosis.
(2) Traumatic urinary fistula: the uterus is not open, the bladder is not empty, the forceps are assisted, and other obstetric operations such as craniotomy, destructive surgery, fetal head aspiration, internal reversal, etc. Irrespective of the operation routine, turbid surgery can damage the vaginal wall, bladder and urethra, uterine incision tear during cesarean section to prolong the injury of the bladder, or suture the ureter and suture the bladder wall during suturing, no untreated during operation And form urinary fistula.
2. Gynecological surgical injury Whether it is transabdominal or transvaginal pelvic gynecological surgery such as radical resection of cervical cancer, attachment resection, total hysterectomy, etc. can cause urinary organ damage and urinary fistula.
3. Corrosion of the drug Corrosive drugs such as ferrets placed in the vagina can cause local tissue to be corroded and necrotic, ulcerated, and eventually form urinary fistula.
4. Cancer after cervical cancer or radiation therapy. Cervical cancer or vaginal cancer can directly invade the bladder wall and urethra or local tissue necrosis after radiotherapy to form urinary fistula. After radiotherapy, urinary fistula can occur 1 to 2 years after radiotherapy. Can also appear 10 years later, other gynecological tumors such as trophoblastic tumors, ovarian cancer, uterine body cancer, etc. can also directly invade the ureter, bladder and cause urinary fistula.
5. Other factors: genital trauma or pelvic fracture can damage the urethra and bladder to form urinary fistula, bladder tuberculosis, bladder stones can also induce urinary fistula, long-term placement of pessary in the vagina, formation of incarceration, tissue compression ischemia, necrosis and urinary fistula .
According to the standards set by the 1979 Hengyang Conference on Urinary Fistula Prevention and Research Collaboration, the urinary fistula can be divided into two categories according to the anatomical part and the pupillary nature:
(1) Classification by anatomical location:
1 urethra vagina: the urethra pupil is connected to the vagina.
2 vaginal fistula: the bladder pupil is connected to the vagina.
3 bladder urethra vaginal fistula: pupils involving the bladder neck, urethra and vagina, the remaining urethra is shorter than 3cm.
4 bladder cervicovaginal fistula: pupils involving the cervix, bladder and vagina, the upper edge of the pupil is higher, the anterior lip of the cervix often severe tear or defect.
5 ureteral fistula: the pupil communicates with the ureter and vagina.
6 urinary fistula combined with rectal vaginal fistula: also known as urinary feces combined with sputum or mixed sputum, pupils involving the urinary system, vagina and rectum.
(2) According to the nature of pupils:
1 simple urinary fistula: bladder vaginal fistula position is low, sputum pore size <3cm, urethral vaginal fistula diameter <1cm, bladder cervix vaginal fistula, cervical activity, pupil easy to expose.
2 complex urinary fistula: bladder vaginal fistula pore size more than 3cm or pupil is not easy to expose, vaginal urethra fistula pore diameter more than 1cm, or cross-cut, longitudinal or partial defects, mixed hemorrhoids, multiple urinary fistula, urinary fistula multiple repair failure.
3 the most complicated urinary fistula; complete urethra, complex mixed hemorrhoids, huge pupil, high pupil position is not easy to expose, urinary fistula combined with severe stenosis scar or occlusion.
Prevention
Female urinary fistula prevention
Prevention: Most urinary fistulas can be prevented, and it is more important to prevent urinary fistula caused by birth trauma. Carefully carry out prenatal examination, carefully observe the labor process, correctly handle abnormal delivery, and prevent the second stage of labor from prolonging and delaying production. When vaginal surgery is used for midwifery, catheterization must be performed before surgery. Surgical instruments should be used carefully. The genitourinary tract should be routinely examined for damage. For long-term labor, bladder and vaginal compression, suspected injury, postpartum should be placed in the catheter for 10-14 days, to maintain bladder emptiness, is conducive to improve local blood supply and prevent the formation of urinary fistula. Gynecological surgery caused by urinary fistula multiple uterine resection of the ureter, the pelvic organs with extensive adhesions should be fully exposed to the ureter, clear anatomical relationship and then resection; if ureter or bladder injury is found during surgery, should Instant patching.
Strengthen perinatal care, continuously improve the quality of obstetrics and gynecological surgery techniques, the vast majority of urinary fistula can be avoided.
Birth injury is the main cause of urinary fistula in developing countries. In the prevention of traumatic urinary fistula, family planning should be emphasized, system management of maternal maternal should be strengthened, regular pregnancy examination should be carried out, pelvic stenosis should be detected early, malformation or abnormal fetal position should be corrected in time. And hospitalization in advance, to strengthen the labor process for the maternal observation, any abnormality of the labor chart or the extension of the second stage of labor should be promptly treated, early termination of delivery to avoid the formation of delayed labor, vaginal surgery delivery, routine catheterization before emptying the bladder, Strictly follow the operating procedures during surgery, carefully use a variety of instruments, apply sharp instruments or broken ends, the broken bones of the broken limbs must be protected by the vaginal wall, routine examination of the reproductive tract, urinary tract injury, found The injury is immediately repaired. If the labor is too long, there is a history of urinary retention and hematuria. The catheter should be placed for about 10 days after birth to prevent the formation of urinary fistula.
After the cure, the patient with urinary fistula should undergo cesarean section when giving birth again.
Regarding the prevention of gynecological surgical injury, fully estimate the difficulties in the operation, grasp the link that is easy to cause injury during surgery, familiarize with the anatomy and variation of pelvic organs, and improve the basic technology of surgical operation. When the pelvic surgery is severely adhered, carefully separate the adhesion. Restore the normal anatomy of the organ. When the whole hysterectomy is performed, the bladder is pushed down to the level of the external cervix. In particular, the two sides of the cervix reach 1 cm outside the rim of the cervix. Always pay attention to the ureter. If necessary, the ureter can be freed and the direction of the pelvic segment can be traced. To avoid damage.
Radiation therapy should avoid excessive dose, use pessary should adhere to the day and night, not long-term placement, do not abuse corrosive drugs in the vagina.
Complication
Female urinary fistula complications Complications, urinary tract infection, bladder stone infertility
The disease can be combined with urinary tract infections and bladder stones. About 1/3 to 1/2 of them have secondary amenorrhea, but there is no exact explanation for the cause. The urinary fistula patients have secondary infertility accounting for about 40%.
Symptom
Female urinary fistula symptoms common symptoms amenorrhea depression bladder vaginal itching eczema pimples
1. Leaky urine and urine continuously flow through the vagina, unilateral ureteral vaginal fistula, still spontaneous urination, and larger vaginal fistula of the pupil can not urinate spontaneously, urinary tract vaginal fistula only when the urine is vaginal outflow.
2. Urinary eczema Due to long-term stimulation of urine, the perineal and perianal skin is red and swollen, thickened, sometimes with papules or superficial ulcers, genital itching and burning.
3. Menstrual disorders 10% to 15% of patients with long-term amenorrhea or menstrual reduction.
4. Depression Because of long-term urine dripping, contaminated underwear, urine odor, it is difficult to coexist with people, bedtime wet at night, sexual life disorders, so mental depression and even world.
5. Gynecological examination of vaginal endoscopy, double and triple examination, to understand the vagina, uterus, while paying attention to the size of the pupil, the location and the extent of the surrounding scar, with or without inflammation, with a metal catheter or uterine probe Urethral tract, understand the length of the urethra, with or without atresia, stenosis, fracture, etc.
Examine
Female urinary examination
1. Cystoscopy can understand the number, size, location, pupil and ureteral orifice, the relationship between the urethra, and understand the bladder capacity, with or without inflammation, stones, diverticulum and so on.
2. The methylene blue test can identify vaginal fistula or ureterovaginal fistula, and dilute methylene blue into the bladder. If the cotton ball in the vagina is dyed blue, it indicates bladder vagina; if the cotton ball in the vagina is not dyed Blue, and see a small pupil, it is prompted for ureterovaginal fistula.
3. Indigo test intravenous infusion of purple 5ml, 5 ~ 7min after seeing blue liquid overflow from the pupil, suitable for the diagnosis of congenital ureteral ectopic or ureteral fistula.
4. Intravenous urography can understand the upper urinary tract, determine the location of ureter and renal function.
Diagnosis
Female urinary fistula diagnosis
diagnosis
According to the symptoms of leakage and dystocia, dystocia or gynecological surgery, combined with gynecological examination, the vaginal leaking urinary tract is not difficult. The important reason is the cause of urinary fistula, the nature, location, size and surrounding tissue. In the case, this is of great significance for proper handling.
Differential diagnosis
1. The ectopic ureteral opening is accompanied by double renal ureteral malformation. In addition to normal urination, continuous sputum urine or urine splashes are seen in the vagina, vestibule, urethra and other parts. Increased abdominal pressure has nothing to do, IVU can be seen in the affected side of both kidneys and double ureters, the upper kidney often has hydronephrosis or hypoplasia.
2. Stress urinary incontinence refers to a sudden increase in abdominal pressure, such as coughing, sneezing, and urine involuntarily leaking from the urethra when lifting heavy objects. When the degree of urinary incontinence is heavier, that is, walking, standing and lying When there is urine overflow, it needs to be differentiated from urinary fistula. When checking for patients with stress urinary incontinence, the pupil can not be found, the abdominal pressure is increased when the bladder is filled, and the urine is discharged from the urethra; but when the index finger and the middle finger are inserted into the vagina Inside, when the urethra is lifted up on both sides of the bladder neck, the urine flow can be stopped, and there is no urine leakage from the vaginal opening. If the vaginal opening still leaks urine, it is urinary fistula.
3. Overflow urinary incontinence refers to the involuntary urination that occurs when the bladder is over-expanded, often secondary to diabetic neuropathy and spinal cord injury. The patient may have no urinary sensation. There is still a lot of residual urine in the bladder after urination. It was found that the pupil in the vagina and the vaginal opening leaked urine.
4. True urinary incontinence due to dysfunction of the bladder neck sphincter and urethral sphincter, urine continuously dripping from the urethra, the patient has no urinary sensation, the bladder is always in an empty state, such urinary incontinence patients can not find vaginal fistula After the hole is pressed, the urethra is leaked without vaginal opening.
5. Tuberculous bladder fistula bladder tuberculosis during the healing process, the bladder contracture, bladder capacity can be <50ml, due to the inability to effectively store urine and severe urinary frequency and urinary incontinence symptoms, imaging examination often shows typical kidney tuberculosis and kidney The ureteral water changes. When the fluid is injected into the bladder, the amount of fluid is only a few tens of milliliters, and the patient feels pain or the fluid is forced to flow out from the urethra.
