VESICO - VAGINAL FISTULA.
Vesico-vaginal fistula, or the establishment of an accidental com munication between the bladder and the vagina by means of a defect in the base of the bladder, is not infrequently met with in two classes of cases. First, those in which a cancerous disease extending from the cervix uteri, and involving the vesico-vaginal septum, has broken down and formed an avenue of communication; second, those in which a protracted labor has been followed by sloughing of the ante rior vaginal wall during the puerperal period. They are also rarely seen as a result of an unhealed incision of the vaginal wall for the ex traction of stone. The cancerous cases are not amenable to treatment and will not therefore be further mentioned; the mode of death is by progression of the disease, pressure upon the ureters, and uremia.
Fistula following Lubor.—Vesico-vaginal fistula may follow labor from a number of causes. Without doubt the most common cause is prolonged pressure of the head of the child in one place, in con sequence of which the circulation is completely cut off and the tis sues bruised; in the course of five or six days or a week a slough more or less neatly punched out of the vesico-vaginal septum falls into the vagina and leaves the fistula. Women with contracted pelvis, or with a sharp bony growth on the posterior surface of the symphysis, are more liable than others to this affection.
It has been the habit in the past to blame the use of the forceps in difficult labors for the production of this trouble, but as Emmet long since pointed out and repeatedly insisted upon, it is not the use of the forceps, but a want of their timely use to relieve the pres sure, which is to blame.
Vesico-vaginal fistula also arises in consequence of a tear through the anterior lip of the cervix extending out into the vaginal vault, and up through the whole septum. This tear also usually extends into the uterus, forming a vesico-utero-vaginal fistula. Not infrequently nature will unite the lips of the cervix below, leaving a vesico-uterine fistula above and a vesico-vaginal fistula beneath, separated by a bridge of uterine tissue. The clinician must be careful to interpret these cases aright, recognizing the fact that the two fistulm were originally but one. Fistula of this character may be the direct result of an anterior median tear produced by the forceps.
Vesico-vaginal fistulie vary greatly in size as well as in their asso ciated complications. The fistula may be so large as to include the whole base of the bladder. On examination, the upper wall of the bladder, red and easily bleeding, is seen hanging clown into the vagi na, looking like an intense inflamed anterior vaginal wall, often more or less oedematous. Other fistulae present an irregular but generally
rounded outline, and occupy any part of the base of the bladder; they are of all sizes, down to an opening as fine as a hair.
It is rare that a woman will pass through a difficult labor, result ing in fistula, without other serious injuries to the lower genital tract. In these cases we often meet with extensive deposits of cicatricial tissue in the vagina, extremely narrowed cicatricial vaginal orifice, distortion of the margins of the fistula by the vaginal cicatrix, and the pinning down of a portion of the fistula to one of the pubic rami by scar tis sue. A patient now under my care presented a complete atresia at the vaginal vault with retention of the menstrual secretions in the uterus ; a vesico-vaginal fistula lay in front of this big enough to admit the thumb, and directly opposite the vesico-vaginal fistula, on the pos terior wall, a recto-vaginal fistula equally as large was found.
The diagnosis of vesico-vaginal fistula is usually easy. There is a constant discharge of urine, although the operator must not be misled by the statement of the patient that she is able to retain it for some time when lying clown. This is due to the fact that a vagina will retain considerable urine in this position. The urine held in this way escapes on arising, but the patient cannot always distin guish between such a mode of discharge and a discharge per ure thrall]. Upon inspection of a patient with a large fistula, the hole in the bladder wall is very conspicuous, and the fact of the communica tion is easily demonstrated by a sound passed through the urethra and bladder into the vagina. A smaller fistula may be more difficult to find and may require the aid of an injection into the bladder of sterilized milk, which will then he seen escaping, drop by drop, from the minute fistuIous orifice, or if the fistula, opens into the uterus, from the cervix. When the patient is placed in the knee-breast posi tion, the bladder fills with air and its walls drop away from the fistula, through which a large part of the bladder can be inspected, if the opening is large. Smaller openings examined through the cystoscope introduced per urethram are often difficult to detect on account of their lying in the plane of vision. When located, the fistula can be made to appear more distinctly by pushing up the bladder wall with the end of the speculum and bringing the opening directly across it.