ABSTRACT

Background:

Post-repair urinary incontinence is a major problem in women who have had successful repair of their vesico-vaginal fistula. Rates of incontinence of 16% to 55% after successful repair of the fistula have been reported. The basis of our hypothesis is the demonstration in the normal patient that 3 oppositely acting directional vectors close the distal and proximal parts of urethra. Adequate elasticity is required in the bladder neck area of the vagina for these two mechanisms to operate independently. The hypothesis Tissue necrosis and consequent scarring in the bladder neck area of the vagina “tether” the stronger posterior vectors to the weaker forward vectors, overcoming them, so that the urethra is opened out instead of being closed. Testing the hypothesis The treatment proposed during the primary fistula repair is to release the vaginal tissue from its scarred attachments to the urethra and pubic bones. After repair of the bladder defect, if there is a gap between the dissected walls of vagina (i.e., a tissue deficit), a skin graft is inserted to restore the elasticity required in the bladder neck area of the vagina for the two separate closure mechanisms to operate independently of each other. Similar principles apply to patients with ongoing incontinence some time after fistula closure. A new classification We believe that there is only one issue as regards fistula classification. If, after full dissection of the vagina off the pubic bones and urethra the two sides of vagina remain separated, then a skin-on flap is required. Any forcible approximation of tissue will lead to problems.