Bladder fistula – existence of the pathological course connecting a bladder to adjacent internals (a vagina, intestines) or skin. Fistulas of a bladder are characterized by release of urine through the reported body, constant infections of uric ways. The volume of diagnostic inspection at fistulas of a bladder has to include gynecologic survey, ultrasonography of a bladder and bodies of a small pelvis, a tsistoskopiya, a hromotsistoskopiya, a fistulografiya, urography, a tsistografiya, a research of urine and dabs. Treatment of fresh fistulas of a bladder can be conservative; at it is long not healing fistulas their excision is shown.
Taking into account the bodies involved in pathological process allocate puzyrno-genital, puzyrno-intestinal and external fistulas of a bladder. Bladder fistulas often have a long current, bring moral and physical sufferings to the patient, lead to an invalidization, exert negative impact on functioning of an urinogenital and intestinal path. The operational urology, gynecology and a proktologiya is engaged in treatment of fistulas.
Types of fistulas
On time of emergence distinguish congenital fistulas of a bladder and acquired. Congenital fistulas of a bladder, along with a cyst of an urakhus and a diverticulum of a bladder, belong to embryonic defects and are formed as a result of a full nezarashcheniye of primary uric channel. Puzyrno-umbilical, puzyrno-intestinal fistulas belong to such types of anomalies.
Much more often meeting and various group is represented by the acquired bladder fistulas. Women depending on body with which the abnormal message of a bladder is formed can have puzyrno-vaginal fistulas, puzyrno-cervical, puzyrno-uterine, puzyrno-pridatkovy, parametralno-puzyrny. Seldom the difficult combined bladder fistulas - uretro-puzyrno-vaginal, mochetochnikovo-puzyrno-vaginal and reservoir and vaginal meet (between the ortotopichesky bladder created from a gut and a vagina). At damages of a wall of a gut are formed mochekishechny (enterovezikalny fistulas).
Quite often for removal of urine in urology resort to artificial imposing of nadlobkovy fistula of a bladder – an epitsistostomiya. As indications to imposing of an epitsistostoma serve the resistant delay of urine and impossibility of carrying out a kateterization of a bladder (for example, at a prostate gland giperplaziya, a prostate cancer, an urethra striktura etc.). Besides, distinguish the external fistulas of a bladder which are reported with skin and the internal fistulas opening in a cavity of bodies.
Fistulas of a bladder of the acquired character can have a traumatic, inflammatory, oncological or radiation origin. As the most frequent reasons of enterovezikalny fistulas serve intestines cancer, a disease Krone, divertikulit.
Puzyrno-genitalnye fistulas occur mainly at women and are connected with the injuries received as a result of childbirth or gynecologic operations. Among them the most part (55-65%) is made by puzyrno-vaginal fistulas. Developing of fistulas between a bladder and genitals at women usually is caused by patrimonial injuries, intraoperative damages (at medical abortion, a diagnostic scraping, a hysterectomy, etc.). Distinguish bladder wounds, urological operations from other reasons of development of fistulas (in particular, transurethral removal of new growths of a bladder).
Fistulas of inflammatory genesis can be formed at break in a bladder of a piosalpinks, a parametritis, prostate gland abscess, etc. purulent formations of a small pelvis. In some cases fistulas arise owing to germination by a tumor of a puzyrny wall at bladder cancer, vagina cancer, a prostate cancer etc. Fistulas of a bladder can develop after radiation of bodies of a small pelvis several months later or even years after the end of treatment.
The course of fistula of a bladder is defined by its look and the involved bodies. External fistulas, as a rule, have the forward short stroke, open on the surface of skin where around a svishchevy opening there is hyperaemia, maceration, gnoynichka. External fistulas of a bladder with more complex structure can have the long twisting course with numerous pockets that causes formation of abscesses and phlegmons in surrounding fabrics.
Puzyrno-vlagalishchnye fistulas (vezikovaginalny) are usually shown 1-2 weeks later after the delivery or gynecologic intervention. In this case fistula of a bladder is characterized by emergence of constant watery allocations from a vagina which intensity can be various.
At fistulas of the small size periodic involuntary dribble of urine at the kept natural urination is observed. Often insignificant releases of urine from a vagina mistakenly take for a stressful incontience. The fistulas located in the bladder basis usually rather wide therefore through a vagina a part or even all urine can be allocated. Along with these symptoms at women violation of a menstrual cycle, frequent cystitis, colpitises is often noted.
The Puzyrno-pridatkovy, parametralno-pridatkovy and combined fistulas proceed with the phenomena of the expressed general intoxication and the pains caused by destructive processes in a small basin. If fistula of a bladder opens in intestines, then from a rectum the kcal and gases is constantly allocated liquid. The urine effluence (through external fistula of a bladder, a vagina, a rectum) is followed moknutiy and irritation of skin, presence of a pungent uric smell, causes psychoemotional frustration in patients and negatively affects all spheres of life.
Mochepuzyrno-vlagalishchny fistula can be found by the urologist or the gynecologist. When ascertaining involuntary dribble of urine carrying out a vaginal research is required. The big fistula connecting a bladder to a vagina is well visible at survey in mirrors as the cavity of a vagina is quickly enough filled with free liquid – urine. At doubts in character of separated resort to a biochemical research of a vaginal transsudat. If in the liquid emitted from a vagina, the level of creatinine exceeds the similar indicator in blood serum then given is urine.
The tsistoskopiya which is carried out against the background of a hard tamponada of a vagina by gauze tampons allows to reveal bladder fistula also. During a tsistoskopiya localization and the sizes of fistula of a bladder, expressiveness of an inflammation and hypostasis mucous are estimated. Small and dot fistulas of a bladder can be found by means of test with dye. For this purpose in a vagina three tampons are established, and solution of an indigokarmin is entered into a bladder on a catheter. When coloring within 15 minutes of the lower tampon the most possibly stressful incontience of urine; when coloring the top tampons existence of fistula of a bladder is supposed.
For the purpose of detection of the accompanying infection of urinogenital ways it is made urine and the vaginal dab separated urethras, bakissledovany. For control of function of kidneys biochemical indicators of blood - creatinine, urea, electrolytes are defined. The most exact data on the nature of fistula of a bladder, its localization and relationship with the next bodies receive when performing contrast researches – vaginografiya, excretory urography, a tsistografiya, a hromotsistoskopiya, a retrograde ureteropiyelografiya. For specification of branching of the course of fistula of a bladder the fistulografiya is carried out.
Detection of mochepuzyrno-intestinal fistulas demands carrying out a manual research and additional survey of a rectum (an anoskopiya, a rektoromanoskopiya). At the fistulas of a bladder caused by radiation therapy concerning cancer tumors it is necessary to exclude a recurrence of an onkoprotsess by means of a biopsy and a histologic research of edges of a fistula.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
At dot (less than 3 mm in the diameter) puzyrno-vaginal fistulas an attempt of their conservative closing is made. For this purpose in a bladder the constant catheter of Foley is established, instillations of a bladder are carried out, mazevy tampons are entered into a vagina, uroseptik and antibiotics are appointed. Scarring of fistulas of a bladder manages to be reached at 2-3% of patients. If within 6-8 weeks fistula of a bladder is not closed independently, it is necessary to refuse conservative therapy in favor of surgical treatment of fistula.
Surgical closing of fistula of a bladder - the fistuloplastika is carried out after medicamentous preparation and subsiding of pyoinflammatory processes in a zone of the pathological course. Irrespective of a type of fistula, in the course of a fistuloplastika the cicatricial changed fabrics are excised, it will be mobilized and the bladder wall is completely separated with the next bodies and fabrics, after refreshing of edges defects are taken in.
Operations on closing of the created fistulas of a bladder make nadlobkovy, transvaginal (at women), promezhnostny (at men) or the combined access. After an ushivaniye of puzyrno-vaginal fistula for some time leave epitsistosty or a constant uric catheter.
Existence of puzyrno-intestinal fistula can demand temporary imposing of a kolostoma, a resection of a segment of a gut, change of mochetochnik in intestines or tsistektomiya with creation of the artificial intestinal tank for urine.
Prevention of fistulas of a bladder from women demands the correct organization of obstetric aid, especially from pregnant women with a narrow basin, a large fruit, the cross provision of a fruit etc.; preventions of intraoperative damage of bodies when performing gynecologic operations.
In all cases more favorable forecast requires timely recognition of a trauma of uric bodies, its correct assessment and the choice of an adequate way of elimination of fistula of a bladder.