Large Vesico-Vaginal Fistula Caused by a Foreign Body
A nulliparous 19-year-old female presented with a 3 week history of a foreign body in the vagina. Her uncle allegedly forcefully inserted the foreign body after she refused a pre-arranged marriage. The presence of this foreign body was associated with purulent and offensive vaginal discharge, dysuria and leakage of urine from the vagina.\nOn examination she was afebrile with stable vital signs. The patient was found to have suprapubic tenderness on palpation. Examination of the genitalia could not be performed due to severe pain.\nA plain pelvic radiograph showed an opacified object within the pelvic cavity [].\nThe clinical radiographic impression was a foreign body in the vagina with associated bladder injury.\nThe patient was examined in theatre under general anaesthesia. The findings were perineal excoriation and clearly identifiable leakage of urine from the vagina. A plastic container approximately 4 cm in diameter was found invading into the vaginal musculature. With the successful removal of the container, a mid-sized vesico-vaginal fistula was noted measuring 2 cm in diameter with significant surrounding fibrosis and debris. A small stone was visualized in the bladder and removed vaginally through the fistula. The patient was then transferred to the ward for interim treatment of a Sitz bath to clean the fistula for later repair.\nAfter 10 days the fistula was deemed operable. A 4 cm vesico-vaginal fistula and considerable associated fibrotic tissue were identified [].[] The ureteric orifices were far from the fistula margins. Hydro-dissection was performed using a specially formulated solution (jungle juice). Fistula margins were dissected with scalpel, then scissors to separate the bladder from the vaginal tissue. Some scarred tissues were excised. Bladder tissue was freed from tension. Repair of the bladder was commenced in a transverse direction, inverting the tissue inward using interrupted sutures (polysorb #2-0). Water-tight repair of the bladder was achieved by single layer closure and confirmed by negative dye test (methylene blue). Then the repair of the vaginal wall with polysorb suture #0 was performed in a transverse direction. The post-operative course was unremarkable. The Foley catheter was removed on day 14 with no leakage of urine through the vagina. Despite involvement of a counselor, psychiatrist and hospital social worker, the patient chose not to initiate legal proceedings.\nShe was discharged with advice to abstain from intercourse for 3 months and we have recommended elective caesarean section should she fall pregnant in the future.