16/09/2026
a) i. Two other types of fistulae and their locations
Apart from vesico-va**nal fistula, examples include
👉Recto-va**nal fistula (RVF)
Abnormal connection between the re**um and va**na.
Causes passage of faeces or flatus through the va**na.
👉Uretero-va**nal fistula
Abnormal connection between the ureter and va**na.
Causes continuous leakage of urine through the va**na despite normal urination.
Other acceptable examples
-Vesico-uterine fistula — connection between the bladder and uterus.
-Recto-uterine fistula — connection between the re**um and uterus.
a) ii. Five predisposing factors for vesico-va**nal fistula marks
👉Prolonged/obstructed labour
The presenting fetal head compresses the bladder and surrounding tissues against the mother's pelvis, causing tissue necrosis.
👉Early pregnancy/childbirth
-Adolescents may have an immature or relatively small pelvis, increasing the risk of obstructed labour.
👉Home delivery without skilled birth attendance
-Complications such as obstructed labour may not be recognized or managed early.
👉Lack of access to emergency obstetric care
-Delayed referral and delayed caesarean section can allow prolonged obstruction and tissue damage.
👉Traumatic or difficult delivery
-Instrumental delivery, difficult manipulation or birth trauma may damage the urinary tract.
Other factors that may be mentioned: previous pelvic surgery, pelvic malignancy/radiotherapy, ge***al tract injury, and neglected obstructed labour.
b) Five investigations used to confirm VVF
1. Dye test
A dye such as methylene blue is introduced into the bladder through a catheter.
A va**nal swab or inspection is used to determine whether blue-stained urine leaks through the va**na.
A positive test supports a vesico-va**nal fistula.
2. Speculum examination
A va**nal speculum is inserted to directly visualize the va**na and fistula.
It helps determine the site, size and number of fistulae.
3. Cystoscopy
A cystoscope is passed through the urethra into the bladder.
It allows direct visualization of the bladder and fistula opening.
It also helps determine the relationship of the fistula to the ureteric orifices.
4. Intravenous urography (IVU/IVP)
Contrast is administered intravenously and X-rays are taken.
It assesses the upper urinary tract and kidneys and can help identify ureteric involvement.
5. Renal tract ultrasound
Ultrasound assesses the kidneys and urinary tract.
It can detect hydronephrosis, obstruction or other urinary tract abnormalities associated with the fistula.
Other acceptable investigations: CT urography, MRI, retrograde pyelography and urine microscopy/culture where infection is suspected.
c) Pre-operative care for Mrs Siame
Pre-operative care should prepare the patient physically, psychologically and socially for fistula repair.
1. Establish rapport and provide psychological support
Introduce yourself and explain the condition in understandable language.
Reassure her that VVF is treatable.
Allow her to express fears and concerns.
Maintain privacy and dignity.
2. Take a complete history
Assess
-Duration of urinary leakage.
-Obstetric history and details of the difficult delivery.
-Previous surgeries or fistula repairs.
-Menstrual and sexual history where appropriate.
-History of recurrent urinary tract infections.
-Current medications and allergies.
-Other medical conditions.
3. Perform a complete physical examination
-Assess general condition and nutritional status.
-Check temperature, pulse, respiratory rate and blood pressure.
-Assess for anaemia, dehydration and infection.
-Examine the abdomen and ge***al tract as appropriate.
4. Confirm the diagnosis and assess the fistula
-Assist with investigations such as dye testing, speculum examination and cystoscopy.
-Determine the site, size and complexity of the fistula.
-Assess whether the ureters or other structures are involved.
5. Investigate for infection
-Obtain urine for urinalysis and urine culture and sensitivity.
-Treat urinary tract infection according to culture results/local guidelines.
-Check for va**nal or other infections and treat appropriately.
6. Blood investigations
Prepare the patient for surgery by checking appropriate investigations such as
-Full blood count/haemoglobin.
-Blood group and cross-match where indicated.
-Urea, electrolytes and creatinine.
-Other tests according to the hospital's surgical protocol.
7. Correct anaemia
-Identify and treat anaemia before surgery.
-Provide iron/folate and dietary advice where appropriate.
-Severe anaemia may require further management before elective surgery.
8. Improve nutritional status
-Assess for malnutrition.
-Encourage a balanced diet rich in protein, iron, vitamins and adequate calories.
-Give nutritional supplementation where necessary.
9. Maintain good personal hygiene
-Encourage regular bathing and ge***al hygiene.
-Keep the perineal area clean and dry.
-Change wet/soiled clothing frequently to prevent skin breakdown and infection.
10. Manage skin excoriation
Continuous urine leakage may cause vulval and perineal dermatitis.
-Clean the affected area gently.
-Keep the skin dry.
-Apply an appropriate barrier preparation if prescribed.
11. Bladder management
-Insert/maintain a urinary catheter if prescribed.
-Ensure the catheter drains freely.
-Monitor urine output.
-Maintain catheter hygiene and prevent infection.
12. Control urinary infection
-Administer prescribed antibiotics.
-Encourage adequate fluid intake unless contraindicated.
-Monitor temperature and symptoms of infection.
13. Pre-operative counselling
Explain
-Nature of the operation.
-Expected benefits.
-Possible risks and complications.
-Need for catheterization after surgery.
-Importance of following postoperative instructions.
14. Explain postoperative expectations
Prepare her for
-Urinary catheter for a period after repair.
-Possible va**nal packing.
-Restricted sexual in*******se during healing.
-Follow-up appointments.
-Gradual return to normal activities.
15. Obtain informed consent
-Ensure the patient understands the procedure.
-Explain benefits, risks and alternatives.
-Obtain appropriate informed consent according to hospital policy.
16. Anaesthetic assessment
-Refer/prepare her for review by the anaesthetic team.
-Identify previous anaesthetic problems, allergies and relevant medical conditions.
17. Psychological and social assessment
VVF can cause stigma, isolation and loss of confidence.
-Provide counselling.
-Assess family/social support.
-Encourage supportive involvement of appropriate relatives with the patient's consent.
18. Sexual/reproductive counselling
-Explain the importance of allowing adequate healing after repair before resuming sexual in*******se.
-Provide appropriate family-planning counselling.
-Discuss future pregnancy planning with the surgical/obstetric team.
19. Prevent pressure sores and improve mobility
If she has been lying down for prolonged periods
-Encourage mobility where appropriate.
-Reposition regularly.
-Maintain skin care.
20. Prepare for the day of surgery
-Ensure fasting according to anaesthetic instructions.
-Complete pre-operative checklist.
-Remove jewellery and other items as required.
-Ensure appropriate surgical clothing.
-Administer prescribed pre-operative medications.
-Confirm investigations and consent are complete.
-Ensure the correct patient and planned procedure are verified.
21. Documentation and handover
-Document assessment, investigations, treatment and patient education.
-Give appropriate handover to the theatre/surgical team.
d) Six preventive measures for VVF to teach the community
1. Encourage skilled attendance at every delivery
Pregnant women should deliver in a health facility with trained/skilled birth attendants so that complications can be detected and managed early.
2. Prevent early pregnancy
Encourage adolescents to delay pregnancy until they are physically and socially prepared. This reduces the risk associated with pregnancy in a very young mother.
3. Promote antenatal care
Women should attend antenatal clinics regularly for:
Risk assessment.
Identification of complications.
Birth preparedness.
Referral planning.
4. Ensure early referral of prolonged/obstructed labour
The community should recognize danger signs such as:
Labour that is not progressing.
Prolonged labour.
Severe abdominal pain.
Abnormal bleeding.
Maternal exhaustion.
Such women should be referred immediately to a facility capable of providing emergency obstetric care.
5. Improve access to emergency obstetric care
Communities should have:
Reliable transport systems.
Emergency referral mechanisms.
Accessible health facilities.
Early decision-making when complications occur.
6. Promote family planning
Access to contraception helps prevent
-Unintended pregnancies.
-Very early pregnancies.
-Closely spaced pregnancies.
This can reduce the risk of obstetric complications associated with VVF.
🧣Additional points that can earn marks
Educate communities about the dangers of home delivery in high-risk pregnancies.
-Encourage women to seek antenatal care early.
-Improve maternal nutrition and prevent severe anaemia.
-Discourage harmful traditional practices that may cause ge***al tract injury.
-Ensure appropriately trained health workers manage labour and delivery.
-Promote maternal health education and birth preparedness.
-Strengthen referral links between community facilities and hospitals.
