OG26.1-2 | Genital Injuries and Fistulae — Summary & Reflection

KEY TAKEAWAYS

Genital Injuries and Fistulae — Summary

Acute genital injuries — classified by site and depth. Perineal tears graded 1st–4th (OASIS = 3rd/4th degree); cervical lacerations and haematomas are common obstetric injuries. All require prompt assessment and layer-by-layer repair under adequate anaesthesia.

Obstetric fistula — results from ischaemic pressure necrosis during prolonged obstructed labour; predominantly vesicovaginal (VVF). Responsible for 2 million prevalent cases globally; concentrated in low-resource settings.

Clinical presentation: VVF = continuous urine leakage per vaginum, no desire to void, no bladder filling. UVF = continuous vaginal leakage WITH preserved urge-to-void and normal voiding (bladder still fills). RVF = flatus/faeces per vaginum.

Diagnosis: Methylene blue dye test (VVF → blue-stained swab); IV indigo carmine (UVF → orange stain); cystoscopy (site, size, relation to ureters); IVU (upper tract); MRI (complex cases).

Management principles:
- Small fresh VVF: catheter drainage 4–6 weeks (conservative)
- Established obstetric VVF: delay repair 3–6 months until tissues soft and vascularised
- Surgical principles: tension-free closure, multilayer repair, healthy margins, vascularised interposition flap (Martius graft), post-op catheter drainage 10–14 days
- UVF: ureteric reimplantation (ureteroneocystostomy)
- RVF: layered repair ± diverting colostomy

Prevention is paramount: skilled birth attendance, recognition and management of obstructed labour, safe surgical technique.

REFLECT

Consider the 20-year-old woman described in the opening scenario. Her VVF was caused by a system failure — not just the obstructed labour, but the absence of accessible skilled obstetric care at a critical moment. If you were posted in a rural PHC with limited resources, what early warning signs during her labour would you have acted upon? What referral decision would you have made and when? How does this case inform your view of the role of safe motherhood initiatives and the link between women's health, access to skilled care, and social outcomes? Record your reflections in your learning journal.