Chapter XIII, Etiology of Prolapse, page 223) being dislocated (Part 3)

fistula has been formed by operation, nature closes the opening, generally in a short time. Vesicovaginal fistula is the most frequent of all the forms of vaginal fistula?, although not nearly so often met with as in the olden days before the art of obstetrics had been perfected to its present high degree of excellence. The vaginal and bladder walls are involved in varying extent. Almost the entire base of the bladder may slough away, leaving the orifices of the ureters exposed in the edge of the fistula, or the opening between the bladder and vagina may be no larger than a pin's point. The symptoms are leakage of urine from the vagina, and, unless great care is main- tained by the patient to keep dry, excoriation, redness, and sore- ness of the vulva, perineum, and thighs. The amount of urine lost will depend on the size of the opening and on the retentive power FISTULA OF THE VAGINA 385 of the vagina. Sometimes urine is retained in the vagina while the patient is recumbent, the pelvic floor being uninjured and the in- troitus small. Often when the fistula is small the patient may void a portion of the urine through the urethra and the rest will escape through the vagina. The diagnosis is made by the history of incontinence and by the physical examination. The digital touch, if the fistula is large, will Fig. 155. — Scheme of the Different Sorts of Genital Fistulae, not Including Fistula-in-Ano. (Gilliam.) 1. Urethrovaginal. 2. Vesico-vaginal. 3. Recto- vaginal. 4. Vesico-uterine. 5. Uretero-vaginal. 6. Entero-vaginal. indicate the size and situation of the fistula. The patient is placed in the Sims position and a Sims speculum introduced. Inspection shows the size, shape, and situation of the fistula. A sound or probe passed through the urethra may be made to appear through the opening in the vagina. In larger fistula) the bladder wall is apt to be much injected (cystitis) and often incrusted with lime salts. 25 386 DISEASES OF THE VAGINA These must be removed gently. Vesico- vaginal fistula gives a fine opportunity to inspect the bladder and to catheterize the ureters. If the fistula is very small and there is doubt as to its situation, the patient is placed in the dorsal position and the bladder is filled with milk and water. Examination of the cleansed vagina through a duckbill speculum will show the point at which the white milk leaks through the fistula. Uretero-vaginal fistula is detected in the same manner. The bladder is filled with milk and water and it is noted that clear urine and no milk collects in the vagina; measure the bladder urine and that which gathers in the vagina, and, if the two kidneys are secret- ing an equal amount, it is possible, by finding that the two quan- tities are the same, to decide that all the urine from one ureter escapes into the vagina. The sense of smell is a great help in de- tecting the presence of urine, for in some instances the differentia- tion of watery fluid coming out of the uterus or the peritoneal cavity from urine is not easy. To aid in distinguishing urine in cases of vaginal fistula it is sometimes of use to give the patient five drops of doubly distilled turpentine on a lump of sugar three times a day. It imparts the characteristic odor of violets to the urine. Methylene blue, one to two grains every four hours given by the mouth, renders the urine a bluish-green color. The colored urine may be seen to escape from a fistula. Urethro- vaginal fistula is a rare variety of fistula due to syphilitic or malignant ulceration or operation on the urethra. The opening between the urethra and vagina is generally small and is situated in the upper course of the urethra. There is no incontinence of urine unless the fistula involves the neck of the bladder. The diagnosis is made by passing a probe into the urethra and through the fistula. For fistulse involving the bladder and ureters see also Chapters XXIV and XXV, pages 474 and 492. Recto-vaginal fistula results in the late stages of cancer of the cervix and also in the case of neglected pessaries and imperfect union of a lacerated perineum. Rarely this fistula results from syphilitic or tuberculous lesion of the vagina. The opening is generally small in size. The symptoms arc the escape of flatus, and also more or less fluid feces, into the vagina. Vaginitis and vulvitis are apt to result from the irritation caused by the fecal matter. FISTULA OF THE VAGINA 387 The diagnosis is founded on the history, and on the examination. The patient is placed in the dorsal position and the anterior vaginal wall raised by a Sims speculum. If the fistula can not be seen a probe is passed in the most likely spots and if it enters an opening which connects with the rectum its point may be felt by a finger in that organ. Also, one may inject the rectum with milk and water and note its escape into the vagina. Entero- vaginal fistula is rare. It results generally from a surgical operation. The presence of feces in the vagina, the exclusion of an opening into the rectum by means of inspection of the rectum through a proctoscope, the character of the fecal matter (chyme), and finding the opening of the fistula in the upper vagina on in- spection and probing with the patient in Sims position, will establish the diagnosis. For fistula-in-ano see Chapter XXVI, page 516.