|Discussion in 'All Categories' started by rekha kumari - Feb 11th, 2012 7:15 pm.|
|hole in bladder wall side
urine always leake
re: urine leakage by Dr M.K. Gupta - Feb 18th, 2012 10:09 pm
Dr M.K. Gupta
|Dear Rekha kumari
If VVF is diagnosed within the first couple of days of surgery, a transurethral or suprapubic catheter ought to be placed and maintained for up to Thirty days. Small fistulas ( under 1 cm) may resolve or decrease during this time period if caution can be used to make sure proper continuous drainage from the catheter.
In 1985, Zimmern figured when the fistula is small , the patient's vaginal leakage of urine is cured with Foley placement, the fistula has a high spontaneous cure rate with a 3-week trial of Foley drainage. He also noted that generally, if at the end of Thirty days of catheter placement the fistula has diminished in dimensions, an effort of continued catheter drainage for an additional 2-3 weeks may be beneficial. Finally, Zimmern figured if no improvement is observed after 30 days, a VVF isn't likely to solve spontaneously. In these situations, prolonged catheterization only boosts the perils of infection while offering no increased benefit to fistula cure.
In their series, Davits and Miranda found complete resolution of 4 VVFs with continuous bladder drainage maintained for 19-54 days. Tancer noted spontaneous closure in 3 of 151 patients (2%). During these 3 patients, continuous bladder catheterization was provided within 3 weeks of index hysterectomy; none had an epithelialized fistula tract, and a pair of had transvesical sutures which were removed during the time of the first cystoscopic examination. The size of the VVFs was not documented.
Elkins and Thompson noted some success with continuous bladder drainage. Unfortunately, the speed of success was unpredictable for the individual patient; the rates ranged from 12-80%. Successful cases were seen as a the following criteria: continuous bladder drainage for up to 4 weeks, the VVFs were diagnosed and treated within 7 days of index surgery, VVFs were less than 1 cm, plus they were not related to carcinoma or radiation.
Estrogen replacement therapy in the postmenopausal patient may assist with optimizing tissue vascularization and healing. Oral hormone replacement therapy/estrogen replacement therapy (HRT/ERT) alone has been discovered to suboptimally estrogenize urogenital tissue in 40% of patients. Treatment with estrogen vaginal cream is usually recommended for patients with VVFs who are hypoestrogenic. A 4- to 6-week treatment regimen just before surgery is commonly recommended. It may be used alone or perhaps in combination with oral HRT/ERT. Dosages vary from 2-4 g placed vaginally at night once per week. Alternatively, the individual may place 1 g vaginally at night 3 times each week.
Corticosteroid and nonsteroidal anti-inflammatory treatments are theorized to reduce early inflammatory changes at the fistula site. However, its efficacy has not been proven. Since it also carries potential risks for impairment of wound healing, when early repair is planned, cortisone is not suitable for the treatment of VVF.
Acidification of urine to diminish risks of cystitis, mucus production, and formation of bladder calculi may be a consideration, especially in the interval between your diagnosis and surgical repair of VVF. Vitamin C at 500 mg orally 3 times daily enables you to acidify urine. Alternatively, methenamine mandelate at 550 mg plus sodium acid phosphate at 500 mg 1-4 times per day also can be administered to achieve urine acidification.
Urised is effective for control of postoperative bladder spasms. It's a combination of antiseptics (methenamine, methylene blue, phenyl salicylate, benzoic acid) and parasympatholytics (atropine sulfate, hyoscyamine sulfate).
Sitz baths and barrier ointments, such as zinc oxide preparations, can offer needed relief from local ammoniacal dermatitis.
The best chance for a surgeon to attain successful repair is to apply the type of surgery with which he or she is most familiar. Techniques of repair include (1) the vaginal approach, (2) the abdominal approach, (3) electrocautery, (4), fibrin glue, (5) endoscopic closure using fibrin glue without or with adding bovine collagen, (6) the laparoscopic approach, and (7) using interposition flaps or grafts.
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