Pelvic organ prolapsed and Genital fistula

Pelvic Organ Prolapse 

Pelvic organ prolapse (POP) is a vaginal bulge or lump that can impair your quality of life. Conditions that injure the pelvic muscles and nerves impair the ability of the pelvic diaphragm to support the organs in the pelvis. When other muscles are injured or stretched, the pelvic diaphragm loses its dome shape and takes on the shape of a funnel. Then it bulges into or out of the vaginal canal.

As the vaginal and uterine prolapse worsens, women may notice bulging tissue protruding through the vaginal opening. Prolapse is frequently referred to as a "hernia" of the pelvic floor.

Pelvic organ prolapse symptoms may include a heavy, dragging feeling or a lump in the vagina, bladder or bowel problems, and discomfort during sexual intercourse.

Causes 

• When any component of the pelvic floor is harmed during vaginal birth, pelvic support might be lost. Back and pelvic fractures caused by falls or motor vehicle accidents may necessitate surgery, pelvic radiotherapy, or both.
• Pregnancy and childbirth cause hormonal changes, and weight gain causes pelvic floor muscles to weaken, resulting in prolapse.
• Menopause and age are widespread in old age, mostly because estrogen hormonal deficiency cannot maintain healthy vaginal tissue and the pelvic organ prolapses.
• Age, menopause, and chronic nerve and muscle illnesses all lead to pelvic floor weakness and the development of prolapse. Furthermore, inherited poor connective tissue is a major contributing component.
• Smoking and/or a persistent cough
• Constipation and persistent straining
• Overweight

Types 

• Anterior wall prolapse (CYSTOCELE): The most prevalent type of pelvic organ prolapse is anterior wall prolapse ("cystocele"). Because of a lack of support in the front wall of the vagina, the bladder descends, rotates, and emerges through the vaginal opening. While there is a large cystocele, urine leakage may occur.

• Posterior wall prolapse (RECTOCELE): Rectocele is a condition that occurs when the posterior wall of the vagina loses its support. The rectum then bulges into and out of the vaginal entrance, and a big rectocele can make it difficult to empty the bowels, causing the patient to push on the wall between the vagina and the rectum to help with evacuation, which is known as "splinting."

• Uterine Prolapse: As the pelvic support is removed at the top of the vagina, the uterus bulges down into the vagina and protrudes outside the body, frequently bringing the bladder or rectum with it. When the uterus totally prolapses and hangs between a woman's legs, she will experience urinary retention or infection.

• Vaginal Vault Prolapse with Enterocele: Women who have had a hysterectomy are at risk of developing relaxation of the top of the vagina or vaginal vault, and the small intestines may occasionally slip into the hernia, resulting in an "enterocele."

Diagnosis 

• Vaginal examination, including a speculum to assess and measure the stage of prolapsed 
• Different degree of prolapse can be identified as symptoms or severity of prolapsed 
• Urodynamic assessment to assess bladder. 

Treatment 

• Change in lifestyle such as weight reduction, quitting smoking, prevention of constipation, avoid heavy lifting and early treatment of cough early 
• Pelvic floor exercises are effective to improve the mild to moderate degree of prolapse 
• Veginal pessary is a plastic or silicone device that fits into the vagina to help support the vaginal walls (usually the front wall) and uterus and less likely to help a posterior (back) wall prolapse. 

 Surgical treatment: It is for prolapsed is to support the pelvic organs and restore them to their natural position and to help ease symptoms through vaginal, abdominal, and laparoscopic approaches. In the case of the anterior (front) wall prolapse (cystocele), the tissue between the vagina and the bladder is sutured and reinforced through vaginal repair. 

 Sacrocolpopexy: A prolapsed cervix or vaginal vault is supported using mesh attached to the sacrum. This procedure may be approached abdominally or laparoscopically / robotically. 

 Vaginal hysterectomy (removal of the uterus): This procedure is sometimes performed as part of the surgery to treat uterine prolapse. 

 Sacrospinous fixation: Slowly dissolving or permanent stitches are placed into the top of the vagina or the cervix, and attached to one or both strong ligaments in the pelvis to provide support to the uterus or vaginal vault. 

Preventive Measures 

• Uterovaginal prolapse is caused by early childbirth and repeated pregnancy, so women should be encouraged to avoid pregnancy and utilize family planning strategies to maintain space between childbirths.
• During the first stage of labor, the nurse midwife should emphasize the importance of not bearing down, and breech or forceps delivery should not be conducted before the cervix has fully dilated.
• Prolonged labor should be avoided in the second stage of labor.
• During the second stage of labor, a liberal episiotomy must be performed.
• Tears or episiotomies must be carefully sutured in the third stage of labor.

Nursing Management  

• The bladder functions need to be assess daily after surgery also. Unusual bladder function that may range from difficulty passing urine to incontinence need to notice carefully. The nurse must record and report input and output chart strictly  
• If the patient is wearing a vaginal pessary, the fit must be examined. If the patient has urinary incontinence, ask him or her to cough or go to the bathroom.
• Tell the patient to return in four to six months for a reassessment.
• The patient's daily weight is vital, and weight loss of more than five kilograms may produce problems with pessary fit.
• Antibiotics can help antibiotic-resistant infections heal quickly after surgery. Teach the patient to clean the pessary once a week, or more frequently, and to rinse it with clean water before inserting it.
• Pelvic floor exercises must be conducted mostly during puerperium and for the duration of the waiting period for surgery.
• Request that the patient wash their hands before and after touching or cleaning the pessaries.
• In order to avoid infection, proper personal hygiene must be maintained.
• Maintain the patient's nutritional status, and a diet high in iron and fiber should be offered and encouraged.
• Heavy weight lifting, chronic cough and constipation, as well as intense exercise for an extended period of time, should be avoided throughout the postnatal period.
• Kegel exercises should be done three times a day to tone up the pelvic floor muscles.

Genital Fistula 

Definition 

Genital fistula is a medical condition characterized by abnormal communication between the genital tract (vagina, cervix, uterus, or perineum) and either the urinary tract (bladder, urethra, or ureter) or the gastrointestinal tract (rectum, colon, anal, or small bowel).

Etiology 

• Obstetric factors account for 80 to 90% of occurrences, owing to protracted obstructed labor, assisted vaginal birth, caesarean section, and operative damage, which occurs primarily in industrialized nations during total hysterectomy and laparoscopic procedures.
• The mother's contractions constantly pushed the baby's head on her pelvis during her extended labor. Soft tissues stuck between the baby's head and her pelvic bone compress, limiting normal blood flow. Sections of tissue die quickly without adequate blood supply, causing holes known as "fistulae."
• Inadequate access to medical care, hunger, and teen pregnancy
• Serious injury or accidents resulting in bladder or urethral perforation, or sexual assault
• Urinary tract anomalies are the most common congenital abnormality.
• Crohn's disease and ulcerative colitis are rare causes that induce inflammation in the digestive tract and generate fistulas.
• Cancer or pelvic radiation treatment

 Sign and symptoms  

• Continuous (day and night) incontinence is a classic presenting indicator. If the fistula is tiny, the only symptom may be watery vaginal discharge accompanied by normal voiding.
• Vomiting and nausea
• Pain in the abdomen
• Pain in the vaginal area or between the vagina and the anus (perineum)
• Controlling bowel movements is difficult.
• Recurrent vaginal infections
• Sexual discomfort
• Vaginal discharge that smells
• Stool or gas passing from the vagina
• Nausea vomiting 
• Belly pain 
• diarrhea 
• Weight loss 
• Fever 

Types  

• Vesicovaginal fistula(VVF):  It is the most prevalent type of genital fistula in which there is improper communication between the bladder and the vagina and urine escapes into the vagina, resulting in genuine incontinence.

• Rectovaginal Fistula (RVF): Rectovaginal fistula is a medical condition in which a connection exists between a woman's rectum and vagina, allowing stool and gas to pass from the bowel into the vagina.

 3. Ureterovaginal fistula (UVF): A ureterovaginal fistula (UVF) is an irregular conduit between the ureter and the vagina, resulting in incontinence, infection, and discomfort; it is frequently detected postoperatively.

Diagnosis 

• Women's ages and socioeconomic status
• Comprehensive obstetric history: The cause is suspected to be a previous history of prolonged labor/trauma during childbirth.
• History of urine leakage-time of leakage, amount of leakage, urination per urethra apart from leakage, feces leakage, gas leakage, previous attempts to repair fistula

In General examination 

• Examination of the abdomen for prior scars
• A distinctive symptom is vulval inspection for the escape of watery discharge per vaginal ammoniacal odor.
• Vulval skin abrasion and wetness
• Perineal tears of varying severity may be seen.

In Per Speculum Examination  

• Sim's position and Sim's Speculum-Any vaginal fluid pooling-Site, size, and number of fistulas
• Examine the degree of inflammation, edema, and infection in the surrounding tissue.
• Bladder mucosa may prolapse visibly through a large fistula.
• When the woman in the sims position is asked to cough, bubbles can be seen coming through tiny fistulae.

Confirmative Tests 

• Dye test: If methylene blue is put into the bladder through a catheter, dye will be visible coming through the orifice if there is a fistula.

• Double dye test: Give the patient phenazoyridine orally, then fill the bladder with the blue-colored solution and insert a tampon. The presence of blue staining indicates VVF or a urethrovaginal fistula.

• Red staining (pyridium): Metal catheter passed through external urethral meatus into the bladder when comes out through the fistula in vagina confirms VVF and patency of urethra 

• (Vaginal Gauze test):  Three separate sponge swabs are placed into the vagina one above the another. The bladder is then filled with a colored agent such as methylene blue through a rubber catheter, and patient asked to do some exertional maneuvers and then the swabs are removed after 10 mins. 

 Result of 3 swab test 

• Discoloration of top most or middle swab - vesicovaginal fistula  
• Uppermost swab wetting but not discoloration- Ureterovaginal fistula 
• Discoloration of lower most swab but upper two swabs remain dry- Urethrovaginal fistula. 
• Methylene enema- A tampon is inserted into the vagina. Then, a blue dye is injected into rectum.After 15 to 20 minutes, if the tampon turns blue, which means the client has a fistula.  
• Barium enema- A contrast dye that helps to see the fistula on an X-ray. Radiologic studies are recommended prior to surgical repair of a vesicovaginal fistula are: 
  • Ureteroscopy 
  • Ultrasound, CT, MRI-done for evaluation of complex fistula 
  • Anorectal or transvaginal ultrasound 
  • Cystoscopic Examination- Cystogram showing extravasation of dye from bladder into vaginal canal 
  • Cystoscopic view of fistula 

 Treatment 

• After 0.5-2 months of urethral catheterization and anticholinergic treatment, the fistula closes spontaneously in 10% of patients, especially if the fistula is modest in diameter and identified early. Foley's catheter is the best option because it has a balloon to keep it in place.
• Because conservative treatments fail in the majority of cases, surgical management is the therapy of choice to closure the aberrant aperture. Because of the gel-like nature of the fibrin sealant, which seals the hole until tissue growth develops from the borders of the fistula, it has been utilized as an adjuvant treatment to treat VVF.
• Anemia, malnutrition, and malaria must all be assessed and treated prior to surgery.
• The type of genital fistula determines whether surgery is performed vaginally, perineally, or abdominally. Surgery should be postponed until the inflammation and edema have healed, and then performed 3 to 6 months later, along with the antibiotic.
• Topical cream and estrogen cream for ammoniacal dermatitis

Nursing Management 

• Patients' dietary and rehabilitative demands must be taken into account.
• Personal cleanliness and skin integrity must be preserved.
• Teach the patient how to keep the environment clean. If stool or a foul-smelling discharge went through the vagina, gently wash it with warm water. Instead of toilet paper, always use unscented soap and unscented wipes.
• To avoid inflammation in your vagina and rectum, use talcum powder or a moisture-barrier cream.
• Psychological counseling is essential for those suffering from this illness.
• Wear loose, breathable cotton garments or other natural fibers.
• To avoid skin contact, persons with leaking urine and stool should wear disposable underwear or adult diapers.

Complication 

•  Abscess 
• Repeated urinary tract infection 
• Vaginal infection 
• Social isolation 
• Depression 
•  Fecal and urine incontinence 
• Another fistula may develop if untreated 

Prevention 

• Eliminate early childhood marriage.
• Putting off the age of the first pregnancy.
• Stopping damaging conventional practices; and
• Proper intrapartum care is required.
• Access to obstetric care on time.
• Perineal tear repaired successfully
• Rectal damage should be identified and treated as soon as possible.