This morning I was at Dr. Kim’s office early to find out how this surgery went and what my future looked like. To my surprise she did not want to remove the catheter today and recommended me to wait another week because she felt like me doing self cath at this point would be too early. In a way I was grateful because I feared that while I am away from home and could not urinate properly, I would wind up in the ER and miss my flight home. So with that fear out of the way I listened while she told me her fears about my present situation.
She told me right now her biggest concern for me was a fistula. I knew about this because of other women, but I also wondered why and what I should look for and do, if it occurred. I am grateful that she took the time to sit with me and tell me honestly why she feared this. My tissue she said is paper thin and it could happen. I knew a fistula is a hole in the bladder that would need repair. She said that if it happened, small fistulas often repair themselves and you have to have a catheter back in to see if it will heal on its own. A larger fistula that does not heal has to be done with surgery and it would be done with a graft.
I asked her how I would know if it had happened. She said if I suspect it has happened, they add the pill that turns your urine orange and then see where it leaks. I have had this pill before to calm my bladder after surgery and it is called Pyridium. She said my daughter could look to see where the leaking came from and of course I now have wonderful home health nurses who will be far more knowledgeable in this matter.
Dr. Kim also explained to me that I will probably have more incontinence now that the sling is cut, but it will not be the way it was before I had fascia surgery. I can live with that and right now it would allow me to be away from the house longer than three hours at a time. Even to go for a doctor’s appointment I have to be on guard and get back home to do self cath.
You may wonder the same as me about how on earth you would distinguish incontinence from a fistula? Dr. Kim knows I am an avid reader because I want to understand what may happen and how to deal with it the best way possible. So when I got back to my hotel room I began searching for a good link that explains this issue well and also about what would happen in a future surgery. Yes I could bury my head in the sand, but if I am going to survive I must understand everything and recognize any symptoms. What I realize by reading, is a fistula in the bladder would actually leak through my vagina, not my urethra as it is supposed to and that is how it would be determined. Now it makes sense.
So how do I feel? Shocked of course but hopeful it wont happen. If it does I am now better equipped with the knowledge I need and I will deal with it IF and when it happens. Right now the thought of more surgery or any antibiotics is enough to make me run for the hills. I want to be left alone to heal and hope all will be well.
Dr. Kim was very gentle as she examined me and she said things feel right. She said she had spoken to Dr. Raz and if things worsen they can do the surgery to close off the bladder neck and I would empty it from my abdomen. I asked if it was the Stoma surgery and she said yes, but the bag would not remain attached at all times. However, she said this is major surgery and it would not be good to do this without first trying other options.
I am not going to view this news with doom and gloom. After all it may never happen. Tomorrow I go home and right now it is the most pressing thing on my mind. This trip has been more than two weeks away from home. With the issue of gentomicin otoxicity to tackle before too long after I get home, I have not been able to go anywhere other than from my room to the lobby just to exchange views. I have barely managed to push a wheelchair to Target and the grocery store and I worried about the extreme dizziness and an accident that could leave me with a broken bone, a long way from home. All I can think of right now is I want to heal. This has not been a vacation. The idea of another surgery fills me with stress. I have had three in nine months and that is enough for hopefully a long time.
What I would like to tell all the manufacturers and the doctors who still put these slings in women every day is this. These products ruin our lives. They cause illnesses that we should never have. They ruin relationships and they financially bankrupt us when we try to get help. We will live with the terrible results for the rest of our lives and none of us deserved this. More of us are speaking out and this will not go underground once again, leaving more women to fall into this terrible trap.
Before I left, Dr. Kim told me her due date for her baby deliver is July 28th ad she will be off for August and September, but Dr. Raz will be here for me if I have any problems. I asked if she was having a girl or boy and she said a boy. I wish her well.
I searched and read many articles and liked this one. Each page has a different explanation of all points of fistulas. I took this part to add to this blog because it explains what it is, and the symptoms. I hope no other woman will be faced with this worry, but remember if we don’t understand about our bodies we are at the mercy of doctors who won’t know what to do for us. We MUST be knowledgeable to live the best life possible. Please read the following.
Patients with vesicovaginal fistula often report painless unremitting urinary incontinence. This is also called total, or continuous, incontinence. Urinary incontinence may be exacerbated during physical activities, leading some women to confuse this with stress incontinence.
Conversely, patients with ureterovaginal fistula may experience constitutional symptoms of fever, chills, malaise, flank pain, and gastrointestinal symptoms in association with continuous urinary incontinence. Constitutional symptoms may result from hydronephrosis secondary to ureteral obstruction or urinary extravasation into the retroperitoneal space.
Acute onset of vesicovaginal fistula immediately after pelvic surgery does not cause constitutional symptoms. If the Foley catheter is still in place, the first sign of impending fistula formation is the presence of hematuria.
Conversely, acute-onset ureterovaginal fistulas are often associated with a difficult postoperative course. These patients present with fever, ileus, and abdominal and flank pain.
Approximately 10-15% of fistulas do not appear for 10-30 days. Some fistulas may not manifest for months. Radiation-induced fistulas may not become apparent for many years after radiation treatment. The development of a typical radiation-induced fistula is heralded by radiation cystitis, hematuria, and bladder contracture. These symptoms are improved dramatically by the sudden presence of vesicovaginal fistula.
For non–radiation-induced postsurgical fistulas, patients may notice a clear vaginal discharge or experience a new onset of urinary incontinence. The urinary incontinence mimics stress incontinence, in which urine loss is more dramatic during physical activities or when the individual stands upright from a lying position. Patients may experience continuous incontinence, requiring the use of several thick pads per day. Symptoms of urinary frequency and urgency are typically absent.
Suspect a possible fistula when a patient reports acute onset of urinary incontinence after a recent gynecologic surgery (eg, hysterectomy or cesarean delivery), if the degree of incontinence is disproportional to the physical findings, or if the medical history and the nature of incontinence are inconsistent.
During a physical examination, patients with newly onset ureterovaginal fistulas may demonstrate flank or abdominal tenderness due to hydronephrosis and/or urinary extravasation into the retroperitoneal space. Patients with vesicovaginal fistulas do not present with abdominal or flank symptoms.
A detailed pelvic examination reveals clear fluid pooling at the apex of the vagina. On close inspection, a pinpoint opening at the vaginal apex is often visualized in mature fistulas. When a fistula has not yet matured (immature fistula), inflamed erythematous vaginal mucosa is visible, with granulation tissue surrounding the fistulous tract. The fistulous opening is often difficult to localize in immature fistulas. In addition, pelvic examination may be tolerated poorly by the patient, further complicating the examination. In these situations, pelvic examination under general anesthesia is warranted.
If vesicovaginal or ureterovaginal fistula is suspected, proceed with a detailed workup as discussed below. As an immediate therapy, insertion of a urethral catheter to minimize urine leakage and the patient’s distress should be tailored to each individual.
Vesicovaginal and ureterovaginal fistulas recognized within 3-7 days after the causative operation may be repaired immediately via a transabdominal or transvaginal approach.
Fistulas identified after 7-10 days postoperatively should be monitored periodically until all signs of inflammation and induration have resolved. Before embarking on fistula repair, the fistula tract should be well epithelialized and the vaginal wall should be soft and supple.
The traditional approach has been to wait at least 3-4 months before attempting fistula closure. However, this philosophy has been challenged. Some surgeons have successfully closed the fistula with or without using a tissue interposition, such as Martius flap or peritoneal flap, without waiting 3-4 months. The main issue being that satisfactory tissue quality and healing must be evident or the operative intervention may not be satisfactory.
Patients with a history of multiple failed repairs, patients with associated enteric fistula with pelvic phlegmon, or patients with a history of pelvic radiation should not undergo fistula repair for at least 6-8 months.
Vesicovaginal fistula is a free communication between the urinary bladder and the vagina. Ureterovaginal fistula is a communication between the distal ureter and the vagina. For further discussion of relevant anatomy, see Surgical Therapy.
Here is the link where you can read more. http://emedicine.medscape.com/article/452934-overview