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UTEROVESICAL FISTULA Youssef s syndrome

kasinamrao@gmail.com. 2. UTEROVESICAL FISTULA (Youssef's syndrome). CASE REPORTPresenting complaints:Bleeding while passing urine since 6years. (Menourea)Pain in the lower abdomen since 6months. Irregular bleeding per vagina since 3months. (Uterine bleeding) Previous his

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UTEROVESICAL FISTULA Youssef s syndrome

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    1. kasinamrao@gmail.com 1 UTEROVESICAL FISTULA (Youssefs syndrome) Dr.K.Malleswar Rao, MD, DGO Civil Surgeon Specialist Dept. of Obstetrics & Gynecology ESI Hospital, Sanathnagar, Hyderabad.

    2. kasinamrao@gmail.com 2 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT Presenting complaints: Bleeding while passing urine since 6years. (Menourea) Pain in the lower abdomen since 6months. Irregular bleeding per vagina since 3months. (Uterine bleeding) Previous history: No h/o urinary incontinence. Nothing particular.

    3. kasinamrao@gmail.com 3 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT Obstetric history: Para 2, Live 2, both deliveries by C-sections, one in Delhi and another at Bihar state. The delivery records are unavailable. She underwent tubectomy. Menstrual history: Previous: 4-5days/30days, regular flow. H/o passing blood in urine at the time of menstrual flow (so called Cyclic Menourea) since 6years. Present: Irregular excessive menstrual flow since 3months associated hematuria since 3months. General Exam: Patient is anemic, P.R. 80/min, BP 110/70mmHg, CVS/RS: NAD, P/A: NAD. Gynaec. Exam: Bimanual vaginal examination: Uterus AV, bulky, mobile, FF, non-tender.

    4. kasinamrao@gmail.com 4 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT INVESTIGATIONS: ROUTINE (BASIC) WORKUP: - 1.CUE on 7-4-04:WNL except haematuria. 2.IVU on 3-3-04:Both are kidneys normal, no evidence of obstruction and dilatation of Pelvicalyceal system. 3.Urine for C/S on 3-3-04: E. coli grown in culture and sensitive to 1.Furadantine, 2.Amikacin. 4. Hb% on 8-3-04: 6gm%. 5. RBS: 103mg%, Blood Urea: 15mg%. 6.B Rh-positive, HIV & Hbs Ag: non-reactive. 7.LFT: S. Bilirubin: 0.72mg%, SGPT: 2 IU/L, Alk. Phos: 4KA. 8. X-Ray Chest PA view: Normal. 9. X-KUB on 8-3-04: No ROD seen.

    5. kasinamrao@gmail.com 5 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT Specific WORK-UP: - 1. U/S scan total abdomen done in a private center on 6-1-04: GB stone 19mm in size, and evidence of UTEROVESICAL FISTULA seen, other findings normal.

    6. kasinamrao@gmail.com 6 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT 2. U/S scan repeated on 8-3-04 in ESI Hospital, Sanathnagar: GB calculus of 13mm size seen, endometrial polyp/ sub-mucous fibroid with cervix hypertrophied and uterine endometrial cavity is in continuity with the bladder, Right Ovary 3/3cm, Left Ovary 3/3cm.

    7. kasinamrao@gmail.com 7 UTEROVESICAL FISTULA (Youssefs syndrome)

    8. kasinamrao@gmail.com 8 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT 3. Double dye test (oral pyridium + Intravesical instillation of Methyline blue dye) done on 3-3-04 revealed no evidence of VVF or UVF.

    9. kasinamrao@gmail.com 9 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT 4. CYSTOSCOPIC Exam. Done in OGH on 25-03-04: Ureter and both Ureteric orifices and Bladder wall are normal; Blood clot present in bladder and it is evacuated.

    10. kasinamrao@gmail.com 10 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT 5. Endovaginal sonogram + Saline infusion sonohysterogram (SIS) had been done with the assistance of equipment company, (as we have no access to the U/S machine with TV probe).

    11. kasinamrao@gmail.com 11 UTEROVESICAL FISTULA (Youssefs syndrome)

    12. kasinamrao@gmail.com 12 UTEROVESICAL FISTULA (Youssefs syndrome) CASE REPORT CLINICAL MANAGEMENT: Preoperatively on pint of blood transfused on 6-04-04 to correct anemia and Hb% improve to 10gm% before surgery. Urinary Tract Infection had been treated by Inj. Amikacin 15mg/kg /day X 10days. Later, Urine became Sterile on Culture.

    13. kasinamrao@gmail.com 13 UTEROVESICAL FISTULA (Youssefs syndrome) On 15-04-2004: Laparotomy done and total abdominal Hysterectomy with Repair of the uterovesical fistula performed. Per-operative findings: 1. Bladder was adherent up to the fundus of the uterus. 2. Uterus was larger than normal size. 3. Sub mucous fibroid polyp found at fundus region. 4. Large fistulous track was found between base of the bladder and anterior wall of the body of the uterus, which was approx. 1.5 inches in size, and in fact bladder wall is in continuity with the uterus as appropriately mentioned in U/S scan.

    14. kasinamrao@gmail.com 14 UTEROVESICAL FISTULA (Youssefs syndrome)

    15. kasinamrao@gmail.com 15 UTEROVESICAL FISTULA (Youssefs syndrome)

    16. kasinamrao@gmail.com 16 UTEROVESICAL FISTULA (Youssefs syndrome)

    17. kasinamrao@gmail.com 17 UTEROVESICAL FISTULA (Youssefs syndrome)

    18. kasinamrao@gmail.com 18 UTEROVESICAL FISTULA (Youssefs syndrome) POST-OPERATIVE MANAGEMENT: Patient was kept on continuous bladder drainage for 14days for proper healing of the bladder wall. Skin sutures were removed on 7th POD. Uneventful P.O. course and went home.

    19. kasinamrao@gmail.com 19 UTEROVESICAL FISTULA (Youssefs syndrome) FOLLOW-UP: She was referred to UROLOGIST for Urodynamic exam., as frequency of urine developed post-operatively. She didn't have any significant urological dysfunction such as Vesicourethral anomalies or dysfunction.

    20. kasinamrao@gmail.com 20 UTEROVESICAL FISTULA (Youssefs syndrome) CLINICAL PRESENTATION Typically, Cyclic Hematuria (Menouria, Vesical menstruation) Lochiauria (Urethral passage of Lochia) In some reported cases, Urinary Incontinence (vaginal leakage of urine) when fistula involves isthmus region (VESICOCERVICAL FISTULA) Herniation of the Amniotic sac through Uterovesical fistula Infertility, Amenorrhea Bladder endometriosis POSSIBLE CAUSES Commonly, following Caesarian Section Previous traumatic (difficult) forceps delivery Migration of (Perforated) Intrauterine Contraceptive Device

    21. kasinamrao@gmail.com 21 UTEROVESICAL FISTULA (Youssefs syndrome) DIAGNOSIS Cystoscopy, Cystogram, Hysterosalpingogram Transabdominal/Transvaginal Sonogram Exclusion of other Genitourinary fistula like Vesico Vaginal Fistula or Uretero Vaginal Fistula by DOUBLE DYE TEST (i.e., intravesical instillation of Methylene Blue+Oral adm. Of Pyridium) SALINE INFUSION SONOHYSTEROGRAM (SIS) + ENDOVAGINAL SONOGRAM

    22. kasinamrao@gmail.com 22 UTEROVESICAL FISTULA (Youssefs syndrome) Sonographic Diagnosis of a Uterovesical Fistula

    23. kasinamrao@gmail.com 23 UTEROVESICAL FISTULA Sonohysterography:- It was performed at the time of menses. The patient was placed in the lithotomy position, and the cervix was visualized with the help of a Sims speculum and an anterior vaginal wall retractor. The cervix was grasped with Volsellum forceps. It was cleaned with povidone-iodine. A Leech-Wilkinson type cannula was introduced into the cervical canal after expelling air from it with saline. The speculum was removed carefully, and an ATL C9-5 endovaginal probe (Philips Ultrasound, Bothell, WA) was introduced into the vagina. Saline was injected into the cannula, and simultaneously the uterus was scanned in the longitudinal plane. The saline freely entered the urinary bladder in a jet through the deficiency in the myometrium, confirming the uterovesical fistula

    24. kasinamrao@gmail.com 24 UTEROVESICAL FISTULA (Youssefs syndrome) MANAGEMENT Conservative approach:i) Cystoscopic fulguration, ii) Cyclic combine hormonal therapy with continuous catheterization,iii) Spontaneous resolution by continuous catheterization Surgical approach:i) Transabdominal transperitoneal repair of fistula with/without Hysterectomy, ii) Fistula repair with Omental interposition or Myouterine flap, iii) Vaginal repair in cases of previous subtotal hysterectomy

    25. kasinamrao@gmail.com 25 UTEROVESICAL FISTULA (Youssefs syndrome) INTERNATIONAL CLASSIFICATION OF DISEASES 619 Fistula involving female genital tract Excludes: vesicorectal and intestinovesical fistula(596.-) 619.0 Urinary-genital tract fistula, female Fistula: cervicovesical ureterovaginal urethrovaginal uteroureteric uterovesical vesicovaginal ICD Version 2007 (http://www.who.int/classifications/apps/icd/icd10online/index.htm?navi.htm+n00 )

    26. kasinamrao@gmail.com 26 Youssefs syndrome

    27. kasinamrao@gmail.com 27 UTEROVESICAL FISTULA First case of menouria was reported in the literature by Machado in 1935. Into about 92 cases were reported since 1908 (on the date of surgery) and it is rare accounting about 4% of all Genitourinary fistulas. Today, 141 articles are reported in Pubmed data. Vesicouterine fistula is a rare complication of gynecologic surgery, which is usually treated by abdominal hysterectomy and bladder repair. We present a case showing the etiology of vesicouterine fistula and contemporary reconstructive techniques. Suggestions for the avoidance of vesicouterine fistulas are also made.

    28. kasinamrao@gmail.com 28 UTEROVESICAL FISTULA SUMMARY A 40 yr old rural woman presented with Menouria (Vesical menstruation) tolerating the symptom in silence since 6 yrs, came to the hospital with intolerable MENORRHAGIA + MENOURIA (due to the growth of submucous fibroid) since 3 months. We had managed the case by TOTAL HYSTERECTOMY ALONG WITH REPAIR OF FISTULA. Though woman developed transient frequency and urgency of urine in postoperative period, she is now totally asymptomatic and relieved of distressing symptoms.

    29. kasinamrao@gmail.com 29 UTEROVESICAL FISTULA Unusual case of post-cesarean vesicouterine fistula (Youssef's syndrome). Therefore, it is pertinent to have periodic training courses (Update of C-section workshops) not only for qualified ObGyn specialists but also for Basic Medical Practitioners in rural areas, since Cesarian delivery is the commonest surgical procedure performed throughout the World today.

    30. kasinamrao@gmail.com 30 Review of literature in Pubmed database (Medline)

    31. kasinamrao@gmail.com 31 1) Unusual case of post-cesarean vesicouterine fistula (Youssef's syndrome). Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H. Department of Urology, Baskent University, 01250 Adana, Turkey. ferhatkilinc@hotmail.com http://www.ncbi.nlm.nih.gov/pubmed/12657106?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed

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    42. kasinamrao@gmail.com 42 UTEROVESICAL FISTULA (Youssefs syndrome) THANKING YOU ALL!!

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