POSTGRADUATE OBSTETRICS & GYNECOLOGY

VOLUME 29 NUMBER 14 July 31, 2009

A BIWEEKLY PUBLICATION FOR CONTINUING MEDICAL EDUCATION IN OBSTETRICS AND GYNECOLOGY

Vesicovaginal Fistula
Learning Objectives: After reading this issue, the participant should be able to: 1. Explain the pathophysiology of vesicovaginal fistula. 2. Describe how to differentiate the causes of gynecologic and obstetric-related vesicovaginal fistula. 3. Describe the diagnosis and initial management of vesicovaginal fistula. Vesicovaginal fistula (VVF) is a gynecologic condition characterized by abnormal communication between the urinary and genital tracts. The most distressing symptom of VVF, namely leakage of urine from the vagina, can result in enormous social and psychological morbidity for the affected patient. VVF is well described in the early gynecologic surgical literature. In the 19th century, the work of several surgeons, most notably James Marion Sims1 in Alabama, paved the way for modern surgical treatment of VVF. Improvement in obstetric care nursing and the performance of cesarean section for obstructed labor, as well as developments in the field of anesthesia, led to the disappearance of obstetric-related VVF in the United States by the mid-20th century.2 VVF encountered in modern obstetric and gynecologic practice in the United States result from complications of gynecologic surgery,3 notably abdominal hysterectomy. Obstetric VVF is the result of neglected prolonged obstructed labor4 and is endemic in less developed areas with adverse socioeconomic conditions and poor obstetric facilities, especially Africa, Asia, and parts of South America. These two classes of VVF have fundamentally different etiology, presentation, and prognosis and will be discussed separately in this article

Okechukwu A. Ibeanu, MD, MPH, and Robert E. Bristow, MD

Gynecologic-Related Vesicovaginal Fistulae

Gynecologic surgical practice in the United States has evolved to encompass an ever-widening variety of surgical
The authors have disclosed that they have no significant relationships with or financial interests in any commercial organizations pertaining to this educational activity. Dr. Ibeanu is Fellow, and Dr. Bristow is Professor and Program Director, Division of Gynecologic Oncology, Johns Hopkins University, 600 N. Wolfe Street, Phipps 281, Baltimore, MD 21287; E-mail: oibeanu1@jhmi.edu.

options for the treatment of disease. Total abdominal hysterectomy is the most common gynecologic surgery. Eighty-two percent of VVF occur as complications of gynecologic surgery, whereas genital cancer and radiotherapy, and general surgery account for less than 5% of cases. Six percent of VVF follow urologic surgery.5 Factors that increase the risk of fistulae are mainly related to intraoperative situations, notably anatomic tissue plane distortion that can be caused by endometriosis, pelvic inflammatory disease, malignancy, prior pelvic irradiation, and inflammatory bowel disease.6 Dissection of the urinary bladder from the uterus in these situations can be difficult, especially when performed bluntly, increasing the chances of injury to the bladder. The use of electrocautery can also result in bladder injury. Inadvertent placement of suture in the bladder is also thought to cause VVF in some cases; however, this is disputed by some authors.7 Most fistulae present within days to 3 weeks after surgery. Radiation fistulae present months to years later, and are due to chronic tissue ischemia caused by endarteritis and fibrosis.8 Leakage of urine through the vagina is the most common presentation. Hematuria, pelvic pain, and difficulty voiding urine can also occur. Some patients may present with unexplained fever followed by defervescence once urine leakage begins. Intraperitoneal leakage of urine can produce peritonitis and ileus.5 Leakage of urine from the vagina should prompt a suspicion of VVF; however, nonclassic presentations may present a diagnostic challenge.6 The patient should be examined with a vaginal speculum in good lighting, in the lithotomy or Sims position. Pooling of urine in the vagina may be noted with large fistulae; nevertheless, the diagnosis should be confirmed by performing a methylene blue dye test. Dye is instilled into
Diagnosis

All staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty and staff conflicts of interest in any commercial organizations pertaining to this educational activity.

The continuing education activity in Postgraduate Obstetrics & Gynecology is intended for obstetricians, gynecologists, and other health care professionals with an interest in the diagnosis and treatment of obstetric and gynecological conditions. 1

Postgraduate Obstetrics & Gynecology

EDITORS
William Schlaff, MD* Professor and Vice Chairman, Chief of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado Lorraine Dugoff, MD* Associate Professor, Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado

FOUNDING EDITORS
Edward E. Wallach, MD Roger D. Kempers, MD

ASSOCIATE EDITORS
J. Christopher Carey, MD Denver Health Medical Center Denver, Colorado Susan A. Davidson, MD University of Colorado Aurora, Colorado Marc A. Fritz, MD University of North Carolina Chapel Hill, North Carolina Alice R. Goepfert, MD University of Alabama, Birmingham, Alabama Veronica Gomez-Lobo, MD Washington Hospital Center Washington, District of Columbia Hope K. Haefner, MD University of Michigan Ann Arbor, Michigan Nancy Hueppchen, MD Johns Hopkins University Baltimore, Maryland Bradley S. Hurst, MD Carolinas Medical Center Charlotte, North Carolina Julia V. Johnson, MD University of Vermont Burlington, Vermont Peter G. McGovern, MD University of Medicine and Dentistry of New Jersey Newark, New Jersey William D. Petok, PhD Clinical Psychologist Baltimore, Maryland Lynn L. Simpson, MD Columbia University Medical Center New York, NY
*Dr. Schlaff has disclosed that he is/was the recipient of grant/research funding from Organon and Wyeth. Dr. Dugoff has disclosed that she is the recipient of grant/research funding from Diagnostic Technologies Ltd.

The vast majority of gynecologic fistulae are addressed surgically; however, a period of expectant management, with transurethral bladder drainage, is generally practiced for small fistulae, in the hope that the lesion closes spontaneously. Such conservative management also allows time for any accompanying tissue inflammation, urinary infection, and perineal dermatitis to be addressed. Lesions smaller than 0.5 cm in patients with uninfected tissue and absence of diabetes, smoking, chronic vascular disease or severe radiaTreatment

the bladder through a Foley catheter while the clinician observes for leakage during the speculum examination. Very small fistulae can be difficult to see, and the placement of a tampon at the vaginal vault may help. The absence of staining should be further investigated by considering a ureterovaginal fistula. This can be accomplished by administering intravenous indigo carmine dye or oral phenazopyridine (Pyridium) and observing for vaginal staining. Cystoscopy may be necessary to visualize difficult lesions, exclude the presence of suture material in the bladder, and confirm ureteral integrity if the methylene dye test is negative. Urine culture and sensitivity test should be performed to diagnose any accompanying urinary infection, which must be treated with appropriate antibiotics. The use of intravenous pyelography or cystography should be individualized, bearing in mind that contrast studies of the bladder have a higher false-negative rate, especially with small lesions, in addition to the risk of contrast exposure. The presence of any medical comorbidity must be noted, especially cigarette smoking, diabetes, immunosuppression, and general medical fitness, in anticipation of further investigation and management.

tion changes may be managed in this way. Infection should be aggressively treated, cigarette smoking avoided, and blood sugar control optimized. The success rate of conservative management is not reliably known. The optimum period for conservative management has not been determined, but most surgeons generally wait an average of 3 to 6 months before surgical repair.9 Any inflammatory reaction or infection should be allowed to subside before embarking on definitive treatment. The surgical treatment of simple gynecologic fistulae, especially posthysterectomy fistulae, is typically approached through the vaginal route. Urologists tend to use the abdominal approach, but most gynecologic surgeons reserve this route for the treatment of fistulae complicated by ureteral or bowel involvement, or recurrent fistulae. Basic surgical principles must be followed. As mentioned above, preoperative optimization of the patient is necessary. Surgical dissection should be aimed at providing at least a good centimeter or two of margin of exposure around the fistula to excise the fistula and scar tissue. This will ensure a tension-free and water-tight approximation of the vaginal and bladder tissue. Tissue blood supply is important for healing. Blood supply to the fistula repair site can be augmented by use of tissue flaps. This is the main reason for the use of tissue flaps during fistula repair surgery. A good example is the Martius bulbocavernosus flap technique,9 which is accomplished by dissecting the vulvar fat pad, diverting it under the vaginal mucosa, and attaching it over the repair before over-sewing it with vaginal tissue. Such flaps may be indicated in patients with chronic diabetes, history of heavy smoking, chronic peripheral vascular disease, and prior radiation, among other conditions.

July 31, 2009

Postgraduate Obstetrics & Gynecology (ISSN 0194-3898) is published biweekly by Lippincott Williams & Wilkins, Inc., 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Customer Service Manager, Audrey Dyson: Phone (800) 787-8981 or call (410) 528-8572. 24-Hour Fax (410) 528-4105 or E-mail audrey.dyson@wolterskluwer.com. Visit our website at LWW.com. Publisher, Nancy Axelrod. Copyright 2009 Lippincott Williams & Wilkins. Priority Postage paid at Hagerstown, MD, and at additional mailing offices. POSTMASTER: Send address changes to Postgraduate Obstetrics & Gynecology, Subscription Dept., Lippincott Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. PAID SUBSCRIBERS: Current issue and archives from 2004 on are now available FREE online at www.lwwnewsletters.com. Subscription rates: Personal: $352.98 US, $513.98 Foreign. Institutional: $662.98 US, $809.98 Foreign. In-training: $112.98 resident nonscored US, $129.98 Foreign. GST Registration Number: 895524239. Send bulk pricing requests to Publisher. Single copies: $17. COPYING: Contents of Postgraduate Obstetrics & Gynecology are protected by copyright. Reproduction, photocopying, and storage or transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result in legal action, including civil and/or criminal penalties. Permission to reproduce in any way must be secured in writing from: Permissions Dept., Lippincott Williams & Wilkins, 351 West Camden Street, Baltimore, MD 21201; Fax: (410) 528-8550; E-mail: arnetta.queen@wolterskluwer.com. For commercial reprints, E-mail matt.westcoat@wolterskluwer.com. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations.

Techniques for Vaginal Fistula Repair. A detailed description of surgical techniques is beyond the scope of this article, and the reader is referred to gynecologic and urologic surgical textbooks for a comprehensive description of procedures. However, a brief overview of surgical options6 is discussed below. Transvaginal Repair: Modified Latzko Colpocleisis. This involves surgical dissection to expose the fistula and a surrounding margin of healthy vaginal tissue. The scarred and fibrotic fistula edges are then excised between the vagina and the urinary bladder. This is followed by closure of the vagina over the fistula opening by placing imbricating sutures in layers, taking care to ensure that the suture lines are nonoppposed. Two layers are usually adequate. Absorbable suture such as 3-0 polyglactin is suitable. Cystoscopy should be performed to ensure a watertight closure. The urinary bladder should be drained for 2 to 6 weeks to heal. Transvaginal Repair: Simple Transvaginal Repair. Fistula dissection is performed as described in the Latzko method. After excision of the fistula tract, the urinary bladder is closed followed by closure of the vagina. The closures should be performed in layers in order to maintain separation of the bladder and vagina with as much healthy tissue as possible. Cystoscopy and bladder drainage should be performed. The issue of bladder drainage is debated. The length of time as well as the method of drainage vary among practitioners. Prolonged drainage is to be avoided in simple fistulae since good healing is to be expected. Success rates for simple fistula repairs range from approximately 80% to 95% as reported in various series. Transurethral catheters are easier to place and remove, however some surgeons routinely use suprapubic catheters exclusively. These aspects of management can be decided based on individual patient factors. Abdominal Repair: ExtravesicalApproach. Complicated fistulae that involve the ureteral orifices, or that need extensive tissue excision, should be approached via laparotomy incisions. The abdominal approach affords superior visualization and bladder mobilization. Additionally, the omentum can be used as an excellent source of blood supply if a tissue interposition flap is needed. The omentum also has good lymphatic drainage and can wall-off the repair site from any surrounding inflammation. Typically, the bladder is dissected off the vaginal cuff to expose the fistula. Once excision of the fistula is complete, the bladder is closed in layers, followed by closure of the vagina. Omental flaps are a good way of restoring some of the spatial separation between the bladder and upper vagina that is lost by surgical removal of the uterus. The rectus abdominis muscle is another good source of tissue flap10 during abdominal fistula repair, but this requires resection of the muscle attachments to the pubis. Abdominal Repair: Transvesical Approach. VVF may be repaired by excision from within the bladder. In this surgical approach, the incision is made at the dome of the bladder, followed by identification of the fistula track. An advantage of this method of repair is that the ureteral orifices can be easily assessed for proximity to

July 31, 2009

Postgraduate Obstetrics & Gynecology

Figure 1. Vesicovaginal fistula.

the fistula. This affords guidance of the dissection away from the ureteral orifices. Once the fistula is excised, the urinary bladder and vagina are closed separately in layers. The use of omental flaps should be individualized. In general, use of correct technique to repair simple VVF is associated with about a 90% success rate. The decision regarding surgical preparation and techniques should take into account individual patient factors.

Obstetric VVF (Figure 1) are endemic in less-developed parts of the world, where a combination of adverse factors precipitates and maintains the heavy caseload of patients. Prolonged obstructed labor is the main causative factor of obstetric VVF. Poverty, lack of education, lack of access to health care, lack of emergency cesarean section facilities, and the social practice of marriage of peripubertal girls with underdeveloped pelves all lead to neglected labor with resultant fetal impaction in the bony pelvis. Ischemic tissue injury leads to sloughing of the bladder and pelvic soft tissue with constant leakage of urine through the vagina.11 Extensive tissue destruction may also involve the rectum and anal sphincter with rectovaginal fistula and fecal incontinence. Constant urinary leakage leaves an odor and leads to perineal chemical dermatitis, sometimes with bacterial superinfection. Nerve impaction and ischemic injury can produce neuropathy with foot drop and muscle wasting. Social morbidity is severe in these patients. Isolation, divorce, destitution, low self esteem, and depression are common. Other issues that may modify the presentation and prognosis in

Obstetric-Related Vesicovaginal Fistulae

Surgical treatment is the usual option for these lesions; however, patient optimization is key in these areas where postoperative support is lacking. Nutritional supplements and oral iron can be given for weeks or months before surgery. Surgical debridement of necrotic and devitalized tissue may need to be performed, in addition to aggressive antibiotic therapy. Preoperatively, aggressive hydration should be used because many patients with VVF limit their fluid intake to reduce the urine flow. Prophylactic antibiotics are not routinely necessary. Due to practical considerations, spinal anesthesia is typically used, therefore necessitating that some fistulae be repaired in multiple operations. Conservative management can be tried initially, although the success rate is low, especially with large lesions. Importantly, this management strategy should be adopted during optimization of the patient for definitive surgery. Surgical techniques for obstetric VVF repair usually aim to excise fibrotic and nonviable tissue and achieve a tension-free and watertight closure of the tissue edges. Detailed description of the surgical techniques used in these repairs is beyond the scope of this text. Generally, a well-delineated fistula at the vaginal apex, with no urethral involvement and minimal scarring, can be repaired using a simple closure in layers. This involves dissection and excision of the fistula track and closure of the urinary bladder and vagina, respectively. Repair of complex fistulae can involve additional measures such as ureteral reimplantation, proximal urethral and bladder neck reconstruction, abdominal repair, and extensive tissue flap placements. It is important to mention that the use of colostomy and urinary diversion is limited in the less-developed areas for several reasons.15 Postoperative
Treatment
4

Diagnosis is usually obvious, as the history and speculum examination often reveal the fistula opening in patients with large obstetric fistulae. The methylene blue dye test should still be performed under direct vision to assess for the full extent of leakage. The presence of other fistulae must be evaluated by history and concurrent rectovaginal examination. Giant fistulae greater than 8 to 10 cm in diameter may have the ureteral orifices visible from the vagina. Scar tissue and fibrosis may involve the bladder neck and urethra. These structures should be palpated to determine the extent of tissue loss. Bladder capacity should be estimated if possible by retrograde filling of the bladder, in order to anticipate the possibility of urinary urgency and voiding problems due to reduced bladder volume postoperatively.13 Diagnostic evaluation of obstetric fistulae has been plagued by the lack of a universally agreed classification system,14 as well as the limitations of the resources available in less developed areas. Additional prognostic information from cystoscopy and urodynamics studies is needed but unavailable at many centers.
Diagnosis

these environments include HIV infection, chronic anemia, malnutrition, and lack of access to health care.12

Postgraduate Obstetrics & Gynecology

intensive care, stoma care, and home support are unavailable. Additionally, complications associated with these procedures have high morbidity and mortality rates in resource-challenged environments. The social and psychological impact of stigmatization of patients with urinary and fecal diversions is a potential problem. Postoperative bladder drainage for a minimum of 2 to 4 weeks is generally used. General supportive measures include sitz baths, aggressive hydration, and analgesia. Pelvic rest should be instituted for as long as it takes to heal completely. If available, physiotherapy can be attempted for foot drop. Complications of fistula surgery include bleeding, infection, soft tissue injury, and bowel injury. Long-term issues include gynatresia, fistula recurrence, and diminished bladder capacity with detrusor overactivity, chronic pain, and sexual dysfunction.13 Resources for addressing these complications in endemic areas are limited. Pregnancy is a real concern among patients with VVF who have undergone surgery. Many women do not have access to contraceptives for financial or religious reasons. The factors that precipitated the first injury may continue to operate in a subsequent pregnancy. Although no specific studies have addressed this issue, most surgeons who repair fistulae agree that the subsequent mode of delivery in patients who have undergone VVF repair should be cesarean section. Ideally, this operation should be performed electively, and the patient should attend an antenatal clinic as early as possible. Other issues of concern relate to sexuality and body image, fear of recurrence of fistula on resumption of intercourse, self-esteem, subsistence after long periods of isolation from the community, reuniting with family and spouse, and availability of follow-up care for long-term problems such as urinary incontinence, pelvic pain, mobility and gait problems, infertility, and depression, among others. Unfortunately, resources for provision of robust follow-up care are lacking in many countries. Psychological support, sexual and marital counseling, physiotherapy, and urinary appliances are unavailable to many patients who are waiting for surgery or who have undergone operations. In the few areas where health programs exist, the basic platform of support is based on providing educational classes and rehabilitation of treated women through vocational skills training.

July 31, 2009

VVF is a surgical epidemic, and the existing case burden is increasing daily given the problems with obstetric care and high maternal mortality rates in VVF-endemic countries. The problem of VVF has only started to receive widespread attention in recent years. Efforts to combat this problem, even quite recently, have mostly been spearheaded by private groups or individuals who have limited resources to make an impact in their areas of operation. Privately run fistula hospitals in Ethiopia, Nigeria, Niger, and other countries have successfully operated for years, with several small series published that detail various aspects of their interventions and results. The United

Global Public Health Efforts

July 31, 2009

Postgraduate Obstetrics & Gynecology

4. 6. 7. 8. 5. Wall LL, Arrowsmith SD, Briggs ND, Browning A, Lassey A. The obstetrics vesicovaginal fistula in the developing world. Obstet Gynecol Survey 2005;60:S3-51. Flores-Carreras O, Cabrera JR, Galeano PA, Torres FE. Fistulas of the urinary tract in gynecologic and obstetric surgery. Int Urogynecol J 2001;12:203-14. Chesson RR, Ibeanu OA. Fistula and urethral diverticulum. In: Bent AE, Cundiff GW, Swift SE, eds. Ostergards Urogynecology and Pelvic Floor Dysfunction, 6th ed. Philadelphia: Lippincott, Williams and Wilkins; 2008:285-312. Meeks GR, Sams JO, Field W, Fulp KS, Margolis MT. Formation of vesicovaginal fistula: the role of suture placement into the bladder during closure of the vaginal cuff after transabdominal hysterectomy. Am J Obstet Gynecol 1997;177:1298-1304. Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Critical Review Oncology/Hematology 2003;48:295-304. Huang W, Zinman L, Bihrle W. Surgical repair of vesicovaginal fistulas. Urol Clin N Am 2002;29:709-723. Reynolds WS, Gottlieb LJ, Lucioni A, et al. Vesicovaginal fistula repair with rectus abdominus myofascial interposition flap. Urology 2008;71:1119-1123. Creanga AA, Genadry RR. Obstetric fistulas: a clinical review. Int J Gynecol Obstet 2007;99: S40-S46. Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Womens Health 2005;50:286-294. Gutman RE, Dodson JL, Mostwin JL. Complications of treatment of obstetric fistula in the developing world: gynatresia, urinary incontinence, and urinary diversion. Int J Gynecol Obstet 2007;99:S57-S64. Waaldijk K. Surgical classification of obstetric fistulas. Int J Gynecol Obstet 1995;49:161-163. Arrowsmith SD. Urinary diversion in the vesico-vaginal fistula patient: General considerations regarding feasibility, safety, and follow-up. Int J Gynecol Obstet 2007;99:S65-S68. United Nations Population Fund (UNFPA). The Campaign to End Fistula. Annual Report, 2004. MacDonald P, Stanton ME. USAID program for the prevention and treatment of vaginal fistula. Int J Gynecol Obstet 2007;99:S112-S116.

Nations Population Fund16 has launched the program End Fistula, which aims to prevent fistulae from occurring, treat affected women, and help treated women return to full and productive lives. Partnerships with private organizations have been formed. These organizations include the International Obstetric Fistula Working Group, Virgin Unite, and EngenderHealth. The United States Agency for International Development17 also supports fistula centers in Bangladesh, Ethiopia, Uganda, Rwanda, and Nigeria. Presentation and management of VVF depend on the specific cause. The focal lesion of gynecologic fistula is a different entity from the field lesion of obstetric fistula. Comprehensive evaluation is necessary, and complex surgical treatment may achieve cure in well-prepared and selected patients. Referral to a surgeon with experience in repair of VVF is an appropriate decision.
REFERENCES 1. 3. 2. Sims JM. On the treatment of vesico-vaginal fistula. Am J Med Sci 1852; 23:59-82. Wall LL. Obstetric fistulas in Africa and the developing world: New efforts to solve an age-old problem. Womens Health Issues 1996;6:229-234. Lee RA, Symmonds RE, Williams TJ. Current status of genitourinary fistula. Obstet Gynecol 1988;72:313-9.

Conclusion

11.

10.

9.

12. 14.

13.

15.

16.

17.

Locate your 12-digit account number on the mailing label of your current issue. Go to: www.lwwnewsletters.com. From the choices on the top yellow toolbar, select Sign On. In the spaces provided, enter your Username and Password. Your username will be the letters LWW (case sensitive) followed by the 12-digit account number on your address label. We have provided an easy-to-remember default password for you: Simply type the numbers 1234. (This password cannot be changed.) 5. Click Sign On. 6. Click Access My Account. 7. Click View or Renew Subscriptions. Click on Postgraduate Obstetrics & Gynecology, and select the current or archive issue you wish to view. All issues are posted in PDF format. You will need Adobe Acrobat Reader installed on your computer to view the issues. To download your free copy of the Acrobat Reader, visit www.Adobe.com. 1. 2. 3. 4. If you have any questions or problems regarding your print or electronic account, please call 1-800-787-8981. *Archive issues are available as far back as January 2004.

View past*, current, and future issues of your paid subscription to Postgraduate Obstetrics & Gynecology online for free! Follow these instructions to log-on to your account.

Postgraduate Obstetrics & Gynecology

July 31, 2009

CME QUIZ: Volume 29, Number 14

To earn CME credit, you must read the CME article and complete the quiz on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. Select the best answer and use a blue or black pen to completely fill in the corresponding box on the enclosed answer form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own files and mail the original answer form in the enclosed postage-paid business reply envelope. Your answer form must be received by Lippincott CME Institute, Inc., by July 30, 2010. Only two entries will be considered for credit. At the end of each quarter, all CME participants will receive individual issue certificates for their CME participation in that quarter. Participants will receive CME certificates quarterly in April, July, October, and the fourth quarter in January of the following year. For more information, call (800) 787-8981. Online quiz instructions: To take the quiz online, go to http://cme.LWWnewsletters.com, and enter your username and password. Your username will be the letters LWW (case sensitive) followed by the 12-digit account number on your mailing label. You may also find your account number on the paper answer form mailed with your issue. Your password will be 1234; this password may not be changed. Follow the instructions on the site. You may print your official certificate immediately. Please note: Lippincott CME Institute, Inc., will not mail certificates to online participants. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Please do not use the answer forms and business reply envelopes that you may have on hand from previous issues of Postgraduate Obstetrics & Gynecology. Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1. The most important factor that contributed to the eradication of obstetric fistula in the United States was A. improved surgical training of gynecology residents B. a decrease in the birth rate and an increase in the number of hospitals built C. widespread availability of cesarean section for the management of arrested labor D. a plateau in the birth weight of newborns 2. Obstetric-related vesicovaginal fistula in endemic countries most commonly results from A. severe infection of the bladder and vagina after delivery in unsanitary conditions B. ischemia of the bladder base due to impaction of the fetal skull in prolonged labor C. traumatic forceps delivery by inexperienced physicians D. bladder injury during cesarean section delivery 3. Vaginal hysterectomy accounts for the majority of cases of posthysterectomy fistula seen in the United States. A. True B. False 4. A patient presents with copious watery vaginal discharge 1 week after a difficult abdominal hysterectomy. The most appropriate next step is A. observation with repeat examination in 1 to 2 weeks B. a 1-week course of broad-spectrum antibiotics C. an intravenous pyelogram D. instillation of methylene blue dye into the bladder to observe for vaginal leakage 5. Bladder injury during hysterectomy can be avoided by use of electrocautery during bladder dissection. A. True B. False 6. The most important reason to use a tissue flap during vaginal fistula repair is to ensure adequate blood supply to the surgical repair site during postoperative healing. A. True B. False 7. Foot drop can result from prolonged nerve compression during obstructed labor. A. True B. False 8. The best probable mode of delivery for a patient who has undergone prior vesicovaginal fistula repair is A. elective cesarean delivery B. trial of vaginal delivery C. vaginal delivery with shortened second stage of labor D. vaginal delivery as long as the patient has a midwife at home with her 9. Colostomy has been used successfully in developing countries to palliate disease in patients with rectal fistulae complicating obstetric childbirth injury. A. True B. False 10. A 15-year-old girl has a vesicovaginal fistula at the vaginal apex, which is complicated by the presence of a large fistula between the upper rectum and posterior vaginal fornix. The best approach for surgical repair is A. vaginal repair of the vesicovaginal and rectovaginal fistulae B. laparotomy with abdominal repair of the vesicovaginal and rectovaginal fistulae C. transvaginal vesicovaginal fistula repair with diverting colostomy for the rectovaginal fistula D. none of the above