Gynecological diagnosis . ellence. The vaginal and bladder wallsare involved in varying extent. Almost the entire base of thebladder may slough away, leaving the orifices of the ureters exposedin the edge of the fistula, or the opening between the bladder andvagina may be no larger than a pins point. The symptoms areleakage of urine from the vagina, and, unless great care is main-tained by the patient to keep dry, excoriation, redness, and sore-ness of the vulva, perineum, and thighs. The amount of urine lostwill depend on the size of the opening and on the retentive power FISTULA OF THE VAGIN
Gynecological diagnosis . ellence. The vaginal and bladder wallsare involved in varying extent. Almost the entire base of thebladder may slough away, leaving the orifices of the ureters exposedin the edge of the fistula, or the opening between the bladder andvagina may be no larger than a pins point. The symptoms areleakage of urine from the vagina, and, unless great care is main-tained by the patient to keep dry, excoriation, redness, and sore-ness of the vulva, perineum, and thighs. The amount of urine lostwill depend on the size of the opening and on the retentive power FISTULA OF THE VAGINA 385 of the vagina. Sometimes urine is retained in the vagina while thepatient is recumbent, the pelvic floor being uninjured and the in-troitus small. Often when the fistula is small the patient may voida portion of the urine through the urethra and the rest will escapethrough the vagina. The diagnosis is made by the history of incontinence and by thephysical examination. The digital touch, if the fistula is large, will. Fig. 155.—Scheme of the Different Sorts of Genital Fistulae, not IncludingFistula-in-Ano. (Gilliam.) 1. Urethrovaginal. 2. Vesico-vaginal. 3. Recto-vaginal. 4. Vesico-uterine. 5. Uretero-vaginal. 6. Entero-vaginal. indicate the size and situation of the fistula. The patient is placedin the Sims position and a Sims speculum introduced. Inspectionshows the size, shape, and situation of the fistula. A sound or probepassed through the urethra may be made to appear through theopening in the vagina. In larger fistula) the bladder wall is apt tobe much injected (cystitis) and often incrusted with lime salts. 25 386 DISEASES OF THE VAGINA These must be removed gently. Vesico-vaginal fistula gives a fineopportunity to inspect the bladder and to catheterize the ureters. Ifthe fistula is very small and there is doubt as to its situation, thepatient is placed in the dorsal position and the bladder is filled withmilk and water. Examination of the cleansed vagina through
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