Historical Notes on Vesicovaginal Fistula

Ronald M. Cyr, MD

Disclosures

January 05, 2011

Vesicovaginal Fistula

"Perhaps there is no disease which, without endangering life, tends to render it more truly miserable, than that species of urinary fistula which occurs in females, in consequence of sloughing of the vagina after parturition."[1]

First Case Report: Treatment of Urinary Incontinence[2]

A young woman, after a labour of some days' continuance, was delivered by the perforator and crotchet of her first child [Much of the work of the early "men-midwives" consisted of destructive operations. Anesthesia was not used in obstetrics until the late 1840s], which had been dead apparently about 2 days [In the absence of obvious maceration, it was difficult to diagnose fetal death in utero. Auscultation of the fetal heart was not done before the 1830s.]...After delivery the urine was discharged involuntarily...The parts about the perineum were considerably swelled, and a very fœtid and dark-colored discharge followed the delivery...and lasted for about a week. During the 5th and 6th days she had the power of retaining the urine for more than 3 hours...from the 7th day, she lost all power of retaining it...

When I saw this patient at the end of 3 weeks from her delivery, the urine was constantly flowing when in bed. She retained it but for a short time when sitting up, and under the latter circumstances she was utterly unconscious of its coming until she felt wetted by its presence...

On introducing a catheter through the urethra, and a finger into the vagina, an opening was immediately discovered just about the neck of the bladder, which exposed the instrument for more than an inch in length, and through which the point of the finger could be passed into the bladder. The edges of the aperture were irregular, soft and yielding, the touching them caused no pain, nor did any blood make its appearance on withdrawing the finger. The swelling of the parts about the entrance of the vagina had subsided quickly under the use of a decoction of chamomile flowers [Anthemis nobilis (Roman chamomile)]...

A flat silver catheter was left in the bladder, and a few days after an elastic gum [sticky latex rubber] bottle was introduced into the vagina. A firm one was selected, capable of containing 2 ounces of water; and had sewn on the convexity of its side a thin fine piece of sponge as large as a dollar. A double string was passed internally through its bottom, and left hanging through its neck. The sponge was smeared with calamine cerate [calamine is zinc carbonate that has been heated to produce zinc oxide and then processed into a fine powder. Mixed with beeswax and lard, it was known as Calamine Cerate or Turner's cerate. Calamine lotion is still used today to relieve the itching of contact dermatitis], the bottle dipped in oil, folded longitudinally and passed into the vagina with the sponge in front. From its elasticity it immediately expanded, and by a finger introduced through the neck it was readily placed in its proper situation, so as to bring the sponge immediately opposite the perforation in the bladder. The catheter was then withdrawn. In this situation it filled the vagina, and kept up a gentle and equable pressure on the injured part, so equable and so effectual that whilst the bottle was in the vagina the urine was perfectly retained for a little more than two hours. If the bladder was not then emptied by the catheter, the urine continued to ooze away until it was drawn off.

Guided by this, the catheter was introduced every 2 hours during the day. This was preferred to keeping the instrument constantly in the bladder, as she found much inconvenience from its remaining there when sitting, and without further mechanical aid it was not possible to keep it steadily in its situation when walking...Provided no urine passed through the opening, the principal object appeared to be obtained, and the patient was enabled at the same time to get out of doors. When in bed a short flat catheter was kept constantly in the bladder...

The comfort afforded by this plan in keeping her dry during the day was exceedingly great...In a short time she learned to pass the catheter herself, and felt happy in being thus relieved from much of her anxiety and dependence ... At the end of 2 months, the opening was not more than large enough to admit the catheter to pass into the vagina...at the end of 5 months...the aperture had closed. The same means were continued however for a fortnight longer, after which the bottle was left off by day, as it was found she remained perfectly dry without it. The catheter however was still introduced every 2 hours whilst up, and at night the bottle and catheter were employed as at first, it being thought most prudent still to keep up a moderate pressure. And to prevent any distension of the bladder, or even the natural action of it which would be required if the urine were expelled without the aid of the catheter.

After a short period the time of drawing off the water was gradually lengthened, until it was retained 6 hours. The use of the catheter was still continued for some weeks longer, though the bottle had been for some time left off. At the end of 9 months she resumed her natural habits, in every respect as well as before her labour.

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