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Ureterovaginal Fistula

UVF

The ureterovaginal fistula is an abnormal passage between the ureter and vagina.


Presentation

A woman with a ureterovaginal fistula develops continuous urinary incontinence and possibly fever, chills, malaise, and flank pain. These symptoms manifest 2 to 4 weeks after gynecological surgery [7]. The urinary incontinence resembles the profile of stress incontinence.

Physical exam

On pelvic examination, there is evidence of vaginal pooling of clear fluid. A mature fistula is observed as a tiny opening at the vaginal apex, however, the opening is not as apparent in an immature fistula. The latter is characterized by inflammation of the vaginal mucosa. Furthermore, granulation tissue along the fistula is another clinical finding.

Turkish
  • Department of Urology Turkish High Specialization Hospital Ankara Turkey[springerlink.com]
Overeating
  • We report 31 such cases seen over an 18-year period, all of which followed surgery for benign gynaecological conditions. Most patients had no urinary symptoms until the sudden onset of incontinence 1 to 4 weeks post-operatively.[ncbi.nlm.nih.gov]
  • The foreign body, an aerosol cap retained for over 2 years, resulted in the formation of a ureterovaginal fistula, an extremely rare complication.[hsrc.himmelfarb.gwu.edu]
  • The ureter is spatulated, a cystotomy created, and a running anastomosis with mucosa-to-mucosa apposition performed over a stent. Care is taken to ensure it is tension free.[ncbi.nlm.nih.gov]
  • . • Emphasizes prevention over quick fixes for more effective handling of urologic complications and better patient outcomes. • Covers both acute and long-term care of patients with urologic complications to equip you to manage more cases. • Features[books.google.es]
Confusion
  • Initially, leakage from the vagina may be confused from peritoneal fluid that leaks from the vaginal cuff. How is a VVF diagnosed? VVF diagnosis is typically made in the office by performing what is called a “pad test”.[columbiaurology.org]
Urinary Incontinence
  • CASE REPORT: This is an unusual occurrence of ureterovaginal fistula resulting from D&C for an incomplete abortion in a patient who had urinary incontinence for 16 years and carried three pregnancies to terms while this lasted.[ncbi.nlm.nih.gov]
  • The urinary incontinence resembles the profile of stress incontinence. Physical exam On pelvic examination, there is evidence of vaginal pooling of clear fluid.[symptoma.com]
  • The patient developed urinary incontinence after removal of the foreign body. Subsequent work-up demonstrated the presence of a right ureterovaginal fistula. The patient underwent an abdominal ureteroneocystostomy.[ncbi.nlm.nih.gov]
  • The main presentation of the ureterovaginal fistula is urinary incontinence despite the normal act of micturition.[medical-dictionary.thefreedictionary.com]
Vaginal Discharge
  • PATIENT(S): A 31-year-old woman presented immediately after TVOR with right lower abdominal pain with irradiation to the suprapubic area and vaginal discharge.[ncbi.nlm.nih.gov]
  • The patient was complaining of a foul-smelling vaginal discharge and lower abdominal pain. On vaginal examination, a hard and large foreign body was found. Examination under anesthesia was performed, and an aerosol cap was removed from her vagina.[ncbi.nlm.nih.gov]
  • Document Type Journal Article Journal Radiology Case Reports DOI 10.1016/j.radcr.2017.07.015 Abstract We present the case of a 13-year-old girl with a recurrent urinary tract infection, malodorous vaginal discharge, and urinary incontinence caused by[hsrc.himmelfarb.gwu.edu]
  • The patient complained of a foul-smelling vaginal discharge and was found to have a 4-cm hard vaginal mass on examination. Urinary incontinence developed subsequently.[journals.lww.com]
Foul Smelling Vaginal Discharge
  • The patient was complaining of a foul-smelling vaginal discharge and lower abdominal pain. On vaginal examination, a hard and large foreign body was found. Examination under anesthesia was performed, and an aerosol cap was removed from her vagina.[ncbi.nlm.nih.gov]
  • The patient complained of a foul-smelling vaginal discharge and was found to have a 4-cm hard vaginal mass on examination. Urinary incontinence developed subsequently.[journals.lww.com]

Workup

The clinical assessment consists of the patient's history, physical exam, and the relevant studies. If the patient is intolerant to the pelvic exam, anesthesia should be considered.

Laboratory tests

The workup should include a complete blood count (CBC), urinalysis, urine culture, and a complete metabolic panel. If the in doubt, confirmation is attained by measuring the fluid's creatinine level, which should be slightly greater than that of plasma creatinine for the fluid to be urine.

Imaging

Investigation studies such as intravenous pyelography (IVP) or computed tomography urography are obtained to evaluate the genitourinary tract. Abnormal results on IVP should warrant further testing with retrograde pyelography, which confirms this diagnosis.

Other procedures may include cystography and the double dye test.

Pneumoperitoneum
  • Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion.[ncbi.nlm.nih.gov]

Treatment

Early surgical repair is the therapy of choice in many women. The surgeon will use his/her approach based on expertise and preference. The repair can be performed through minimally invasive techniques such as laparoscopy and robotic surgery [8], which are associated with shorter hospital stays and decreased morbidity [9].

Conservative therapy

Preoperative treatment with conjugated estrogen can soften the vaginal tissue, especially in women with atrophic vaginitis [10]. Also, some clinicians will place catheter drainage of small fistulae for 4 to 6 weeks in an attempt to heal the condition.

Prognosis

Ureterovaginal fistula repair yields excellent results, especially when performed by experienced and skilled surgeons. The initial procedure is typically more successful than further attempts.

Etiology

Most cases of ureterovaginal fistulae arise from ureteral injuries sustained during pelvic surgery [1] while others stem from devastating vaginal deliveries. Another cause of fistulae is radiation to the pelvis, although this type develops a month to years later.

Epidemiology

While the majority of ureterovaginal fistulae in the United States and other developed countries are attributed to hysterectomy procedures [2], complicated childbirth is the leading cause in developing regions [3].

Sex distribution
Age distribution

Pathophysiology

During female pelvic surgery, the ureter is prone to injury especially during dissection of nearby tissue or an iatrogenic error involving the ureter or its vasculature [4]. This damage will cause ischemia, necrosis, and eventually the formation of this anatomical defect. Additionally, vaginal deliveries with obstructed and long-standing labor can cause injury to the vaginal mucosa and lead to fistula formation. Note that a ureterovaginal fistula is often accompanied by a vesicovaginal fistula [5] [6].

Prevention

Surgeons should take precautions while operating to prevent the formation of an iatrogenic ureterovaginal fistula.

Summary

The ureterovaginal fistula is a communication tract between the distal ureter and vagina that emerges as a complication of gynecological surgery or obstetric trauma. This condition is diagnosed by the clinical presentation, history, pelvic exam, and imaging studies. Prompt recognition and surgical repair can result in good outcomes.

Patient Information

The ureterovaginal fistula is a connection between the ureter and the vagina. This type of fistula forms when there are complications in gynecological surgery (such as hysterectomy) or after difficult childbirth. The symptoms include urine incontinence, fever, chills, and malaise. This is diagnosed through the history, pelvic exam, and imaging studies. Treatment is early surgical repair of the fistula.

References

Article

  1. McVary KT, Marshall FF. Urinary fistulae. In: Gillenwater JY, editor. Adult and pediatric urology. 4th ed. Philadelphia: Lippincott, Williams and Wilkins; 2002. pp. 1271–1295.
  2. Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surgery, Gynecology, and Obstetrics. 1992;175(6):501–506.
  3. Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstetrical and Gynecological Survey. 1996;51(9):568–574.
  4. Ross G Jr. Ureterovaginal fistula. In: Seidman EJ, Hannon PM, editors. Current Urologic Therapy. 3rd ed. Philadelphia: W.B. Saunders; 1994. pp. 242–245.
  5. Tahzib F. Epidemiological determinants of vesicovaginal fistula. British Journal of Obstetrics and Gynaecology. 1983;90(5):387–391.
  6. Ozumba BC, Attah CA. Ureteral injury in obstetric and gynecologic operations in Nigeria. International Journal of Gynecology and Obstetrics. 1991;36(2):131–135
  7. Yu NC, Raman SS, Patel M, et al. Fistulas of the genitourinary tract: a radiologic review. Radiographics. 2004;24 (5):1331-1352.
  8. Sharma S, Rizvi SJ, Bethur SS, et al. Laparoscopic repair of urogenital fistulae: A single centre experience. Journal of Minimal Access Surgery. 2014;10(4):180-184.
  9. Laungani R, Patil N, Krane LS, Hemal AK, Raja S, Bhandari M. Robotic-assisted ureterovaginal fistula repair. Report of efficacy and feasibility. Journal of Laparoendoscopic and Advanced Surgical Techniques A. 2008;18(5):731–734.
  10. Ghoniem GM, Warda HA. The management of genitourinary fistula in the third millennium. Arab Journal of Urology. 2014;12(2):97-105.

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Last updated: 2018-06-21 23:58