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Vesicovaginal Fistula

Vesico Vaginal Fistula

A vesicovaginal fistula develops when a tract forms between the vagina and the urinary bladder. It commonly manifests with urinary leakage.


Presentation

A distinguishing characteristic of vesicovaginal fistulas is leakage of urine into the vagina, which can either be permanent or intermittent. It is usually intermittent when the fistula is small. Urinary incontinence or vaginal discharge may also occur, especially after radiotherapy or surgery to the pelvis. A history of antecedent surgery is not necessary in those cases. A vesicovaginal fistula should also be suspected in the presence of hematuria, urine stream abnormalities, pyelonephritis or recurrent cystitis. Postoperative patients should undergo a thorough workup if they complain of abdominal, pelvic or flank pain, prolonged ileus and fever.

The course of vesicovaginal fistulas varies, depending on the cause of the condition. For 90% of the patients, it takes 7 to 30 days after pelvic surgery for symptoms to appear. Fistulas that occur after delivery due to a laceration of the anterior vaginal wall typically present 24 hours later. The presentation is also acute, when the laceration of the bladder is responsible for the development of the condition. In contrast, fistulas resulting from radiation progress very slowly, with symptoms appearing within a period between 30 days to 30 years later. Radiation generally causes necrosis due to slow devascularization and manifests initially with hematuria, radiation cystitis and contracture of the bladder.

Asymptomatic
  • The patient remains asymptomatic after more than a year and a half. CONCLUSIONS: Laparoscopic resolution of vesicovaginal fistula is perfectly feasible and safe.[ncbi.nlm.nih.gov]
Excoriation
  • Causing distressing symptoms such as a loss of continence and vulval excoriation, conventional teaching has always advocated an open surgical approach as described by Sims in 1852.[ncbi.nlm.nih.gov]
Urinary Incontinence
  • CVVF should be suspected in any girl with urinary incontinence, urinary tract infections from birth, vaginal swelling or hydrocolpometras, as well as in adults with menouria.[ncbi.nlm.nih.gov]
  • None of the patients had voiding dysfunction, urinary incontinence, retention or urinary tract infection.[ncbi.nlm.nih.gov]
  • The pilot data suggest that patients with persistent urinary incontinence following VVF closure may also have significant voiding dysfunction.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair.[ncbi.nlm.nih.gov]
  • A 72-year-old woman consulted our clinic complaining of severe urinary incontinence. The leakage was continuous and significant and she was feeling a "vaginal mass".[ncbi.nlm.nih.gov]
Vaginal Discharge
  • BACKGROUND: An enterovaginal or vesicovaginal fistula is a complication resulting in vaginal discharge of succus, urine, or stool that can lead to significant complications. For low-volume fistulae, tampons or pads may be used.[ncbi.nlm.nih.gov]
  • Vaginal fistula Indications Patients with vaginal fistulas usually present 1 to 3 weeks after a gynecologic surgery with complaints of continuous urinary incontinence, vaginal discharge, pain or an abnormal urinary stream.[fistularepair.com]
  • In some, this is first noticed as an increase in vaginal discharge or drainage. Most patients will present one to four weeks after hysterectomy. A very small defect may not produce continuous leakage and intermittent urine may be noticed.[gynecologicsurgery.com]
  • Urinary incontinence or vaginal discharge may also occur, especially after radiotherapy or surgery to the pelvis. A history of antecedent surgery is not necessary in those cases.[symptoma.com]
  • Patients may complain of urinary incontinence or an increase in vaginal discharge following pelvic surgery or pelvic radiotherapy with or without antecedent surgery.[emedicine.com]
Pelvic Pain
  • One woman presented with an inability to have sexual intercourse, and the other with severe cyclic pelvic pain. Diagnostic workup unveiled congenital vesicovaginal fistula and distal vaginal agenesis in both.[ncbi.nlm.nih.gov]
  • PATIENT: A 77-year-old woman presented with complaints of vaginal leakage of urine, dysuria, and pelvic pain. She had a Gellhorn pessary placed 12 years prior without further evaluation or removal.[ncbi.nlm.nih.gov]
  • A 55-year-old woman presented with pelvic pain, vaginal bleeding and an offensive discharge. The patient subsequently described late-onset asthma, chronic sinusitis, unexplained polyarthralgia and intermittent paraesthesia of both hands.[academic.oup.com]
Adnexal Mass
  • METHODS: A 55-year-old morbidly obese female presented with complaints of menometrorrhagia and complex adnexal mass.[ncbi.nlm.nih.gov]

Workup

Workup is broad and involves a thorough physical and pelvic exam, imaging tests and specific procedures.

The vagina should be fully inspected with an evaluation of mobility, as well as the determination of the accessibility of the fistula. The physician should also investigate the presence of edema, inflammation and infection. It is important to evaluate any association with a rectovaginal fistula.

Fluid that is found within the vaginal vault requires testing for urea potassium and creatinine. This helps in differentiating between vaginitis and vesicovaginal fistula.

Diagnosis can be established by an intravenous administration of an Indigo carmine dye and checking whether the dye can be visualized in the vagina. The presence of any urine discharge should prompt the physician to uncover the source by performing a cystourethroscopy. If ureter involvement is confirmed, then an intravenous pyelogram should be performed. The differential diagnosis of urine discharge is broad and includes multiple or single urethrovaginal, vesicovaginal or ureterovaginal fistulas as well as fistulas between the cervix, vagina, uterus, fallopian tube and the urinary tract.

A urine culture is routinely performed before surgery and antibiotics are prescribed in case it is positive. In addition, patients who previously suffered from a malignancy in the area should undergo a biopsy of the fistula in combination with urinalysis and urine cytology.

Some imaging procedures should also be performed prior to surgery. These include an intravenous urogram that helps to rule out injury to the ureters or a ureteral fistula. Around 10% of vesicovaginal fistulas are associated with ureteral fistulas. In some cases, the intravenous urogram may be negative but clinical suspicion remains elevated. This should prompt the physician to consider a ureteropyelography during the cystoscopy.

The presence of bullous edema and diverticula within the walls of the bladder can lead to an inadequate cystoscopy. In this case, color doppler ultrasonography should be employed with the concomitant administration of contrast into the urinary bladder. Recent studies suggest that Doppler Ultrasonography can detect vesicovaginal fistulas in 92% of patients. The presence of the jet phenomenon within the bladder wall and toward the vagina is critical for the identification of the fistula [7].

Atelectasis
  • Perioperatively, there was 1 Clavien-Dindo grade 1 complication (ileus), and 2 grade 2 complications (readmission with Clostridium difficile infection and atelectasis).[ncbi.nlm.nih.gov]

Treatment

The treatment of vesicovaginal fistula can either be conservative or surgical. If the fistula occurs 1 to 3 days after surgery, the condition can be resolved medically by inserting a transurethral or subrapubical catheter for as long as 30 days. During this period the catheter should be continuously drained. This is usually sufficient for small fistulas to resolve.

The development of vesicovaginal fistulas can be avoided if specific guidelines are followed during surgical operations [8]. In case fistulas develop, the issue can be approached surgically in several ways. These include a transvaginal approach, a transabdominal approach and laparoscopic or robotic repair.

The transabdominal approach is performed whenever the fistula cannot be adequately visualized with vaginal exposure, or when the fistula is associated with the distal ureters. Difficulty in visualization occurs when there is a narrow vagina, a retracted defect or a high vaginal defect.

The transvaginal approach has several advantages. It can decrease the risk of blood loss, avoid laparotomy and the opening of the bladder as well as shorter hospital stays and quicker recoveries. Evidence indicates that is equally effective as the transabdominal approach.

On the other hand, the laparoscopic repair aims to avoid the many complications of open surgery and decrease hospitalization duration. The technique was first used for vesicovaginal fistulas in 1994 and has since continuously improved [9]. It involves the placement of catheters in the ureters and in the fistula. This can ultimately help to identify the ureters and the fistula when performing the laparoscopy.

Robotic repair has shown promise but its use is mainly restricted to assistance in suturing. Nonetheless, some case reports are published in which the complete surgery was performed robotically. These suggest successful results and low associated morbidity, although their scientific significance is still not confirmed because of small samples [10].

Management following surgical procedures is extremely important in preventing complications. Bladder spasms can occur after the surgery and may result in compromised healing as well as pain. They are best treated with anticholinergic medication [11]. In addition, the bladder should be continuously drained with a urethral catheter, ensuring minimal tension in the repair and allowing tissue integration. Transabdominal surgeries require the postoperative placement of a suprapubic catheter. When both catheters are in place, drainage is not impeded if one of the catheters is blocked.

Prognosis

Prognosis of vesicovaginal fistulas is excellent. Surgical repair is extremely successful with success rates reaching 100% after the second attempt, despite the fact that it is more complicated and difficult to perform than the first operation. There is an approximate 90% chance of success after the first surgery [6]. Fistulas that result from radiation have a slightly worse prognosis with success rates below 90%, although skilled surgeons can still perform highly successful operations.

Etiology

In the developed world, vesicovaginal fistulas occur most commonly as a result of iatrogenic manipulation of the bladder, leading to direct injury. In particular, a dissection of the bladder in an incorrect plane can eventually result in vascular ischemia and necrosis. Other potential causes include injury of the bladder wall during electrocautery and bladder lacerations while performing surgery. Fistulas in these cases tend to be small, due to the focal nature of the injury. A range of other surgeries can also lead to the development of vesicovaginal fistulas, such as urethral slain procedures, repairs of urethral diverticula, electrocautery of bladder papillomas and surgical treatment for pelvic carcinomas. Studies done in Mayo Clinic revealed that 85% of all vesicovaginal fistulas were associated with pelvic operations and 75% with hysterectomy. The study was conducted across a duration of 30 years and involved 800 patients.

On the other hand, the most common cause in the developing world is obstructive labor. Due to long periods of pressure by the fetus on the urethra, bladder and vagina, severe edema, necrosis, hypoxia and sloughing may occur. Women in developing countries typically have large fistulas, involving the anterior cervix, urethra bladder and the bladder trigone. For these reasons, dysfunction in the bladder can still take place even after the fistula is repaired. Damage is usually neuropathic in nature and manifests additionally with incompetency of the urethral sphincter.

Vesicovaginal fistulas tend to occur in countries where marriages are encouraged at an early age, before sufficient development of the pelvis. Many other cultural factors can also increase the risk amongst women in developing countries. These include female circumcision, Gishiri incisions to the anterior vaginal wall and insertion of harmful substances within the vagina in order to treat obstetric diseases. The issue is further complicated by severe malnutrition that affects the dimensions of the pelvis, leading to an elevated risk of malpresentation and cephalopelvic disproportion. Developing countries have also poor access to obstetric and medical care, even in cases of obstructed labor. In fact, the latter may be prolonged for weeks [2] [3].

Several risk factors contribute to the risk of vesicovaginal fistulas. These include infection, abscesses, uterine myomas, diabetes, past pelvic inflammatory disease, surgeries in the pelvis or vagina, ischemia, carcinoma, endometriosis and arteriosclerosis [4].

Epidemiology

The incidence of vesicovaginal fistula in the United States is still uncertain, with reports indicating values that range from 0.05% to 2%. These most commonly occur after total abdominal hysterectomy. The frequency of the condition remains underestimated in the developing world. Reports in Nigeria indicate that incidence amounts to 2.11 cases for every 100 births [5]. The most common cause of vesicovaginal fistulas in the developing world is prolonged obstructed labor.

Sex distribution
Age distribution

Pathophysiology

The sequence of events underlying the pathophysiological mechanisms of the disease starts after a dissection of the bladder results in devascularization or tearing in the posterior part of the bladder wall. In some cases, a suture may be wrongly placed in the bladder, ultimately leading to a decrease in blood perfusion, necrosis, and the formation of a fistula.

Fistulas can also occur after labor. The neck of the bladder becomes compressed from the head of the fetus and the anterior arch of the pubis. Eventually, this leads to a similar sequence of ischemia, necrosis and fistula formation.

Prevention

Vesicovaginal fistulas can be prevented when obstructed labor is avoided. Thus, social and economic action is great beneficial when it is targeted at young women who are at increased risk. Such intervention should take place before the woman becomes pregnant. In fact, it may be initiated in utero and continued during adolescence and womanhood. Adequate nutrition may be started in all pregnant women to prevent the development of the condition in the future in the baby. In addition, excellent antenatal and postnatal care should be provided for all women in rural areas.

Summary

Vesicovaginal fistula is a medical condition in which a fistula develops between the urinary bladder and the vagina. Causes are multifactorial and depend on whether the patient is in a developing or a developed country. In the developing world, the condition is associated with cultural habits, as well as poor nutritional status. The latter can lead to the development of a small pelvis and a higher risk of obstructed labor. With obstructed labor, the fetus exerts elevated pressure over important organs such as the urinary bladder, ultimately leading to a decrease in blood perfusion, necrosis and, finally, the formation of a fistula. Patients most commonly present with leakage of urine in the vagina. Treatment is surgical with very high rates of success [1].

Patient Information

Vesicovaginal fistula describes a medical condition in which an abnormal tract develops between the urinary bladder and the vagina. This can result in the leakage of urine in the vagina.

Causes vary and depend on whether the patient is in a developing or a developed country. Women in developing countries are at higher risk of obstructed labor; when labor is obstructed, the fetus exerts large amount of pressure over pelvic organs. This can restrict blood perfusion and eventually leads to the death of tissue (necrosis). The process is then further complicated by the formation of a tract that links the bladder to the vagina.

On the other hand, most cases of vesicovaginal fistulas occur in developed countries because of inadvertent injury to the bladder during pelvic surgeries.

Treatment is surgical with success rates that surpass 90%. Preventive measures are targeted at decreasing the risk of obstructed labor in developing countries by improving nutrition and access to medical care.

References

Article

  1. Sims JM. On the treatment of vesico-vaginal fistula. Am J Med Sci. 1852; 23:59–82.
  2. Capes T, Ascher-Walsh C, Abdoulaye I, Brodman M. Obstetric fistula in low and middle income countries. Mt Sinai J Med. 2011 May-Jun; 78(3):352-61.
  3. Tebeu PM, Fomulu JN, Khaddaj S, et al. Risk factors for obstetric fistula: a clinical review. Int Urogynecol J; 2011 Dec 6.
  4. Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet. 1992 Dec; 175(6):501-6.
  5. Ijaiya MA, Rahman AG, Aboyeji AP, et al. Vesicovaginal fistula: a review of nigerian experience. West Afr J Med; 29 (5): 293-8.
  6. Flynn MK, Peterson AC, Amundsen CL, et al. Functional outcomes of primary and secondary repairs of vesicovaginal fistulae via vaginal cuff scar excision. Int Urogynecol J Pelvic Floor Dysfunct. 2004 Nov-Dec; 15(6):394-8; discussion 398.
  7. Volkmer BG, Kuefer R, Nesslauer T, et al. Colour Doppler ultrasound in vesicovaginal fistulas. Ultrasound Med Biol. 2000 Jun; 26(5):771-5.
  8. Blaivas JG, Heritz DM, Romanzi LI. Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol. 1995; 153:1110–3.
  9. Nezhat CH, Nezhat F, Nezhat C, et al. Laparoscopic repair of a vesicovaginal fistula: A case report. Obstet Gynecol. 1994; 83:899–901.
  10. Sundaram BM, Kalidasan G, Hemel AK. Robotic repair of vesicovaginal fistula: case series of five patients. Urology. 2006; 67:970–3.
  11. Carr LK, Webster G. Abdominal repair of vesicovaginal fistula. Urology. 1996; 48:10–1.

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Last updated: 2018-06-22 01:18