You are in: eMedicine Specialties > Urology > Fistulas Vesicovaginal and Ureterovaginal FistulaArticle Last Updated: May 25, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Sandip P Vasavada, MD, Co-Head, Section of Female Urology, Joint Appointment, Urological Institute and Department of Gynecology, Co-Director, Center for Pelvic Neuromodulation, Cleveland Clinic Foundation Sandip P Vasavada is a member of the following medical societies: American Urogynecologic Society, American Urological Association, and International Continence Society Coauthor(s): Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at CWRU; Co-Section Head, Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, Cleveland Clinic Foundation Editors: Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center; Professor and Vice Chairman, Department of Urology, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: incontinence, urinary incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, Foley catheter, decompensated bladder, detrusor instability, detrusor hyperreflexia, overactive bladder, fistula, total incontinence, continuous incontinence, ureterovaginal fistula, vesicovaginal fistula, ectopic ureter, hysterectomy, complications of female pelvic surgery INTRODUCTIONSection 2 of 12
  Vesicovaginal and ureterovaginal fistulas are perhaps the most feared complications of female pelvic surgery. More than 50% of fistulas occur after hysterectomy for benign diseases such as uterine fibroids, menstrual dysfunction, and uterine prolapse. Urinary incontinence resulting from these fistulas may mimic symptoms of stress urinary incontinence. The acute onset of urinary incontinence occurring shortly after a difficult hysterectomy should raise suspicions for vesicovaginal or ureterovaginal fistulas. A high index of clinical suspicion, coupled with appropriate diagnostic tests and surgical intervention, result in excellent outcomes. History of the ProcedureDescriptions of urinary fistulas have been well described as early as ancient times by Hippocrates and Rufus. In developed countries, the most common cause of vesicovaginal fistula is gynecologic surgery (eg, hysterectomy). Obstetric trauma resulting in fistula formation is most common in underdeveloped countries. Although he was not the first to perform a surgical repair for vesicovaginal fistula, J. Marion Sims described a surgical approach using 3 surgical principles of fistula repair as follows: (1) excise all scar tissue, (2) obtain fresh margins, and (3) close the tract without overlapping suture lines (Harris, 1950). Transabdominal and transvaginal are commonly chosen surgical approaches for the correction of vesicovaginal fistula. Historically, the site of the fistula often dictated the surgical approach. Supratrigonal fistulas (fistulas above the interureteric ridge) typically were approached transabdominally. Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally. Most surgeons prefer the transabdominal approach for both the supratrigonal and infratrigonal fistulas because access to the fistula is easier. Supratrigonal fistulas are more difficult to reach transvaginally. Currently, the transvaginal approach is preferred because it is a less morbid procedure. The transvaginal approach is the safest and most comfortable for the patient. However, if the fistula site is difficult to access transvaginally, transabdominal route remains a safe alternative. ProblemFistula is defined as a communication between 2 organ sites. Vesicovaginal fistula is a free communication between the urinary bladder and the vagina. The urine from the bladder freely flows into the vaginal vault, leading to total or continuous incontinence. Ureterovaginal fistula is a communication between the distal ureter and the vagina. The urine from the ureter bypasses the bladder and flows into the vagina. This also results in total or continuous incontinence. FrequencyThe actual incidence of vesicovaginal fistula is not known. However, the incidence of vesicovaginal fistula resulting from hysterectomy is estimated to be less than 1%. Approximately 10% of fistulas may involve one or both ureters. Some fistulas may be more complex, involving adjacent organs. If the rectum is involved in the inflammatory reaction, rectovaginal fistula may develop. EtiologyIn the United States, more than 50% of the fistulas occur after hysterectomy for benign diseases such as uterine fibroids, menstrual dysfunction, or uterine prolapse. Pelvic radiation is the primary cause of delayed fistula, which can occur from one month to many years after the initial radiation treatment. Radiation treatment typically is used to treat cervical or endometrial carcinoma. Vesicovaginal fistula may occur with or without cancer recurrence. In developing countries, obstetrical complications are the most common cause of vesicovaginal and ureterovaginal fistula. PathophysiologyUnrecognized bladder injury during a difficult hysterectomy or cesarean delivery may result in vesicovaginal fistula formation. The majority of vesicovaginal fistulas are caused by excessive blunt dissection of the bladder during the mobilization of the bladder flap, which causes devascularization or an unrecognized tear of the posterior bladder wall. Alternatively, if the vaginal cuff suture was incorporated unknowingly into the bladder, this can result in tissue ischemia, necrosis, and subsequent fistula formation. The ureter may become injured during the dissection around the infundibulopelvic ligament or ligation of the uterine vessels. Unexpected pelvic hemorrhage may obscure the surgeon's vision and result in ureteral injury that manifests as delayed ureterovaginal fistula. Fistulas resulting from vaginal birthing occur during difficult or prolonged labor. The head of the fetus compresses the trigone or the bladder neck against the anterior arch of the pubic symphysis. This may result in tissue ischemia, necrosis, and eventual fistula formation. Today, this is a rare occurrence in the United States. ClinicalThe clinical history of vesicovaginal or ureterovaginal fistula usually is straightforward. Typically, a gynecologic procedure, such as hysterectomy, is involved. Often, the operation is reported to have been technically challenging. Poor intraoperative exposure coupled with heavy bleeding at the operative site often are risk factors. Associated bladder injury may have occurred and been repaired. Patients with vesicovaginal fistula often complain of painless urinary incontinence that occurs all the time. This also is called total, or continuous, incontinence. Urinary incontinence may be exacerbated during physical activities, leading some women to confuse this with stress incontinence. Conversely, patients with ureterovaginal fistula may experience constitutional symptoms of fever, chills, malaise, flank pain, and gastrointestinal symptoms in association with continuous urinary incontinence. Constitutional symptoms may occur as a result of hydronephrosis secondary to ureteral obstruction or urinary extravasation into the retroperitoneal space. Acute onset of vesicovaginal fistulas immediately after pelvic surgery does not cause constitutional symptoms. If the Foley catheter is still in place, the first sign of impending fistula formation is the presence of hematuria. Conversely, acute onset of ureterovaginal fistulas often is associated with a difficult postoperative course. These patients manifest symptoms of fever, ileus, and abdominal and flank pain. Approximately 10-15% of fistulas do not appear for 10-30 days. Some fistulas may not manifest for months. Radiation-induced fistulas may not become apparent for many years after radiation treatment. The development of a typical radiation-induced fistula is heralded by radiation cystitis, hematuria, and bladder contracture. These symptoms are improved dramatically by the sudden presence of vesicovaginal fistula. For non–radiation-induced postsurgical fistulas, patients may notice clear vaginal discharge or experience a new onset of urinary incontinence. The urinary incontinence mimics stress incontinence, where urine loss is more dramatic during physical activities or when standing upright from a lying position. Patients may experience continuous incontinence, requiring the use of several thick pads per day. Symptoms of urinary frequency and urgency typically are absent. Suspect a possible fistula when a patient complains of acute onset of urinary incontinence after a recent gynecologic surgery (eg, hysterectomy or cesarean delivery), if the degree of incontinence is out of proportion to the physical findings, or if the medical history and the nature of incontinence are inconsistent. During a physical examination, patients with new-onset ureterovaginal fistulas may demonstrate flank or abdominal tenderness due to hydronephrosis and/or urinary extravasation into the retroperitoneal space. Patients with vesicovaginal fistulas do not manifest abdominal or flank symptoms. A detailed pelvic examination reveals clear fluid pooling at the apex of the vagina. On close inspection, a pinpoint opening at the vaginal apex often is visualized in mature fistulas. When a fistula has not yet matured (immature fistula), inflamed, erythematous vaginal mucosa is visible, with granulation tissue surrounding the fistulous tract. The fistulous opening often is difficult to localize in immature fistulas. In addition, pelvic examination may be tolerated poorly by the patient, making the examination even more difficult. In these situations, pelvic examination under general anesthesia is warranted. If vesicovaginal or ureterovaginal fistula is suspected, proceed with a detailed workup as discussed below. As an immediate therapy, insertion of a urethral catheter to minimize urine leakage and the patient's distress should be tailored to each individual. INDICATIONSSection 3 of 12
A fistula recognized within 3-7 days after the operation may be repaired immediately by either a transabdominal or a transvaginal route. Fistulas identified after 7-10 days postoperatively should be monitored at periodic intervals until all signs of inflammation and induration are gone. Before embarking on fistula repair, the fistula tract should be well epithelialized and the vaginal wall should be soft and supple. The traditional approach has been to wait at least 3-4 months before attempting fistula closure. However, this philosophy has been challenged. Some surgeons have successfully closed the fistula with or without using a tissue interposition, such as Martius flap or peritoneal flap, without waiting 3-4 months. Patients with a history of multiple failed repairs, patients with associated enteric fistula with pelvic phlegmon, or patients with a history of pelvic radiation should not undergo fistula repair for at least 6-8 months. RELEVANT ANATOMYSection 4 of 12
Vesicovaginal fistula is a free communication between the urinary bladder and the vagina. Ureterovaginal fistula is a communication between the distal ureter and the vagina. For further discussion of relevant anatomy, see Surgical therapy. CONTRAINDICATIONSSection 5 of 12
The presence of an active vaginal infection or persistent inflammatory process at the fistula site is a contraindication to surgical repair. Historically, the transvaginal approach has been contraindicated for supratrigonal fistulas. However, this is no longer an absolute contraindication. Whether to use a transabdominal or transvaginal approach is now dictated by the surgeon's experience and preference. In the past, surgical repair of any vesicovaginal fistula before 3 months was discouraged for fear of recurrence and inadequate healing. However, the principle of delayed repair no longer is an absolute principle. The timing of fistula repair now is dictated by the nature of the local tissues around the fistula site. Surgical repair may commence if no vaginal infection is present and if the inflammatory process at the fistula site has resolved. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic FindingsIf the fistulous tract is excised as part of the repair technique, the specimen should be sent to pathology to review the histologic findings. Pathologic findings vary depending on the cause of the fistula. These causes might include foreign body giant cell reaction, malignancy, or chronic inflammation. Giant cell reaction may be present if a foreign body was part of the cause of the fistula (eg, a nonabsorbable suture ligature of a uterine vessel catching the vaginal cuff and the bladder wall). Radiation-induced fistulas manifest because of late changes caused by the radiation. After cessation of radiation therapy, fibrosis occurs in the bladder lamina propria. As fibrosis occurs in the subepithelial tissues, hyalinization of the connective tissues is observed. Often, large bizarre fibroblasts, ie, radiation fibroblasts, may be encountered. An obliterative arteritis may be observed in medium-to-small vessels. These vascular changes may result in atrophy or necrosis of the bladder epithelium, which causes ulceration or the formation of fissures. Fistulas resulting from cervical carcinoma may demonstrate either squamous cell carcinoma or adenocarcinoma. Fistulas arising from iatrogenic injury manifest with signs of acute and chronic inflammation. An acute inflammatory response is suggested by the presence of abundant neutrophils. In patients with chronic inflammation, the predominantly lymphocytic infiltrate is associated with macrophages. In addition, interstitial tissue fibrosis and necrosis may be present. TREATMENTSection 7 of 12
Medical therapyNo medical therapy is available that corrects vesicovaginal and ureterovaginal fistula. However, conjugated estrogen (oral or transvaginal) helps vaginal tissues become softer and more pliable for upcoming fistula repair. This is especially important for postmenopausal women and women with atrophic vaginitis. For personal hygiene and skin care, sitz baths with a solution of permanganate or baking soda douches may be helpful. For a small fistula, an initial trial of urethral catheter drainage may be attempted for 4-6 weeks. However, catheter drainage or fulguration of the edges of the fistula tract rarely results in a cure. Surgical therapyThe main factor in correcting vesicovaginal fistula is to separate the fistulous communication between the bladder and the vagina. This can be accomplished by inserting interposing tissue between the 2 organs and obtaining a watertight tension-free closure. Pinpoint fistulas may respond to conservative management with urethral catheter drainage and fulguration of the fistulous tract, but success rates may be low. Persistent incontinence after an adequate period of watchful waiting requires open exploration and formal fistula repair. Historically, the site of the fistula often dictated the surgical approach. Supratrigonal fistulas (fistulas above the interureteric ridge) typically were approached transabdominally. Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally. The transvaginal approach is the safest and most comfortable for the patient. A history of previous failed repairs does not preclude transvaginal reconstruction. Fistulas located in the infratrigonal area, fistulas near the bladder neck, and those occurring after hysterectomy usually are amenable to transvaginal reconstruction. Transvaginal repairs do not require excision of the fistula tract. In corrections of extensive fistulas after radiation therapy, a combined transvaginal and transabdominal approach with fixation of the omentum in the space between the vagina and urinary bladder often is useful. Ureterovaginal fistulas may be treated with an internal stent. However, persistent fistulas despite stent placement warrant surgical exploration and ureteral reimplantation. The basic rule for fistula repair is that the first operation has the best chance of success, and surgeons should use the approach with which they feel most comfortable. All adjuncts should be included to assure successful closure of the fistula. Preoperative detailsInformed consent discussions should include potential risks, including, but not limited to, ureteral injury, bladder injury, rectal injury, recurrence of fistula, persistent fistula, bleeding, and infection. Inform the patient if a Martius fat pad or gracilis muscle flap will be used. Preexisting urinary tract infection should be cleared, and preoperative conjugated estrogen therapy is helpful. Broad-spectrum intravenous antibiotics are administered preoperatively. Intraoperative detailsTransvaginal approach Place the patient in a dorsal lithotomy position. Insert a percutaneous suprapubic tube and urethral catheter. Insert a posterior-weighted vaginal speculum, and put a self-retaining vaginal retractor in place. Identify the fistula, and place traction sutures on the vaginal mucosa next to the fistula site. For traction, a small urethral catheter (8F)is inserted into the fistula. If the tract is very small, dilate the fistula to an acceptable size for urethral catheter insertion. Using an inverted J-shaped incision, circumscribe the fistula site. Dissect the anterior vaginal wall off the underlying pubocervical fascia. Close the fistula tract (bladder mucosa) vertically using 3.0-absorbable sutures in a watertight fashion. Close the pubocervical fascia using 3.0-absorbable sutures horizontally. Excise the redundant vaginal mucosa. Approximate the vaginal incision using 2.0-absorbable sutures, without causing an overlapping suture line. Place Betadine-soaked packing in the vagina. Alternatively, a Latzko partial colpocleisis technique can be employed. For this technique, 2 concentric circular incisions around the fistula tract are used. The vaginal mucosa is excised in quadrants. The fistulous tract, pubocervical fascia, and vaginal mucosa are closed in layers, without overlapping suture lines. In cases where closure is difficult or tenuous, a Martius fat pad (pedicle flap) may be harvested from the labia majora and interposed. A cylindrical bundle of bulbocavernosus and pedicled fat are developed carefully, preserving the superior external pudendal artery. A capacious tunnel under the vaginal mucosa between the labia majora and the fistula site then is developed. The labial pedicle flap is brought through the vaginal mucosal tunnel and sutured to the edges of the fistula repair. The vaginal mucosa then is closed over the fat pad. Transabdominal approach Place the patient in a modified lithotomy position. Insert a urethral catheter. Make an infraumbilical incision and carry it down into the peritoneal cavity. Expose the pouch of Douglas. Completely mobilize the bladder and bivalve it at the dome. Identify the ureteral orifices and the fistula tract. Cannulate both ureteral orifices with pediatric feeding tubes for easy identification. Circumscribe and excise the fistula. Separate the bladder from the vagina. If performing omental interposition, the abdominal incision should be carried to the epigastrium, with mobilization of the omentum. Separate avascular adhesions to the transverse colon. Divide and ligate the left gastroepiploic and short gastric vessels. Mobilize the omentum using the right gastroepiploic pedicle. Medially mobilize the ascending colon and hepatic flexure. Pass the omentum, which is hinged on the right gastroepiploic artery, behind the ascending colon and into the pelvis. Close the vagina using 2.0-absorbable sutures. Suture the distal aspect of the omentum to the distal limits of the space between the vagina and the bladder. Close the bladder in 2-3 layers. Put the suprapubic tube and pelvic drains in place. If ureteral reimplantation is necessary, dissect out the ureter prior to fistulectomy. Reimplant the ureter in the upper bladder wall after the fistula is closed. The ureter should be stented postoperatively. Postoperative detailsContinue intravenous antibiotics until the patient is able to tolerate an oral diet. To prevent bladder spasms, prescribe anticholinergics. Remove pelvic drains when the output becomes minimal, usually prior to discharge. Follow-upRemove the urethral catheter and perform a cystogram 10-14 days following surgery. Alternatively, intravesical methylene blue may be used. If no evidence of extravasation is present, the suprapubic tube also may be removed. If a persistent leak is present, leave the suprapubic tube in place and perform a cystogram 2 weeks later. When the cystogram does not define extravasation, the suprapubic tube may be removed. For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Intravenous Pyelogram, Cystoscopy, and Foley Catheter. COMPLICATIONSSection 8 of 12
Potential complications associated with repairing large vesicovaginal fistulas include the development of transient vesicoureteral reflux or de novo detrusor instability. Reflux and bladder spasms resolve spontaneously with anticholinergic therapy. If a large fistula is present, the nearby ureteral orifice is at risk of becoming obstructed during the repair. If this is the case, the ureter must be reimplanted during the initial operation. The most feared complication is the recurrence of fistula. If this occurs, a proper period of waiting is advised. The subsequent repair should be performed with a Martius flap, peritoneal interposition, or gracilis muscle flap. Complications associated with ureterovaginal fistula repair include urinary extravasation and ureteral stricture formation. Persistent urinary leak can be treated with percutaneous nephrostomy drainage, ureteral stent(s), and/or Foley catheter drainage. For short ureteral strictures, minimally invasive endoscopic treatments can be employed. OUTCOME AND PROGNOSISSection 9 of 12
The success rate of repairing a vesicovaginal and ureterovaginal fistula approaches 90% at first attempt and approaches 100% after a second attempt. However, realize that the second operation is more extensive and more complex compared to the first operation. Often, the surgical approach must be changed, and additional procedures, such as Martius flap, peritoneal flap, omental flap, or gracilis muscle flap, must be performed in combination with the fistula repair. For complex repairs involving radiated tissues, the success rate is less than 90%, but, for experienced surgeons, the outcome remains highly successful. FUTURE AND CONTROVERSIESSection 10 of 12
The following factors remain controversial: (1) the timing of operative repair, ie, early versus delayed; (2) the surgical approach, ie, transvaginal versus transabdominal; (3) the excision of the fistula, ie, to excise versus to not excise; and (4) the use of local tissue flaps, ie, Martius flap, gracilis muscle, or other. Resolution of these controversies depends on the preference and clinical experience of the surgeon. For uncomplicated fistulas, early repair using a transvaginal approach without excising the fistulous tract is recommended. Local tissue flaps or myocutaneous flaps are not employed routinely, except in situations of complex or recurrent fistula formation. As an alternative to open surgical repair, some authors have reported encouraging results using fibrin glue as an effective sealant for vesicovaginal fistulas. Thus, endoscopic injection of fibrin glue may be a minimally invasive treatment alternative for correction of selected vesicovaginal fistulas. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Vesicovaginal and Ureterovaginal Fistula excerpt Article Last Updated: May 25, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
