Vesicovaginal and Ureterovaginal Fistula

Urogynecology

Clinicals - History

Fact Explanation
A history of a predisposing condition The commonest predisposing condition is prolonged, obstructed labor. The pathophysiology is; pressure necrosis of the anterior vaginal wall and underlying bladder neck or urethra occurs as the tissues are compressed between the fetal head and the posterior surface of the symphysis pubis ,and the necrotic tissue sloughs away and is expelled after approximately 10 days, at which point incontinence ensues. The other known causes of fistulae are surgical injury (i.e. in bladder neck or pelvic surgeries, adhesiolysis), pelvic irradiation, endometriosis and anatomical distortions of the pelvis (i.e. large fibroids). The surgeries that pose a higher risk are hysterectomy (75% of cases) and urological or lower gastrointestinal pelvic surgery(2%). The causes for poor wound healing (i.e. anemia, chronic steroid use) are also contributing factors. A history of a predisposing condition
The commonest predisposing condition is prolonged, obstructed labor. The pathophysiology is; pressure necrosis of the anterior vaginal wall and underlying bladder neck or urethra occurs as the tissues are compressed between the fetal head and the posterior surface of the symphysis pubis ,and the necrotic tissue sloughs away and is expelled after approximately 10 days, at which point incontinence ensues. The other known causes of fistulae are surgical injury (i.e. in bladder neck or pelvic surgeries, adhesiolysis), pelvic irradiation, endometriosis and anatomical distortions of the pelvis (i.e. large fibroids). The surgeries that pose a higher risk are hysterectomy (75% of cases) and urological or lower gastrointestinal pelvic surgery(2%). The causes for poor wound healing (i.e. anemia, chronic steroid use) are also contributing factors.
Leaking of urine from vagina It is a very embarrassing condition, and the females usually present about one to two weeks following a surgical insult. Leaking of urine from vagina
It is a very embarrassing condition, and the females usually present about one to two weeks following a surgical insult.
Hematuria of urine leaking in the post-operative period Continuing hematuria or urine leaking in the post-operative period can raise the suspicion of a surgical insult and an impending vaginal fistula. Hematuria of urine leaking in the post-operative period
Continuing hematuria or urine leaking in the post-operative period can raise the suspicion of a surgical insult and an impending vaginal fistula.

Clinicals - Examination

Fact Explanation
Surgical scar The females who present with vesicovaginal fistula or ureterovaginal fistula are most probably presenting following a surgery in the pelvis. The scar could be obvious. (i.e. pfenestiel scar, laparoscopy scar). Surgical scar
The females who present with vesicovaginal fistula or ureterovaginal fistula are most probably presenting following a surgery in the pelvis. The scar could be obvious. (i.e. pfenestiel scar, laparoscopy scar).
Urine leaking from the vagina In detailed gynecological examination, urine leaking from the vagina might be obvious. Urine leaking from the vagina
In detailed gynecological examination, urine leaking from the vagina might be obvious.
Perineal dermatitis Due to chronic leakage of urine and skin irritation. Perineal dermatitis
Due to chronic leakage of urine and skin irritation.

Investigations - Diagnosis

Fact Explanation
Three-swab test The diagnostic investigation for ureterovaginal fistula. Three-swab test
The diagnostic investigation for ureterovaginal fistula.
Double dye test It is a confirmatory test for vesicovaginal fistula, this involves inserting a urinary catheter, filling the bladder with dye, clamping the catheter, and observing if the dye leaks through the vagina via the fistula. Double dye test
It is a confirmatory test for vesicovaginal fistula, this involves inserting a urinary catheter, filling the bladder with dye, clamping the catheter, and observing if the dye leaks through the vagina via the fistula.
Cystoscopy Can be used to view site, size, number of fistulae. Cystoscopy
Can be used to view site, size, number of fistulae.
Magnetic Resonance Imaging Indicated when there is a suspicion of neoplasm causing multiple fistulae or there is bizzarre anatomy and closer study of it is necessary before closing the fistula. Magnetic Resonance Imaging
Indicated when there is a suspicion of neoplasm causing multiple fistulae or there is bizzarre anatomy and closer study of it is necessary before closing the fistula.

Investigations - Management

Fact Explanation
Complete blood count To exclude anemia, infection and thrombocytopenia before the surgical management option. Complete blood count
To exclude anemia, infection and thrombocytopenia before the surgical management option.

Management - Supportive

Fact Explanation
Awaiting spontaneous closure of the fistula For smaller vesicovaginal defects. Meanwhile drainage of the bladder with catheters should be done. Awaiting spontaneous closure of the fistula
For smaller vesicovaginal defects. Meanwhile drainage of the bladder with catheters should be done.
Patient education and reassuring Plays a major role since effortless urinary incontinence can affect a woman's life badly. Reassurance that the defect can be corrected and the course of the healing should be done. Patient education and reassuring
Plays a major role since effortless urinary incontinence can affect a woman's life badly. Reassurance that the defect can be corrected and the course of the healing should be done.

Management - Specific

Fact Explanation
Glue injection Injecting platelet rich plasma and platelet rich fibrin glue in a transvesican or transvaginal route is a safe, effective and minimally invasive approach for the treatment of urinary tract fistulae which obviate the need for open surgery since it can be done by endoscopy also. Fibrin glue is attractive as a tissue sealant because it prevents fibrosis and promotes healing through its effects on fibroblasts and collagen synthesis. Glue injection
Injecting platelet rich plasma and platelet rich fibrin glue in a transvesican or transvaginal route is a safe, effective and minimally invasive approach for the treatment of urinary tract fistulae which obviate the need for open surgery since it can be done by endoscopy also. Fibrin glue is attractive as a tissue sealant because it prevents fibrosis and promotes healing through its effects on fibroblasts and collagen synthesis.
Tension free surgical repair The surgical correction should not be delayed unless there is an inflammation of infection present, since urinary incontinence can have devastating effect on a woman's life. The repair can be done in transabdominal or transvaginal route but the first has the highest success rate, but the latter is associated with rapid recovery. The principles of surgical correction are removal of debris and inflammatory material, creating a tension free flap (i.e. Latzko procedure, Martius flap) and promoting optimal conditions for wound healing. (i.e. correction of anemia) Laparoscopic repair has been known to present the success rate of transabdominal approach of open surgery. Rotational bladder flap can be used for multiple or large fistulae. Tension free surgical repair
The surgical correction should not be delayed unless there is an inflammation of infection present, since urinary incontinence can have devastating effect on a woman's life. The repair can be done in transabdominal or transvaginal route but the first has the highest success rate, but the latter is associated with rapid recovery. The principles of surgical correction are removal of debris and inflammatory material, creating a tension free flap (i.e. Latzko procedure, Martius flap) and promoting optimal conditions for wound healing. (i.e. correction of anemia) Laparoscopic repair has been known to present the success rate of transabdominal approach of open surgery. Rotational bladder flap can be used for multiple or large fistulae.

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  1. ABOU-EL-GHAR ME, EL-ASSMY AM, REFAIE HF, EL-DIASTY TA. Radiological diagnosis of vesicouterine fistula: role of magnetic resonance imaging. J Magn Reson Imaging [online] 2012 Aug, 36(2):438-42 [viewed 26 August 2014] Available from: doi:10.1002/jmri.23667
  2. ANGIOLI ROBERTO, PENALVER MANUEL, MUZII LUDOVICO, MENDEZ LUIS, MIRHASHEMI RAMIN, BELLATI FILIPPO, CROCè CLARA, PANICI PIERLUIGI BENEDETTI. Guidelines of how to manage vesicovaginal fistula. Critical Reviews in Oncology/Hematology [online] 2003 December, 48(3):295-304 [viewed 27 August 2014] Available from: doi:10.1016/S1040-8428(03)00123-9
  3. APIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65
  4. ARBOE MD, TEITELBAUM DH, DILLMAN JR. Combined 3D rotational fluoroscopic-MRI cloacagram procedure defines luminal and extraluminal pelvic anatomy prior to surgical reconstruction of cloacal and other complex pelvic malformations. Pediatr Surg Int [online] 2012 Aug, 28(8):757-63 [viewed 26 August 2014] Available from: doi:10.1007/s00383-012-3122-6
  5. BLAIVAS JERRY G., HERITZ DIANNE M., ROMANZI LAURI J.. Early Versus Late Repair of Vesicovaginal Fistulas: Vaginal and Abdominal Approaches. The Journal of Urology [online] 1995 April, 153(4):1110-1113 [viewed 27 August 2014] Available from: doi:10.1016/S0022-5347(01)67522-0
  6. BLUMENREICH MS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition [web]; Chapter 153, The White Blood Cell and Differential Count. [viewed 08 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/
  7. CHIN ARNOLD I., RUTMAN MATTHEW, RAZ SHLOMO. Transverse Vaginal Septum with Congenital Vesical-Vaginal Communication and Cyclical Hematuria. Urology [online] 2007 March, 69(3):575.e5-575.e7 [viewed 26 August 2014] Available from: doi:10.1016/j.urology.2007.01.001
  8. D'ARCY FRANK T., JAFFRY SYED. The treatment of vesicovaginal fıstula by endoscopic injection of fıbrin glue. The Surgeon [online] 2010 June, 8(3):174-176 [viewed 27 August 2014] Available from: doi:10.1016/j.surge.2009.10.018
  9. DAVITS R. J. A. M., MIRANDA S. I.. Conservative Treatment of Vesicovaginal Fistulas by Bladder Drainage Alone. [online] 1991 August, 68(2):155-156 [viewed 26 August 2014] Available from: doi:10.1111/j.1464-410X.1991.tb15285.x
  10. EZZAT MAHMOUD, EZZAT MOHAMMED M., TRAN VIET Q., ABOSEIF SHERIF R.. Repair of Giant Vesicovaginal Fistulas. The Journal of Urology [online] 2009 March, 181(3):1184-1188 [viewed 27 August 2014] Available from: doi:10.1016/j.juro.2008.10.152
  11. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.65400
  12. GOPALAKRISHNAN GANESH, KUMAR SANTOSH, KEKRE NITINS. Vesicovaginal fistula: An update. Indian J Urol [online] 2007 December [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.32073
  13. HANASH KAMAL A., AL ZAHRANI HASSAN, MOKHTAR ALAA A., ASLAM MUHAMMAD. Retrograde Vaginal Methylene Blue Injection for Localization of Complex Urinary Fistulas. Journal of Endourology [online] 2003 December, 17(10):941-943 [viewed 26 August 2014] Available from: doi:10.1089/089277903772036334
  14. HASSAN MA, EKELE BA. Vesicovaginal fistula: Do the patients know the cause?. Ann Afr Med [online] 2009 December [viewed 27 August 2014] Available from: doi:10.4103/1596-3519.56241
  15. JOSHI S, BHALERAO A, SOMALWAR S, CHAUDHARY S. A rare case of irreparable vesico-vaginal fistula of 45 years duration successfully managed by urinary diversion J Midlife Health [online] 2011, 2(1):37-39 [viewed 27 August 2014] Available from: doi:10.4103/0976-7800.83272
  16. KAMAT NAGESH. Vesico-vaginal fistula. BJU Int [online] 2005 July, 96(1):192-192 [viewed 26 August 2014] Available from: doi:10.1111/j.1464-410X.2005.05656_4.x
  17. KAPOOR R, ANSARI MS, SINGH P, GUPTA P, KHURANA N, MANDHANI A, DUBEY D, SRIVASTAVA A, KUMAR A. Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach Indian J Urol [online] 2007, 23(4):372-376 [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.36709
  18. LATZKO WILLIAM. Postoperative vesicovaginal fistulas. The American Journal of Surgery [online] 1942 November, 58(2):211-228 [viewed 26 August 2014] Available from: doi:10.1016/S0002-9610(42)90009-6
  19. MEEKS G. G., ROTH TED M.. Vesicovaginal and Urethrovaginal Fistulas. GLOWM [online] 2009 December [viewed 26 August 2014] Available from: doi:10.3843/GLOWM.10064
  20. MIRANDA EDUARDO PAULA, RIBEIRO GUSTAVO PINTO, ALMEIDA DIEGO COSTA, SCAFURI ARIEL GUSTAVO. Percutaneous injection of fibrin glue resolves persistent nephrocutaneous fistula complicating colonic perforation after percutaneous nephrolithotripsy. Clinics [online] 2009 December, 64(7):711-713 [viewed 27 August 2014] Available from: doi:10.1590/S1807-59322009000700017
  21. MOON SG, KIM SH, LEE HJ, MOON MH, MYUNG JS. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings Korean J Radiol [online] 2001, 2(2):97-104 [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97
  22. MOORE KATHLEEN N., GOLD MICHAEL A., MCMEEKIN D. SCOTT, ZORN KRISTIN K.. Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma. Gynecologic Oncology [online] 2007 September, 106(3):498-501 [viewed 27 August 2014] Available from: doi:10.1016/j.ygyno.2007.04.030
  23. NERLI RB, REDDY M. Transvesicoscopic Repair of Vesicovaginal Fistula Diagn Ther Endosc [online] 2010:760348 [viewed 26 August 2014] Available from: doi:10.1155/2010/760348
  24. RAJAMAHESHWARI N, SEETHALAKSHMI K, VARGHESE L. Menouria due to congenital vesicovaginal fistula associated with complex genitourinary malformation Indian J Urol [online] 2009, 25(4):534-536 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.57924
  25. RANDAWA A, KHALID L, ABBAS A. Diagnosis and Management of Ureterovaginal Fistula in a Resource-Constrained Setting: Experience at a District Hospital in Northern Nigeria Libyan J Med [online] , 4(1):41-43 [viewed 26 August 2014] Available from: doi:10.4176/081101
  26. SCHIMPF MO, MORGENSTERN JH, TULIKANGAS PK, WAGNER JR. Vesicovaginal Fistula Repair Without Intentional Cystotomy Using the Laparoscopic Robotic Approach: a Case Report JSLS [online] 2007, 11(3):378-380 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015832
  27. SHARMA SAMEER K., PERRY KENT T., TURK THOMAS M.T.. Endoscopic Injection of Fibrin Glue for the Treatment of Urinary-Tract Pathology. Journal of Endourology [online] 2005 April, 19(3):419-423 [viewed 27 August 2014] Available from: doi:10.1089/end.2005.19.419
  28. SHIRVAN MALIHEH KESHVARI, ALAMDARI DARYOUSH HAMIDI, GHOREIFI ALIREZA. A Novel Method for Iatrogenic Vesicovaginal Fistula Treatment: Autologous Platelet Rich Plasma Injection and Platelet Rich Fibrin Glue Interposition. The Journal of Urology [online] 2013 June, 189(6):2125-2129 [viewed 27 August 2014] Available from: doi:10.1016/j.juro.2012.12.064
  29. SINGH A, KUMAR M, SHARMA S. Iatrogenic urethrovaginal fistula with transverse vaginal septum presenting as cyclical hematuria Indian J Urol [online] 2011, 27(4):547-549 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.91451
  30. TABAKOV I.D., SLAVCHEV B.N.. Large Post-Hysterectomy and Post-Radiation Vesicovaginal Fistulas:: Repair by Ileocystoplasty. The Journal of Urology [online] 2004 January, 171(1):272-274 [viewed 26 August 2014] Available from: doi:10.1097/01.ju.0000101801.95459.54
  31. TAYLER-SMITH K, ZACHARIAH R, MANZI M, VAN DEN BOOGAARD W, VANDEBORNE A, BISHINGA A, DE PLECKER E, LAMBERT V, CHRISTIAENS B, SINABAJIJE G, TRELLES M, GOETGHEBUER S, REID T, HARRIES A. Obstetric Fistula in Burundi: a comprehensive approach to managing women with this neglected disease BMC Pregnancy Childbirth [online] :164 [viewed 26 August 2014] Available from: doi:10.1186/1471-2393-13-164
  32. WALL L LEWIS. Obstetric vesicovaginal fistula as an international public-health problem. The Lancet [online] 2006 September, 368(9542):1201-1209 [viewed 27 August 2014] Available from: doi:10.1016/S0140-6736(06)69476-2
  33. WIT ESTHER M. K., HORENBLAS SIMON. Urological complications after treatment of cervical cancer. Nat Rev Urol [online] December, 11(2):110-117 [viewed 26 August 2014] Available from: doi:10.1038/nrurol.2013.323