Vesicovaginal Fistula

This is a connection established between the bladder and the vagina so that the patient presents with urinary incontinence.

This is an injury, often secondary to an obstetric manipulation, gynecologic surgery, radiation or invasive cancer of the cervix. Patients will present with constant leakage of urine.

DIAGNOSIS

Cystoscopy usually reveals the fistulous opening between the bladder and vagina.

Vaginography, which is performed by inserting a catheter into the vagina, instilling a radio-opaque solution and taking the appropriate x-rays, will usually show the vesicovaginal, ureterovaginal and/or rectovaginal fistula. If the fistula is very small and not readily apparent, it may be necessary to instill methylene blue via a catheter and detect any staining on a vaginally-placed tampon. If no methylene blue dye is found staining a vaginal pledget, then intravenous indigo carmine should be administered; and if staining is detected, a ureterovaginal fistula may be responsible. If the staining is found only at the string end of the tampon, then the leakage probably represents urethral incontinence and not leakage from a vesicovaginal fistula.

TREATMENT

Repair is usually undertaken some 8-12 weeks after the injury. This time delay allows resolution of wound inflammation prior to attempting corrective surgery. In postmenopausal patients, estrogen replacement prior to surgery may improve the chances of successful closure. Treatment options include the following:

A. Conservative

For very small fistulae, an indwelling Foley catheter to remain in place for about 4 weeks may result in closure.

B. Endoscopic

Cauterizing a very small fistulous tract in the bladder and/or the vagina may allow healing of the fistulous tract. Curetting with a fine probe may possibly seal a fine fistulous tract by allowing fresh margins to heal.

C. Surgery

1. Transvesical approach.

This approach is usually done when the fistula is located at the level of the ureteral orifices or higher or if the vagina is stenotic. After opening the bladder, ureteral stents are placed to identify the ureters. The fistula is exposed, circumscribed and excised, thus allowing closure of the individual vaginal and bladder layers. Omentum can be useful to interpose between suture lines to improve healing rates.

2. Vaginal approach.

This approach is ideal for low-lying fistulae with an adequate vagina. The fistula is excised and surrounding tissues gently mobilized to allow layered closure. Immediately prior to the repair, cystoscopy and ureteral catheterization may be reasonable to allow identification of the ureteral orifices.

Postoperative care.

A light vaginal pack is used for 24 hours. A Foley catheter is left for about 14 days. The appropriate anti-spasmodics are used to prevent bladder spasms and damage to the repair site. Antibiotics are also administered. Patients are also instructed to avoid intercourse for at least 6 weeks after surgery to allow complete healing of the repair site.