Urogenital tract fistulas in women
- Alan D Garely, MD
Alan D Garely, MD
- Chairman, Department of Obstetrics and Gynecology
- Director of Urogynecology and Pelvic Reconstructive Surgery
- South Nassau Communities Hospital
- Associate Professor of Obstetrics and Gynecology
- Mount Sinai School of Medicine
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
Urogenital fistulas are abnormal communications between the female genital tract and the bladder, urethra, or ureters. The etiology and incidence of urogenital tract fistulas vary geographically. In the United States and other developed countries, these fistulas are uncommon and are most often sequelae of gynecologic surgery, and less often as a result of obstetric injury, severe pelvic pathology or radiation therapy . In contrast, in developing countries, urogenital fistulas are a common complication of obstructed labor during childbirth [2,3]. In developed countries, patients with successfully repaired bladder and ureteral fistulas usually have no residual problems. In developing countries, incontinence often persists due to bladder neck and urethral sphincter injury, abnormal detrusor activity, vaginal strictures, and fibrosis of the bladder .
Urogenital fistulas in women in developed countries are reviewed here. Obstetric urogenital fistulas in resource-limited settings are discussed separately. (See "Obstetric fistulas in resource-limited settings".)
TYPES OF UROGENITAL FISTULA
The type of urogenital fistula is based upon the anatomic location of the connecting tract (figure 1). Vesicovaginal fistulas are approximately three times more common than ureterovaginal fistulas, with uretero-vesicovaginal fistulas being very infrequent. Clinicians rarely encounter vesico-uterine, vesico-cervical, vesico-peritoneal, and vesico-colonic fistulas (these usually occur only in the presence of colonic diverticula or cancer).
EPIDEMIOLOGY AND RISK FACTORS
In the United States, estimates of urogenital fistula formation range from less than 0.5 percent after simple hysterectomy to 10 percent after radical hysterectomy. Although radical hysterectomy is associated with an increased rate of urogenital fistula formation, it is not clear whether there will be an appreciable increase in the overall fistula formation rate with laparoscopic and robotic technique [5-7]. According to data in the United States National Hospital Discharge registry, among 2,329,000 operations performed on the female urinary and genital systems in 2007, there were less than 5000 procedures for vesicovaginal fistula repair .
Most urogenital fistulae occur after hysterectomy for benign disease. A study in the United Kingdom showed a 0.12 percent incidence of vesicovaginal fistula following all types of hysterectomy . The highest incidence occurred following radical hysterectomy, with a rate of 1.14 percent, and the lowest rate was 0.02 percent following vaginal hysterectomy for pelvic organ prolapse. Among women having a hysterectomy for benign indications, patients over 50 years had a lower incidence of fistula formation than women less than 40 years [10-12].
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- TYPES OF UROGENITAL FISTULA
- EPIDEMIOLOGY AND RISK FACTORS
- ETIOLOGY AND PATHOGENESIS
- CLINICAL PRESENTATION
- EVALUATION OF WOMEN WITH SUSPECTED UROGENITAL FISTULA
- Pelvic examination
- Dye test
- Cystoscopy and imaging studies
- DIFFERENTIAL DIAGNOSIS
- Timing of surgery
- Vesicovaginal fistulas
- - Posthysterectomy vesicovaginal fistula
- - High vaginal vault fistula from other causes
- Vaginal approach
- Abdominal approaches
- Urethrovaginal fistulas
- Ureteral fistulas
- - Ureterovaginal fistulas
- Anastomotic repair
- Anatomic considerations
- - Ureteroperitoneal fistulas
- Vesico-colonic fistulas
- Obstetric fistulas
- - Vesico-uterine fistulas
- Surgical sealants
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS