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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 1992; 175:501.
- Waaldijk, K. The surgical management of bladder fistula in 775 women in Northern Nigeria. Benda BV, Nymegen, 1989.
- Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190:1011.
- Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368:1201.
- Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988; 72:82.
- Kobayashi E, Nagase T, Fujiwara K, et al. Total laparoscopic hysterectomy in 1253 patients using an early ureteral identification technique. J Obstet Gynaecol Res 2012; 38:1194.
- Magrina JF, Kho RM, Weaver AL, et al. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008; 109:86.
- Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report 2010; :1.
- Hilton P, Cromwell DA. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service--a retrospective cohort study examining patterns of care between 2000 and 2008. BJOG 2012; 119:1447.
- Hilton P. Urogenital fistula in the UK: a personal case series managed over 25 years. BJU Int 2012; 110:102.
- Methfessel HD, Retzke U, Methfessel G. [Urinary fistula after radical hysterectomy with lymph node excision]. Geburtshilfe Frauenheilkd 1992; 52:88.
- Emmert C, Köhler U. Management of genital fistulas in patients with cervical cancer. Arch Gynecol Obstet 1996; 259:19.
- Duong TH, Taylor DP, Meeks GR. A multicenter study of vesicovaginal fistula following incidental cystotomy during benign hysterectomies. Int Urogynecol J 2011; 22:975.
- Bai SW, Huh EH, Jung DJ, et al. Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:360.
- Trovik J, Thornhill HF, Kiserud T. Incidence of obstetric fistula in Norway: a population-based prospective cohort study. Acta Obstet Gynecol Scand 2016; 95:405.
- Karram MM. Lower Urinary Tract Fistulas. In: Urogynecology and Reconstructive Pelvic Surgery, 3rd ed, Walters MD, Karram MM. (Eds), Mosby Inc, Philadelphia 2007. p.450.
- Kinsella TJ, Bloomer WD. Tolerance of the intestine to radiation therapy. Surg Gynecol Obstet 1980; 151:273.
- Sværdborg M, Birke-Sørensen H, Bek KM, Nielsen JB. A modified surgical technique for treatment of radiation-induced vesicovaginal fistulas. Urology 2012; 79:950.
- Platell C, Mackay J, Collopy B, et al. Anal pathology in patients with Crohn's disease. Aust N Z J Surg 1996; 66:5.
- Galandiuk S, Kimberling J, Al-Mishlab TG, Stromberg AJ. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg 2005; 241:796.
- Cirocchi R, Cochetti G, Randolph J, et al. Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review. Tech Coloproctol 2014; 18:873.
- Carl P. Vesico-ovarian fistula in suppurative ovarian inflammation and salpingitis. J Urol 1990; 143:352.
- Hui JY, Harvey MA, Johnston SL. Confirmation of ureteric patency during cystoscopy using phenazopyridine HCl: a low-cost approach. J Obstet Gynaecol Can 2009; 31:845.
- Findley AD, Solnik MJ. Prevention and management of urologic injury during gynecologic laparoscopy. Curr Opin Obstet Gynecol 2016; 28:323.
- Doyle PJ, Lipetskaia L, Duecy E, et al. Sodium fluorescein use during intraoperative cystoscopy. Obstet Gynecol 2015; 125:548.
- MOIR JC. Personal experiences in the treatment of vesicovaginal fistulas. Am J Obstet Gynecol 1956; 71:476.
- 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 2012; 36:438.
- Afifi K, Tudor G, Nagrani R. Vaginal discharge: an unusual presentation of degenerated uterine fibroid. J Obstet Gynaecol 2010; 30:69.
- Raassen TJ, Verdaasdonk EG, Vierhout ME. Prospective results after first-time surgery for obstetric fistulas in East African women. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:73.
- Singh O, Gupta SS, Mathur RK. Urogenital fistulas in women: 5-year experience at a single center. Urol J 2010; 7:35.
- Hadley HR. Vesicovaginal fistula. Curr Urol Rep 2002; 3:401.
- Garza Cortés R, Clavijo R, Sotelo R. Laparoscopic treatment of genitourinary fistulae. Arch Esp Urol 2012; 65:659.
- Liao CY, Tasi RS, Ding DC. Gynecological surgery caused vesicovaginal fistula managed by Latzko operation. Taiwan J Obstet Gynecol 2012; 51:359.
- Demirci U, Fall M, Göthe S, et al. Urovaginal fistula formation after gynaecological and obstetric surgical procedures: clinical experiences in a Scandinavian series. Scand J Urol 2013; 47:140.
- Hoch WH, Kursh ED, Persky L. Early, aggressive management of intraoperative ureteral injuries. J Urol 1975; 114:530.
- Boateng AA, Eltahawy EA, Mahdy A. Vaginal repair of ureterovaginal fistula may be suitable for selected cases. Int Urogynecol J 2013; 24:921.
- Schlossberg SM. Ureteral healing. Semin Urol 1987; 5:197.
- Aungst MJ, Sears CL, Fischer JR. Ureteral stents and retrograde studies: a primer for the gynecologist. Curr Opin Obstet Gynecol 2009; 21:434.
- Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. Br J Obstet Gynaecol 1998; 105:397.
- Latzko, W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg 1992; 48:211.
- Yarmohamadi A, Asl Zare M, Ahmadnia H, Mogharabian N. Salvage repair of vesicovaginal fistula. Urol J 2011; 8:209.
- Farahat YA, Elbendary MA, Elgamal OM, et al. Application of small intestinal submucosa graft for repair of complicated vesicovaginal fistula: a pilot study. J Urol 2012; 188:861.
- Mohr S, Brandner S, Mueller MD, et al. Sexual function after vaginal and abdominal fistula repair. Am J Obstet Gynecol 2014; 211:74.e1.
- Mackenrodt, A. Die operative Heilung grosser Blasenscheiden-fistein. Zentralbl Gynakol 1894; 8:180.
- Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727.
- Tran VQ, Ezzat M, Aboseif SR. Repair of giant vesico-vaginal fistulae using a rotational bladder flap with or without a gracilis flap. BJU Int 2010; 105:730.
- Eilber KS, Kavaler E, Rodríguez LV, et al. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol 2003; 169:1033.
- Altaweel WM, Rajih E, Alkhudair W. Interposition flaps in vesicovaginal fistula repairs can optimize cure rate. Urol Ann 2013; 5:270.
- Ezzat M, Ezzat MM, Tran VQ, Aboseif SR. Repair of giant vesicovaginal fistulas. J Urol 2009; 181:1184.
- Lee UJ, Goldman H, Moore C, et al. Rate of de novo stress urinary incontinence after urethal diverticulum repair. Urology 2008; 71:849.
- Kliment J, Beráts T. Urovaginal fistulas: experience with the management of 41 cases. Int Urol Nephrol 1992; 24:119.
- Papanikolaou A, Tsolakidis D, Theodoulidis V, et al. Surgery for ureteral repair after gynaecological procedures: a single tertiary centre experience. Arch Gynecol Obstet 2013; 287:947.
- Guerriero, WG. Ureteral trauma. In Guerriero WG (ed): Management of Acute and Chronic Urologic Injury. Appleton-Century-Crofts, E. Norwalk, CT, 1984.
- Hurd WW, Chee SS, Gallagher KL, et al. Location of the ureters in relation to the uterine cervix by computed tomography. Am J Obstet Gynecol 2001; 184:336.
- Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16:237.
- Yip SK, Leung TY. Vesicouterine fistula: an updated review. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9:252.
- Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002; 34:335.
- Novi JM, Rose M, Shaunik A, et al. Conservative management of vesicouterine fistula after uterine rupture. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:434.
- Leng WW, Amundsen CL, McGuire EJ. Management of female genitourinary fistulas: transvesical or transvaginal approach? J Urol 1998; 160:1995.
- Nardos R, Menber B, Browning A. Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterization. Int J Gynaecol Obstet 2012; 118:21.
- Barone MA, Widmer M, Arrowsmith S, et al. Breakdown of simple female genital fistula repair after 7 day versus 14 day postoperative bladder catheterisation: a randomised, controlled, open-label, non-inferiority trial. Lancet 2015; 386:56.
- 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