Urethrovaginal Fistula - Causes, Symptoms, Diagnosis, Treatment, and Complications

What Is a Urethrovaginal Fistula?

Normally the urinary system and the organs present in it are completely separated from the genital tract. The urinary system comprises organs that work to filter the blood, form urine, and allow the passage of urine outside the body. The female genital tract contains organs that receive the sperms during intercourse and protect the internal organs from infection. So, it is clear that both these systems are structurally and functionally different from each other.

However, when these two systems get connected to each other due to injury, inflammatory diseases, or cancer, the condition is known as an enterovesical fistula. The term “fistula” denotes the abnormal communication between the two organs, blood vessels, or other structures. It has been named the urethrovaginal fistula because the communication starts from the urethra and ends at the vagina.

What Are the Different Types of Genitourinary Fistula?

A genitourinary fistula is a general term used to describe the abnormal communication between the vagina and the organs of the urinary system. The genitourinary fistula has been classified according to the organs involved. The classification has been described in the table below:

What Are the Causes of Urethrovaginal Fistula?

The vaginal fistulae are quite common and have been reported to occur in 50,000 to 100,000 women every year. The causes of urethrovaginal fistula have been described below:

1. Urethral Trauma - Urethral trauma is one of the most common causes of urethrovaginal fistula. The urethral injuries in females are mainly caused by fractures, pressure due to childbirth, hitting against a hard object, sexual assault, and accidents or car crashes. These injuries damage the urethra to the extent that the urine leaks into the surrounding organs, including the vagina resulting in a urethrovaginal fistula.

2. Injury Due to Catheter - A catheter is a tube inserted into the urinary bladder through the urethra to facilitate the drainage of urine. Normally, the catheter consists of a balloon that remains in the bladder when it is inserted. The balloon is inflated with water as it helps the catheter to stay in place. The balloon needs to be deflated before the removal of the catheter. However, when the catheter is removed without deflating the balloon, it causes urethral injury, and this is one of the reasons for the urethrovaginal fistula. The other reason for urethral injury could be the improper insertion of a catheter or not applying the lubricating solution over the catheter.

3. Iatrogenic - Iatrogenic means the fistula can develop during a medical examination or surgical procedures like cesarean delivery (C-section) and hysterectomy. The iatrogenic causes have been described below:

   1. Cesarean Delivery (C-Section) - It is different from the normal delivery as the incisions are made in the abdomen to deliver the baby. The injury to the urethra occurs if the delivery has to be performed under emergency conditions and the labor (contractions to push the baby) are slow.

   2. Hysterectomy - Hysterectomy is a procedure in which the urinary bladder is removed surgically. It can cause damage to the urinary bladder, urethra, and the structures supporting them. This increases the chance of abnormal communication between the urethra and the vagina.

   3. Pelvic Radiotherapy - The organ present between the legs and the abdomen is known as the pelvis. Pelvic radiotherapy is done when the organs present in the pelvis are affected by cancer. Radiotherapy makes the tissue-thin, and it gets damaged easily, increasing the risk of fistula.

What Are the Symptoms of Urethrovaginal Fistula?

Urethrovaginal fistula, or the abnormal communication between the urethra and the vagina, presents with the following symptoms:

1. Urinary incontinence or the leakage of urine from the vagina is the most common symptom.

2. The risk of urinary tract, vaginal, and kidney infections increases.

3. The patient might experience pain at the time of intercourse due to the leakage of urine.

4. The urine smells bad.

5. The urine shows the presence of bubbles as it passes through the urethra.

6. Discharge from the vagina is usually foul-smelling.

7. The patient feels irritation and itching in the skin present around the vagina and the other organs because of the urine leakage.

What Methods Are Used to Diagnose Urethrovaginal Fistula?

The diagnosis of the urethrovaginal fistula is based on medical history and certain tests. The diagnostic methods are described below:

• Medical History - The medical history gives an idea about the following:

  • Symptoms of the condition.

  • Time of their onset.

  • Other conditions the patient is suffering from.

  • The medications being taken by the patient.

  • Family history.

  • If the patient has undergone any major surgery in the past.

• Physical Examination - The physical examination mainly involves a pelvic exam. The doctor might examine the vagina and the vulva visually or insert a gloved finger into the vagina to feel the size and shape of the organs. It helps the doctor check the problems present in the vagina and the surrounding organs.

• Laboratory Examination - The following laboratory tests are usually performed:

  • Urinalysis - The patient is required to collect the urine in a container. Next, the urine sample is sent for examination in the laboratory under a microscope. If the urine contains bacteria and white blood cells, urinary tract infection can be suspected.

  • Blood Tests - The doctor recommends the patient undergo a blood test to check the general health of the patient and if he is suffering from any infection or not.

• Imaging Tests - The following imaging tests are usually recommended to confirm the diagnosis:

  • Fistulogram X-ray - Fistulogram is a procedure in which X-ray images of the internal organs are obtained. First, the patient is laid on the X-ray table, and a catheter is inserted into the urethra. Next, a special type of liquid (contrast material) is injected into the body through the catheter. X-rays are then taken from different angulations to view the exact location of the fistula.

  • Intravenous Urography - A special liquid known as the contrast medium is injected into the body through the veins. The images are obtained as the liquid fills the urinary bladder. In the case of a urethrovaginal fistula, the leakage of the liquid into the vagina is usually visible on the X-ray.

  • Cystoscopy - A small telescope-like instrument known as a cystoscope is inserted into the urinary bladder through the urethra to check the location of the fistula.

  • Computed Tomography (CT) Scans - This procedure provides three-dimensional (3D) images of the internal organs of the body. The patient is laid on a table that slides into a tunnel-like device where the X-rays are taken. These images give an idea about the degree to which the urethra is attached to the vagina and the presence of air in the urethra.

  • Sigmoidoscopy - The doctor inserts an instrument into the rectum through the anus to examine the large intestine. It helps to check if the presence of bubbles in the urine is due to a connection between the urethra and the vagina.

  • Magnetic Resonance Imaging (MRI) Technique - As the name suggests, this method uses both magnetic fields and radio waves to give out an image of the organs present internally and to see the location of the fistula.

How Is a Urethrovaginal Fistula Treated?

The treatment depends upon the type of fistula present. A small fistula will heal over time and does not require a surgical intervention. So, the treatment can be divided into conservative and surgical. Both the treatment options have been described below:

1. Conservative Treatment - The fistula will heal by itself if it is small and the tissues around it are healthy. A tube known as a catheter is inserted to allow the drainage of urine so that it does not interfere with the healing of the fistula. In the case of a ureterovaginal fistula, a tube known as the ureteral stent might be inserted and left in place to keep the ureters open. It allows the passage of urine without any damage to the healing fistula.

2. Surgical Treatment - The surgery aims to repair the fistula by removing the affected tissue. First, the fistula is located with the help of X-rays. Depending upon the location, the doctor approaches the fistula either through the abdomen or vagina. The tissue that communicates with the urethra is removed, and the area is sutured. A catheter is usually left in place for a few days to facilitate the drainage of urine. The tissues present around the urethra heal after some time. The affected organs start working normally after the healing is complete.

What Are the Complications of the Urethrovaginal Fistula?

Suppose the urethrovaginal fistula is left untreated for long, the risk of urinary tract infections and vaginal infections increases. It is because the bacteria can easily enter the vagina through the urethra and cause infection. The urine might leak into the vagina, and the patient may suffer from urinary incontinence. Also, it takes time for the urethra to heal after the surgery.

Conclusion:

A urethrovaginal fistula is a condition wherein abnormal communication develops between the urethra and the vagina. The urine leaks through the vagina, increasing the risk of infection. There are several causes of urethrovaginal fistula, including urethral trauma, pregnancy, and pelvic fractures. The condition is not life-threatening but becomes serious when the patients ignore the symptoms. They feel embarrassed to discuss it with the doctor, which causes severe complications. It is important to consult the doctor at the earliest because the condition can be easily managed by a conservative approach. However, there are surgical options available if the tissues around the fistula are damaged. It takes time for the site to heal, but the results of the surgery are great.