Vesicovaginal and Ureterovaginal Fistula - Causes, Symptoms, and Treatment

Introduction -

Vesicovaginal and urethrovaginal fistula can be one of the most troublesome complications of obstetric trauma and pelvic surgery. They are abnormal connections between the vagina and other structures. The vesicovaginal fistula is a commonly occurring vaginal fistula, whereas the ureterovaginal fistula occurs rarely.

What Is a Fistula?

A fistula is an abnormal passage or connection between two body parts, such as two organs or blood vessels that do not usually connect. Fistula can occur naturally or due to injury, surgery, radiation, or inflammation. A fistula may develop at any part of the body, however, the most common ones are found around the anus. There are three types of fistula,

• Complete fistula.

• Incomplete fistula.

• Blind fistula.

What Is a Vaginal Fistula?

A vaginal fistula is an unusual opening or connection that connects the vagina with other structures. There are several types of vaginal fistula that include,

• Vesicovaginal Fistula - It is a common type of vaginal fistula. Also known as bladder fistula, it is an abnormal connection between the vagina and urinary bladder.

• Ureterovaginal Fistula - This occurs when an abnormal connection is created between the vagina and the ducts that take urine from the kidneys to the urinary bladder.

• Urethrovaginal Fistula - It is also called a urethral fistula; the abnormal opening is seen between the vagina and the tube that carries urine out of the body (urethra).

• Rectovaginal Fistula - In this type of vaginal fistula, there is an abnormal passage between the vagina and the lower part of the large intestine called the rectum.

• Colovaginal Fistula - In this type of fistula, the connection occurs between the vagina and the colon.

• Enterovaginal Fistula - With this type of vaginal fistula, there is a connection between the small intestine and the vagina.

What Are the Causes for Vesicovaginal and Uretrovaginal Fistula?

The most common cause of fistula include:

• Complicated childbirth.

• Abdominal surgery like hysterectomy or cesarean section.

• Radiational therapy.

• Traumatic injuries during surgical procedures.

• Pelvic, colon, or cervical cancer.

• Bowel diseases like diverticulitis or Crohn’s disease.

• Infections and inflammation to the urinary bladder, vagina, and cervix.

• Traumatic injury, for instance, falls on sharp objects or accidents.

• Congenital conditions.

• Foreign bodies like neglected pessaries (a device that can be inserted into the vagina to support its internal structure).

What Are the Symptoms of Vesicovaginal and Uterovaginal Fistula?

Vesicovaginal Fistula -

• Continuous involuntary urine leakage.

• No feeling of urination.

• The skin over the vagina appears inflamed and red.

• The smell of urine in patients.

Uterovaginal Fistula -

• Urine leakage.

• Absence of menstruation.

• Blood in the urine.

• Infertility.

• Miscarriages during the first trimester.

What Is the Treatment for the Ureterovaginal Fistula?

The treatment goals for ureterovaginal fistula are to preserve renal function, prevent or treat urinary sepsis, and cure urinary incontinence. Successful treatment of uterovaginal fistula depends on the time of diagnosis of the disease following the previous surgery, degree of injury to the ureter, site of injury, and time of referral to the urologist.

There are two approaches for treating ureterovaginal fistula:

1. Conservative management.

2. Surgical techniques.

1. Conservative Management:

The conservative management is indicated when the fistula is diagnosed early and is small. It is recommended with the expectation of spontaneous closure in the small fistula. Prolonged use of self-retaining bladder catheters is helpful in such cases. Intuitive healing is reported in five percent of women.

• Indwelling Catheter - The procedure for conservative management involves the placement of a bladder catheter for four to six weeks with simultaneous hormonal therapy to stop the menstruation that seems to promote spontaneous healing. The treatment has been reported positive for small early diagnosed fistulae.

• Stent placement - Endoscopic ureteric stenting is considered one of the most effective minimally invasive approaches for treating ureterovaginal fistula. The advantage of using stents is that it provides proper urinary drainage and prevents the escape of urine to a coexisting uterovaginal fistula. The longer the duration of ureteric stenting, the more likely is the spontaneous correction of more advanced fistula. The common complication of using stent is stent migration.

2. Surgical Management:

Surgical management is indicated when there is a failure of conservative treatment or in cases with a large fistula. The different approaches for surgical closure of uterovaginal fistula include vaginal, extraperitoneal, or transperitoneal laparotomies; in laparoscopic and robotic procedures, O’Connor’s surgical technique is used to treat uterovaginal fistula. First, the bladder is moved with the dissection of the fistulous tract and the opening of the uterus cavity. Then, using two layers of stitches, the bladder is repaired, and with one layer of suture, the uterus is closed. A vascularized tissue is usually placed to eliminate dead space and prevent hematoma formation.

Complications of ureterovaginal fistula

• The leaking of urine into the surrounding tissues.

• Urinoma (mass formed by encapsulated extravasated urine).

• Ureteral stricture (narrowing of the lumen of the duct that carries urine from the kidneys to the bladder).

What Is the Treatment for Vesicovaginal Fistula?

1. Conservative Methods:

• Fulguration of the Fistula Tract - It is done when the fistula is small and has occurred recently. The fistula tract is fulgurated (destruction of abnormal tissues with electrocautery), which facilitates fibrosis.

• Fibrin Glue Injection - This glue is injected transvaginally with cystoscopic guidance after the fulguration of the fistulous tract. Fibrin glue could also be used as an interposition agent.

• Injection of Platelet-Rich Plasma - Platelet-rich plasma is injected around the fistula tract, which joins the fistula mechanically, and the growth factors derived from platelets stimulate fibrosis.

• Indwelling Catheter - If the size of the fistula is small and the patient complains of occasional urine leakage, a catheter is placed inside the bladder for 6 to 8 weeks, resulting in fistula closure.

2. Surgical Method:

Before surgery, the first step is to treat any infections, inflammation, and necrosis.

The timing of the surgery depends on a few factors like,

• Nature of the injury that has caused fistula.

• Presence of any foreign body or disease.

• Nutritional status of the patient.

• Immunity status of the patient.

There are two surgical approaches, the vaginal approach, and the abdominal approach. The surgeons select the appropriate one depending on the following factors:

• Location of the fistula.

• Available space in the vaginal cavity.

• Ability to obtain suitable flaps for surgery.

• Need of any other procedures.

3. Laparoscopy Method:

Laparoscopy of the vesicovaginal fistula is done without opening the bladder and uses an intracorporeal suture (sutures done within the body). It fastens the postoperative recovery and reduces the hospital stay.

Conclusion:

Vesicovaginal and uterovaginal fistula have distressing complications due to continuous leaks of urine. Despite good surgical techniques and preventive measures, these injuries can still occur. Therefore, appropriate and spontaneous management can be beneficial.