Vesicovaginal Fistulas - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Fistula is a condition in which an unnatural connection forms between two organs, affecting the functioning of the associated organs significantly. In the vesicovaginal fistula, a connection is established between the bladder and vagina, creating discomfort and other associated symptoms.

What Are Vesicovaginal Fistulas?

The vesicovaginal fistula (VVF) is a track that links two important parts of the body - the bladder and vagina. The bladder is the part that collects and holds urine. The bladder is then connected to the tube-like structure called the urethra, which then leads to an opening known as a urethral opening. Urine is released through that opening. In a vesicovaginal fistula, an unnatural pathway bridges the bladder on one end and the vaginal wall on the other. As a result, urine that is stored in the bladder leaks into the vagina. Then, urine starts leaking abnormally through the vaginal opening instead of the urethra, which is quite awkward for the patient.

How Are Vesicovaginal Fistulas Formed?

• Vesicovaginal fistulas can be either congenital or acquired. Congenital means that one can develop the condition by birth or be born with the specific condition. Congenital vesicovaginal fistulas are less common. On the other hand, acquired vesicovaginal fistulas develop for numerous other reasons, including traumatic and complicated childbirth, surgical complications, radiation and laser treatment involving the vagina, physical trauma, cancers involving the lower abdominal area, and certain inflammatory disease conditions.

• Among all these, obstructed labor is the foremost reason for developing a vesicovaginal fistula. When the child's head is much larger than the mother's pelvic width, obstructed labor occurs. As a result, during delivery, the fetal head causes bladder trauma, which manifests as a vesicovaginal fistula, and it develops within a couple of weeks. In addition, assisted childbirths using instruments like forceps may also lead to trauma and subsequent fistula development.

• Certain surgeries involving the lower abdomen, like C-sections and uterus removal, as well as surgeries to correct incontinence and prolapsed vaginal walls, may also damage the bladder, leading to fistula development.

• Biopsy, when performed intravaginally, also increases the risk of developing VVF.

• Finally, treatment options like radiation and laser may injure the bladder creating an unnatural pathway linking the bladder and vagina. And these fistulas do not develop all of a sudden; it sometimes develops years after the procedure.

• Physical trauma from accidents or sexual trauma may lead to fractures and injuries in the pelvic region and pose the risk of developing these fistulas.

• Certain inflammatory conditions like Crohn's may also lead to the development of VVF.

• Cancers involving the lower abdominal organs like the bladder, pelvis, cervix, or colon also lead to fistula development.

What Are the Different Types of Fistulas?

There are two broad categories of fistula - simple fistula and complex fistula. A simple fistula is generally smaller in dimension and single in number, while a complex fistula is larger in dimension and tends to persist for longer.

What Are the Symptoms of Vesicovaginal Fistulas?

Persistent smelly discharge through the vagina is the classic symptom of vesicovaginal fistula. The discharge smells like urine, creating discomfort and humiliation. It is also associated with pain during sexual intercourse. In addition, when urine drips through the vaginal tract, it leads to certain infections that could result in pain while having sex. Other associated symptoms include a significant rise in body temperature, pain in and around the abdominal area, a sudden drop in weight without significant reason, and gastrointestinal issues like nausea, vomiting, and diarrhea.

How Is Vesicovaginal Fistula Diagnosed?

Diagnosis requires a thorough medical history, a pelvic examination, and other confirmatory tests or procedures. First, a thorough medical history helps identify the symptoms and past surgeries or labor, which clarifies the diagnosis. Next, the pelvic region's physical examination helps assess other coexisting conditions like infections or inflammations. Finally, a confirmatory diagnosis is made with the help of procedures like dye tests, cystoscopies, retrograde pyelograms, fistulograms, cystography, flexible sigmoidoscopy, computed tomography (CT) urogram, combined vaginoscopy - cystoscopy, pelvic magnetic resonance imaging (MRI), endocavitary ultrasound, subtraction magnetic resonance fistulography, and intravenous pyeloureterogram.

• In the dye test, a specific dye is used to fill the bladder to check the dye's leakage through the vagina. Methylene blue is commonly used for this procedure.

• Cystoscopy is done with the help of a device called a cystoscope which helps to detect the path and origin of the fistula. It also helps to identify all sorts of injuries in the urethra and bladder.

• The retrograde pyelogram is a radiographic technique using a special dye to detect urine leakage into the vagina.

• Fistulograms are another radiographic technique that specifically detects the number of fistulas.

• Combining vaginoscopy - cystoscopy is an advanced diagnostic procedure.

• Flexible sigmoidoscopy is done with the help of a sigmoidoscope, which has a camera embedded in it, providing clear visualization.

• Transvaginal sonography provides a confirmatory diagnosis of the condition.

• CT and MRI scans of the fistulous tract also aid in diagnosis.

What Are the Available Treatment Options for Vesicovaginal Fistula?

• Treatment for VVF largely depends on the size and nature of the fistula. Most of the smaller fistulas of recent origin do not require complex surgical intervention; they heal voluntarily within two months. However, in such patients, catheters are advised to manage urine leakage.

• In addition, if the fistulous tract is mildly epithelialized, then electrocoagulation helps to remove the epithelial layer, facilitating catheterization and healing.

• Anticholinergic drugs may also be prescribed by doctors to treat unwanted bladder muscle contractions.

• Fibrin sealants are also used to close fistulas when there is significant inflammation associated with the VVF.

• Surgical interventions have to be considered in the case of a well-established large VVF with epithelialized tract. The different surgical approaches for VVF closure are transvaginal, laparoscopic, transabdominal, transurethral, transperitoneal, and robotic surgeries. However, transvaginal and transabdominal are the frequently preferred approaches.

• Transvaginal is more conservative as the fistula is approached vaginally. The transabdominal approach is preferred if VVF is coupled with any other abdominal condition.

• Flaps should be used to treat vesicovaginal fistulas that develop in a previously irradiated area to ensure significant blood supply. So the choice of surgical approach varies from one patient to another and must be considered individually.

Are There Any Complications Associated With VVF?

• Repeated infections and inflammations in the vagina.

• Infections in the lower urinary tract.

• Inability to control urination.

• Formation of an abscess.

Conclusion:

Vesicovaginal fistulas are a highly distressing condition where the person feels leaky deep down there. It considerably hampers the social life of an individual. However, it can be promptly managed with the available treatment methodologies. In most simple cases, VVF can be managed without surgery. So instead of stressing about the issue, consult with a specialist doctor at the right time.