Vesicovaginal fistula

Specialty: Gynecology and breast.

• Continuous loss of urine through the vagina
• vaginal urinary fistula
• vaginal urine drip

Why it occurs

• Inadvertent surgical injury to the bladder or ureter during an abdominal or laparoscopic hysterectomy (most common benign cause in developed countries)
• Prolonged obstructed labor with pressure necrosis of the vesicovaginal tissues (more common cause in developing countries)
• Sequela due to deferred pelvic radiotherapy
• Locally advanced carcinoma of the cervix or vagina

Initial workup

Vaginal physical examination with speculum (you can observe urine output or the fistulous orifice). Bladder filling test with methylene blue (dye is instilled into the bladder through a Foley catheter and it is observed if it stains a vaginal gauze; if it does not stain but there is leakage, suspect ureterovaginal fistula). Cystoscopy and computed tomography urography (Uro-CT) to specify the exact location of the fistula and rule out associated ureteral injuries.

Standard management

• There are no drugs that close large established vesicovaginal fistulas. In very small fistulas detected early, spontaneous closure can be attempted by continuous bladder catheterization with a Foley catheter for 4-6 weeks associated with antibiotic prophylaxis with Nitrofurantoin 100 mg orally daily. The definitive treatment is surgical closure (vaginal or laparoscopic) after a few months to allow the resolution of the initial tissue inflammatory process (note: maintain abundant hydration to avoid urinary infections).