What is Vesicovaginal Fistula?
A vesicovaginal fistula is a condition where there’s an unusual connection between the bladder and the vagina. This leads to constant urine leakage through the vagina. It often happens due to injuries from childbirth or gynecological procedures. In developed countries like the United States, the most common cause is complications during gynecological surgery. For example, bladder injuries during a hysterectomy procedure are quite common.
However, in developing nations, this condition is typically caused by complications during childbirth like obstructed labor leading to tissue damage from pressure.
To diagnose this condition, a thorough examination is necessary. Most of the time, it requires surgery to repair the problem. Several aspects need to be considered for the surgery, including the timing, surgical method, the use of graft material, post-surgery care, and the surgeon’s expertise. These have to be perfectly managed for a successful outcome.
However, even after surgery, there’s a chance that the fistula could reappear, which is the main concern following the operation.
What Causes Vesicovaginal Fistula?
The reasons for having a vesicovaginal fistula (an abnormal opening between the bladder and the vagina) can be different – it can either be something you’re born with (congenital) or something you get (acquired). Acquired vesicovaginal fistula further splits into categories like obstetric (related to childbirth), surgical, malignant (related to cancer), from radiation, and others. Although it’s rare, some people can be born with a vesicovaginal fistula, usually along with other abnormalities in the urinary and genital systems.
Most often, vesicovaginal fistulas happen after an injury during childbirth or gynecological procedures. In developed countries, like North America, the most common reason for a vesicovaginal fistula is a bladder injury during hysterectomy (an operation to remove the uterus). However, in developing countries, the most common cause of vesicovaginal fistula is a difficult childbirth that results in tissue damage due to persisting pressure. Women from lower-income backgrounds with poor nutrition, less education, early marriage and childbearing, and inadequate access to medical care during childbirth are at a higher risk of developing a vesicovaginal fistula.
Other less common ways to get a vesicovaginal fistula include surgeries in the back of the abdomen, blood vessel or pelvis surgeries, medical procedures on the urinary or genital systems, infections and inflammations, sexual trauma, laser procedures in the vagina, violence, and foreign objects in the vagina.
Risk Factors and Frequency for Vesicovaginal Fistula
Vesicovaginal fistula is a condition that is quite rare in the developed world but is much more common in developing and underdeveloped regions. At least 3 million women in underserved countries are living with this unrepaired condition. It’s estimated that 2 million of these women are residing in sub-Saharan Africa and South Asia. Shockingly, up to 130,000 new cases occur each year in Africa due to complications during childbirth. However, because of the stigma associated with this affliction, it’s challenging to determine the exact number of women worldwide it affects.
In developed countries, the most common cause of vesicovaginal fistula is a surgery called a hysterectomy. This operation is responsible for 80% of the annual cases. Interestingly, the likelihood of developing a vesicovaginal fistula after a hysterectomy depends on the type of hysterectomy performed.
- The risk is highest with laparoscopic procedures, with about 2.2 cases in every 1000 surgeries.
- Transabdominal procedures are the second highest, with about 1 case in every 1000 surgeries.
- The risk is lowest with the transvaginal approach, with about 0.2 cases in every 1000 surgeries.
Signs and Symptoms of Vesicovaginal Fistula
Vesicovaginal fistula is a medical condition where a patient experiences continuous urinary leakage through the vagina, particularly after recent pelvic surgery. Symptoms and the timing of their appearance can vary. Typically, patients report urine leakage 7 to 12 days after pelvic surgery, likely due to tissue damage that occurred during the process.
Doctors can confirm this condition using a simple dye test. A tampon or gauze is placed in the vagina, then the bladder is filled with a special type of blue dye. The patient is then asked to walk around for a short while. When the tampon or gauze is removed, if it has any blue dye near the top, the presence of a vesicovaginal fistula is confirmed. However, if the dye is only noticed at the bottom of the tampon, it could be due to spilling of the dye during the filling process or some other form of urinary leakage.
The fistula’s size, number, and location is typically assessed in a clinical setting and are important to know before corrective surgery is performed. A physical examination, using a lighted speculum, is done to look for any inflammation, infection, dead tissue, or other abnormalities in the bladder or vagina. If any such issues are identified, the corrective surgery may be postponed for 2 to 3 months, enough time for the tissue to heal and approach optimal health. But if the tissue appears healthy and free of inflammation, the surgery doesn’t need to be delayed.
In order to help with diagnosis or identify any other injuries, doctors typically make use of office cystoscopy and contrast studies such as CT urograms.
Testing for Vesicovaginal Fistula
If you’re showing signs of having a genitourinary fistula (an abnormal connection between the genital tract and the urinary tract), your doctor might ask questions about your symptoms and medical history. They will be particularly interested in whether you’ve recently had surgery or experienced other conditions like cancer radiation, obstructed labor or injury, similar to the patient discussed in our example. You may also be asked about the volume and characteristics of any fluid leaking, such as the color and smell, which can help distinguish fistula symptoms from general urinary incontinence. People with urogenital fistulas often have to change their pads frequently due to heavier leakage.
A physical examination commonly involving a split speculum examination can help diagnose this. Additional examinations could be performed under anesthesia, and a dye test might be carried out to identify any fistulae. The urethra is compressed with a gauze sponge while the bladder is filled with colored fluid for the dye test. After the bladder is filled, the patient will be asked to cough, causing any leakage to stain a tampon or cotton swabs placed earlier. The color of the staining can indicate whether a vesicovaginal fistula (between the bladder and the vagina) or a uretrovaginal fistula (between the urethra and the vagina) is present.
Imaging plays a significant role in confirming this condition. Cystoscopy, a procedure that allows your doctor to examine the lining of your bladder, can help determine the remaining injury in the bladder and characteristics of any fistula openings. Other procedures like a retrograde pyelography (an X-ray image of the bladder, ureters, and kidneys after a dye is injected through a tube in the urethra that can reach the ureters) may provide information regarding the ureteral integrity. Pelvic MRI (Magnetic Resonance Imaging), in particular, is more thorough compared to other medical imaging techniques for observing issues like vesicouterine fistula (an unusual tract between the urinary bladder and the uterus).
Clinically, a double-dye test is commonly performed to confirm the diagnosis. For this, the patient takes oral phenazopyridine (a pain reliever affecting the urinary tract) and a tampon or gauze is inserted into the vagina. Once the bladder is sufficiently full, the tampon is removed and inspected for orange-staining. Then, the bladder is back-filled with a diluted blue dye and inspected again. If orange staining is observed without blue-staining, a uretervaginal fistula (between ureter and vagina) is suspected. If both are present, a vesicovaginal fistula is likely, but they also need to rule out that a ureterovaginal fistula isn’t additionally present. Further confirmation may take place through additional imaging, such as transvaginal ultrasonography and cystoscopy.
Another imaging option is a multiphasic CT urogram, which is often used before surgery to identify any other potential fistula or abnormalities. The specific categorization of the vesicovaginal fistula will depend on its size and whether it’s associated with other conditions or complications, such as radiation exposure or if there was a previous unsuccessful repair.
Treatment Options for Vesicovaginal Fistula
For small, early-detected vesicovaginal fistulas (a type of abnormal connection or opening between the bladder and the vagina) that are not cancerous, less aggressive treatments, referred to as conservative management, may be used to help the opening close naturally. This typically involves the placement of a small tube known as a transurethral Foley catheter into the bladder to drain urine for about 2 to 8 weeks. Medications to relax the bladder can also be used to help manage symptoms.
If this less aggressive approach does not work, or if the fistula is found later and is larger, a procedure known as electrocoagulation may be used. In electrocoagulation, an electric current is used to burn and seal the opening. This procedure is followed by the placement of a transurethral Foley catheter for about 2 to 4 weeks to aid in healing. Electrocoagulation can be performed either through the bladder (cystoscopically) or through the vagina (vaginally). Another option is the use of a special type of glue, called fibrin glue, to help close the opening, although the results from this approach can vary.
If these methods fail, surgery may be needed. The success of surgery depends on accurately diagnosing the problem, correctly timing the surgery, and following basic surgical principles. The surgeon’s training and expertise, as well as the type and location of the fistula, will influence the method of repair. The best chance for successful repair is with the first surgery. Complex fistulas, such as those related to radiation treatment of the pelvis or recurrent fistulas, may require the placement of well-vascularized tissue (tissue with a good blood supply) for a successful repair.
After surgery, the bladder should be continuously drained via a transurethral Foley catheter. This catheter stays in place for two to three weeks until the surgical site has healed. A test called a cystography, which uses x-rays to visualize the bladder, is usually performed before removing the catheter to make sure the repair is successful. If this is not an option, other methods of testing, such as filling the bladder with fluid to look for leakage, or inspecting the bladder with a scope (cystoscopy), may be used. Some patients might receive medications to help calm the bladder and manage symptoms associated with the catheter. Preventative antibiotics are not usually needed while the catheter is in place. To facilitate healing, patients are advised to refrain from sexual intercourse and certain physical activities for 6-8 weeks after the surgery.
What else can Vesicovaginal Fistula be?
If a patient complains of unusual vaginal fluid leakage about 1 to 2 weeks after pelvic surgery or obstructed labor, it’s important to properly evaluate the situation. This might be a sign of a vesicovaginal fistula, a condition where an abnormal connection has formed between the bladder and the vagina. Usually, a medical professional would diagnose this condition using tests such as a clinical evaluation and a tampon dye test.
Another test that might be used is checking for a high creatinine level in the vaginal fluid, which could confirm that the fluid is urine. However, high creatinine could also be a result of different types of urinary incontinence where urine collects in the vagina, so doctors need to interpret these results carefully. Additional checks such as office cystoscopy and imaging studies can also be used to aid in the evaluation.
But keep in mind, abnormal vaginal fluid leakage after pelvic surgery or childbirth could be due to other reasons, including:
- Infections
- Inflammation
- Cancerous growths
- Types of urinary incontinence like urgency or stress-induced
- Other abnormalities related to the urinary and genital organs
What to expect with Vesicovaginal Fistula
Vesicovaginal fistula, which is an abnormal connection between the bladder and the vagina, often needs surgery for a solution because simple treatments usually do not work. Studies have found that surgical repair of this issue has been successful at rates between 70% to 100%. The type of surgery, whether accessed via the vagina or through the abdomen, shows almost equal success rates in non-radiated patients – about 91% and 97% accordingly.
The vaginal route to repair is usually a less invasive choice and can be carried out relatively early. A specific study found that performing the surgery through the abdomen was successful in every case (24 out of 24). This study also found an overall success rate of 87.5% (28 out of 32 patients) for the first attempts at surgical repair of simple vesicovaginal fistulas, regardless of the surgical approach used.
However, in patients who have undergone radiation treatment, repairing fistulas can be less common and more complex. The success rates for these patients can vary greatly, from 40% to 100%. In repeated cases, the use of flaps like those mades from labial fat pad or omentum (a fold of tissue in the abdomen) can serve as a protective measure during healing.
Possible Complications When Diagnosed with Vesicovaginal Fistula
After a surgery to fix a vesicovaginal fistula (a connection between the bladder and vagina), the main complication can be the fistula coming back. It’s quite common for patients to experience the frequent need to urinate and a sudden desire to urinate immediately after surgery. In the long run, patients may also experience urgency when needing to urinate and stress urinary incontinence, which is an involuntary leakage of urine when pressure is exerted on the bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
In cases where the fistula was caused by childbirth and the muscles that control urination are damaged, stress urinary incontinence is quite common. To alleviate the symptoms of urgency to urinate, there are medications available that can help. Stress urinary incontinence can be managed with standard treatments for this condition.
Unfortunately, failure and recurrence of the fistula happens in about 30% of the cases where it is repaired. In cases where it recurs, it’s often advised to wait 2-3 months before trying the repair again. Using surgical techniques that involve the use of flaps can also increase the odds of successfully repairing the fistula.
Potential Complications:
- Recurrence of the fistula
- Urinary frequency and urgency immediately following the surgery
- Long-term complications such as persistent urinary urgency and stress urinary incontinence
- Potentially needing to avoid surgery for 2 to 3 months in case of recurrence
Preventing Vesicovaginal Fistula
A vesicovaginal fistula is a distressing health problem in which an unusual channel or connection forms between the bladder and vagina, causing uncontrolled leakage of urine. This issue is commonly seen following injuries related to childbirth and women’s reproductive health procedures. In developed countries, the most frequent cause of this condition is due to surgeries on female reproductive organs.
Although most cases of vesicovaginal fistula require surgical treatment to completely resolve the problem, some cases can be successfully managed with less invasive methods. However, despite a good outlook for patients receiving the right treatment, it is crucial to focus on preventing this condition from happening in the first place.
This involves prioritizing women’s reproductive health, ensuring emergency services for childbirth-related complications, and ensuring the availability of surgeons who are skilled in surgeries involving the pelvic area. There’s also a need to create awareness among the general public about how widespread this issue is and the steps that can be taken to prevent it.
