What is a vesicovaginal fistula?

Vesicovaginal Fistula: Definition, Causes, and Management

A vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina that allows continuous involuntary discharge of urine into the vaginal vault, causing significant physical, psychological, and social distress to affected patients. 1

Epidemiology and Etiology

The causes of VVF differ significantly between developing and developed countries:

• In developing countries: Primarily caused by obstructed labor
• In developed countries: Mostly iatrogenic causes including:
  • Hysterectomy (most common - approximately 1 in 1000 post-hysterectomy patients)
  • Radiation therapy for gynecologic malignancies
  • Pelvic infections
  • Surgical complications 2

Other less common causes include:

• Malignancies of the pelvic organs
• Pelvic trauma
• Inflammatory bowel disease

Clinical Presentation

Patients with VVF typically present with:

• Continuous involuntary leakage of urine from the vagina
• Odorous discharge
• Recurrent urinary tract infections
• Perineal pain
• Dyspareunia
• Significant impact on quality of life 3, 2

Diagnosis

Diagnosis of VVF involves several imaging modalities:

1. CT with IV contrast: Has a diagnostic sensitivity of 76.5% for fistula detection and helps visualize collapsed fistula tracts 3

2. Fluoroscopic vaginography: Highly sensitive (79%) with a positive predictive value of 100% using water-soluble contrast 3

3. MRI with IV contrast: Provides superior soft tissue delineation, particularly useful for visualizing collapsed tracts 3

4. Transrectal ultrasound: High positive predictive value (100% for anorectal opening, 93% for vaginal opening) 3

5. Cystoscopy: Confirms the fistula orifice and allows for stent insertion to identify the tract 4

Important note: Barium enema is not recommended as the primary diagnostic method due to poor effectiveness (sensitivity as low as 7.7-34%). Water-soluble contrast is preferred over barium to avoid complications from extravasation into the peritoneal cavity 3

Management

Conservative Management

• Should be used only in carefully selected patients with small, recent fistulas 1
• May include continuous bladder drainage and antibiotics

Surgical Management

Timing of repair:

• Delayed repair is better than early repair - waiting at least 4-6 weeks prior to attempting repair allows for resolution of inflammation 1, 5

Surgical approaches:

1. Transvaginal approach (preferred):

   • Lower morbidity
   • Higher success rates (91% on average)
   • Minimal complications
   • Should be the first choice for most VVF repairs 1, 5

2. Transabdominal approach:

   • Success rate of approximately 97%
   • Often used with omental flap interposition
   • Particularly useful for complex or large fistulas 5, 6

3. Transvesical approach:

   • Success rates around 68.42% for primary repairs
   • May be used for specific anatomical considerations 6

4. Laparoscopic approach:

   • Emerging technique with good outcomes
   • Benefits include minimal bleeding and smaller incisions 4

Special Considerations for Radiation-Induced Fistulas

• Require more individualized management
• Success rates are lower (40-100%)
• May require complex surgical procedures or urinary diversion 5

Postoperative Care

• Anticholinergics should be used in the postoperative period for better bladder healing 1
• Adequate bladder drainage is essential
• Close follow-up to monitor for recurrence

Outcomes

• Combined conservative and surgical treatments have success rates exceeding 90% 2
• Recurrent fistulas may require multiple repair attempts with decreasing success rates for each subsequent repair 6
• Patients with successful repairs experience significant improvement in quality of life

VVFs represent a challenging but treatable condition that requires prompt diagnosis and appropriate management by experienced surgeons to achieve optimal outcomes.