What is the management approach for a female of reproductive age with a history of complicated deliveries or uterine surgeries presenting with a vesicouterine fistula?

Management of Vesicouterine Fistula

Surgical repair via transabdominal approach is the definitive treatment for vesicouterine fistula in women of reproductive age, with surgery delayed 2-3 months post-delivery to allow tissue healing and inflammation resolution. 1, 2, 3

Diagnostic Confirmation

Imaging is essential to confirm the diagnosis and define fistula anatomy:

• CT cystography with water-soluble contrast is the preferred initial imaging modality, with the American College of Radiology recommending it over conventional fluoroscopic cystography for superior diagnostic accuracy in detecting bladder fistulas 4

• MRI pelvis with IV contrast provides superior soft tissue resolution and is equally sensitive to CT for evaluating vesicouterine fistulae, particularly useful for assessing complex anatomy, multiple tracts, or active inflammation 4

• Hysterogram performed with a short-tipped cannula is the best method for direct visualization of the fistulous tract between bladder and uterus 5

• Cystoscopy should be performed to directly visualize the fistula opening in the bladder and rule out other urogenital fistulas 1, 3

Clinical Presentation Recognition

The classic triad (Youssef's syndrome) includes:

• Cyclic hematuria (menouria) - blood in urine corresponding to menstrual cycle 1, 2, 5
• Amenorrhea - absence of vaginal menstruation 1, 2
• Urinary incontinence - continuous or intermittent vaginal urine leakage 1, 2, 6

Additional presentations may include:

• Secondary infertility and first-trimester abortions 1, 2
• Recurrent urinary tract infections 3
• Isolated urinary incontinence without other symptoms 6

Treatment Algorithm

Conservative Management (Limited Role)

Conservative management with bladder catheterization for 4-8 weeks should only be attempted when:

• The fistula is discovered immediately after delivery (within days) 1
• The fistula is very small 1
• Success rate is less than 5%, making this approach rarely effective 1, 2

Hormonal management may be attempted in women presenting with Youssef's syndrome before proceeding to surgery 1

Surgical Repair (Definitive Treatment)

Timing of surgery:

• Delay surgery for 2-3 months post-delivery to allow resolution of inflammation, tissue edema, and optimal wound healing 1, 3
• Preoperatively treat any urinary tract infections before surgical repair 1

Surgical approach selection:

• Transperitoneal (transabdominal) approach is the most effective with the lowest relapse rate and should be the preferred method 1, 5, 6
• Transvesical-retroperitoneal approach is an alternative option 1
• Vaginal approach has higher failure rates and is generally not recommended for vesicouterine fistulas 5
• Laparoscopic and robotic-assisted repair are emerging options with comparable results to open surgery for appropriately selected cases 2

Surgical technique:

• Excision of the fistulous tract 6
• Separate closure of bladder and uterine walls in layers 6
• Omental interposition may be used but is not always necessary 6
• Maintain bladder catheterization for 14 days postoperatively 6

Future Reproductive Considerations

Pregnancy outcomes after repair:

• Pregnancy rate after successful repair is 31.25% 1
• Term delivery rate is 25% 1

Mode of delivery after repair:

• Repeat cesarean section is mandatory for all subsequent deliveries to prevent fistula recurrence 1
• Vaginal delivery carries unacceptable risk of fistula recurrence and should be avoided 1

Prevention Strategies

Intraoperative measures during cesarean section:

• Empty the bladder completely before beginning the procedure 1
• Carefully dissect the lower uterine segment with meticulous technique 1
• Consider intraoperative transvaginal or transrectal ultrasound to detect bladder injury immediately if bloody urine appears in the Foley catheter or if there is suspicion of bladder injury during dissection 1
• Immediate repair if injury is detected intraoperatively prevents the need for delayed secondary surgery and associated morbidity 1

Critical Pitfall to Avoid

Do not rely on clinical examination alone - imaging confirmation with CT cystography or MRI is mandatory, as the American College of Radiology emphasizes that imaging is superior to clinical evaluation for detecting fistulous tracts 4