Definition and epidemiology
Urogenital fistulas include the following, in descending order of frequency:
- Vesicovaginal fistula
- Ureterovaginal fistula
- Urethrovaginal fistula
- Vesicouterine fistula
- Rectovaginal fistula
- Pelvic surgery
- Pelvic irradiation
- Prolonged/obstructed labour
In the developed world, surgery and irradiation are the most common causes. In the developing world, obstructed labour is the most common cause.
The vesicovaginal fistula is the most common urogenital fistula. It’s a communication between the bladder and the vagina.
Patients present with urine incontinence due to the continuous leakage of urine into the vagina.
Physical examination of the vagina is essential. The opening of the fistula may be visible, and urine leakage may be grossly visible. In cases where the diagnosis is uncertain, we can use a dye test. A dyed sterile fluid (indigo carmine or methylene blue) is instilled into the bladder through a bladder catheter. A tampon is inserted into the vagina and later examined for dye. Cystoscopy may also be used.
If discovered early, the patient should be catheterised for approx. 4 weeks to allow the fistula to heal by itself.
If it doesn’t heal, surgical repair is necessary. The procedure is called the Latzko procedure. The patient should be catheterised for 1 – 2 weeks afterward to let the fistula heal.
The ureterovaginal fistula is a communication between the ureter and the vagina. It also presents with urine incontinence.
Diagnosis is similar as for vesicovaginal fistula. To distinguish between vesicovaginal and ureterovaginal fistulas, we can use two separate dyes of different colours, one administered into the bladder and the other orally or IV. The colour of the dye on the tampon will tell you whether the dye came from the bladder or the ureter.
Percutaneous stenting the affected ureter for some time (1 – 3 months) allows the ureterovaginal fistula to heal. Surgical repair is the second option.
The urethrovaginal fistula is a communication between the urethra and the vagina. The symptoms are as for the previous two fistulas, and the treatment is surgical.
The vesicouterine fistula is a communication between the bladder and the uterus. It mostly occurs after C-section.
It usually presents with urine incontinence due to continuous leakage of urine through the vagina. Conservative treatment with bladder catheterisation causes spontaneous closing of the fistula in only 5% of patient. The secondary treatment is surgical.
The rectovaginal fistula is a communication between the rectum and the vagina. These are rare, but can be secondary to Crohn disease.
Patients may present with gas or faeces in the vagina, and signs of infection.
Nil per os usually allows the fistula to heal after a few weeks. Parenteral nutrition is required in the meantime. The second choice is surgery.
B2. Congenital anomalies of the genital tract (diagnosis and therapy)