History

Fact Explanation
A history of a predisposing condition The commonest predisposing condition is prolonged, obstructed labor. The pathophysiology is; pressure necrosis of the anterior vaginal wall and underlying bladder neck or urethra occurs as the tissues are compressed between the fetal head and the posterior surface of the symphysis pubis ,and the necrotic tissue sloughs away and is expelled after approximately 10 days, at which point incontinence ensues. The other known causes of fistulae are surgical injury (i.e. in bladder neck or pelvic surgeries, adhesiolysis), pelvic irradiation, endometriosis and anatomical distortions of the pelvis (i.e. large fibroids). The surgeries that pose a higher risk are hysterectomy (75% of cases) and urological or lower gastrointestinal pelvic surgery(2%). The causes for poor wound healing (i.e. anemia, chronic steroid use) are also contributing factors. [1, 2, 3, 4, 5, 6, 7, 8]
Leaking of urine from vagina It is a very embarrassing condition, and the females usually present about one to two weeks following a surgical insult. [1, 7]
Hematuria of urine leaking in the post-operative period Continuing hematuria or urine leaking in the post-operative period can raise the suspicion of a surgical insult and an impending vaginal fistula. [9, 10, 11, 12, 13, 14]
References
  1. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.65400
  2. KUMAR S, KEKRE NS, GOPALAKRISHNAN G. Vesicovaginal fistula: An update Indian J Urol [online] 2007, 23(2):187-191 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.32073
  3. KAPOOR R, ANSARI MS, SINGH P, GUPTA P, KHURANA N, MANDHANI A, DUBEY D, SRIVASTAVA A, KUMAR A. Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach Indian J Urol [online] 2007, 23(4):372-376 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.36709
  4. LATZKO WILLIAM. Postoperative vesicovaginal fistulas. The American Journal of Surgery [online] 1942 November, 58(2):211-228 [viewed 26 August 2014] Available from: doi:10.1016/S0002-9610(42)90009-6
  5. TABAKOV I.D., SLAVCHEV B.N.. Large Post-Hysterectomy and Post-Radiation Vesicovaginal Fistulas:: Repair by Ileocystoplasty. The Journal of Urology [online] 2004 January, 171(1):272-274 [viewed 26 August 2014] Available from: doi:10.1097/01.ju.0000101801.95459.54
  6. MOON SG, KIM SH, LEE HJ, MOON MH, MYUNG JS. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings Korean J Radiol [online] 2001, 2(2):97-104 [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97
  7. RANDAWA A, KHALID L, ABBAS A. Diagnosis and Management of Ureterovaginal Fistula in a Resource-Constrained Setting: Experience at a District Hospital in Northern Nigeria Libyan J Med [online] , 4(1):41-43 [viewed 26 August 2014] Available from: doi:10.4176/081101
  8. RAJAMAHESHWARI N, SEETHALAKSHMI K, VARGHESE L. Menouria due to congenital vesicovaginal fistula associated with complex genitourinary malformation Indian J Urol [online] 2009, 25(4):534-536 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.57924
  9. SINGH A, KUMAR M, SHARMA S. Iatrogenic urethrovaginal fistula with transverse vaginal septum presenting as cyclical hematuria Indian J Urol [online] 2011, 27(4):547-549 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.91451
  10. CHIN ARNOLD I., RUTMAN MATTHEW, RAZ SHLOMO. Transverse Vaginal Septum with Congenital Vesical-Vaginal Communication and Cyclical Hematuria. Urology [online] 2007 March, 69(3):575.e5-575.e7 [viewed 26 August 2014] Available from: doi:10.1016/j.urology.2007.01.001
  11. MOON SG, KIM SH, LEE HJ, MOON MH, MYUNG JS. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings Korean J Radiol [online] 2001, 2(2):97-104 [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97
  12. MEEKS G. G., ROTH TED M.. Vesicovaginal and Urethrovaginal Fistulas. GLOWM [online] 2009 December [viewed 26 August 2014] Available from: doi:10.3843/GLOWM.10064
  13. WIT ESTHER M. K., HORENBLAS SIMON. Urological complications after treatment of cervical cancer. Nat Rev Urol [online] December, 11(2):110-117 [viewed 26 August 2014] Available from: doi:10.1038/nrurol.2013.323
  14. ANGIOLI ROBERTO, PENALVER MANUEL, MUZII LUDOVICO, MENDEZ LUIS, MIRHASHEMI RAMIN, BELLATI FILIPPO, CROCè CLARA, PANICI PIERLUIGI BENEDETTI. Guidelines of how to manage vesicovaginal fistula. Critical Reviews in Oncology/Hematology [online] 2003 December, 48(3):295-304 [viewed 26 August 2014] Available from: doi:10.1016/S1040-8428(03)00123-9

Examination

Fact Explanation
Surgical scar The females who present with vesicovaginal fistula or ureterovaginal fistula are most probably presenting following a surgery in the pelvis. The scar could be obvious. (i.e. pfenestiel scar, laparoscopy scar). [1, 2, 3, 4]
Urine leaking from the vagina In detailed gynecological examination, urine leaking from the vagina might be obvious. [2, 5]
Perineal dermatitis Due to chronic leakage of urine and skin irritation. [6]
References
  1. KAPOOR R, ANSARI MS, SINGH P, GUPTA P, KHURANA N, MANDHANI A, DUBEY D, SRIVASTAVA A, KUMAR A. Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach Indian J Urol [online] 2007, 23(4):372-376 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.36709
  2. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.65400
  3. TABAKOV I.D., SLAVCHEV B.N.. Large Post-Hysterectomy and Post-Radiation Vesicovaginal Fistulas:: Repair by Ileocystoplasty. The Journal of Urology [online] 2004 January, 171(1):272-274 [viewed 26 August 2014] Available from: doi:10.1097/01.ju.0000101801.95459.54
  4. MOON SG, KIM SH, LEE HJ, MOON MH, MYUNG JS. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings Korean J Radiol [online] 2001, 2(2):97-104 [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97
  5. RANDAWA A, KHALID L, ABBAS A. Diagnosis and Management of Ureterovaginal Fistula in a Resource-Constrained Setting: Experience at a District Hospital in Northern Nigeria Libyan J Med [online] , 4(1):41-43 [viewed 26 August 2014] Available from: doi:10.4176/081101
  6. MOON SUNG GYU, KIM SEUNG HYUP, LEE HAK JONG, MOON MIN HOAN, MYUNG JAE SUNG. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings. Korean J Radiol [online] 2001 December [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97

Differential Diagnoses

Fact Explanation
Vaginitis or cervicitis Infection/ inflammation of the vagina or cervix can lead to discharge form the vagina, mistakenly identified as urine. Simple speculum examination will show inflammatory process that is going on. If in a doubt, microbiological studies will confirm the pathogens. [1, 2, 3, 4, 5, 6]
Peritoneal vaginal fistula It's a very rare and unique condition, can be a result of pelvic surgeries, and usually heals spontaneously. The dye tests are negative in this condition. [7, 8]
Cervical carcinoma Last, but the most important differential, especially where the patients present with an insidious onset vaginal discharge. Cervical cytology should be investigated immediately. [9,10]
References
  1. VERSTRAELEN HANS, VERHELST RITA, VANEECHOUTTE MARIO, TEMMERMAN MARLEEN. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. Arch Gynecol Obstet [online] December, 284(1):95-98 [viewed 27 August 2014] Available from: doi:10.1007/s00404-011-1861-6
  2. CARR PL, FELSENSTEIN D, FRIEDMAN RH. Evaluation and Management of Vaginitis J Gen Intern Med [online] 1998 May, 13(5):335-346 [viewed 27 August 2014] Available from: doi:10.1046/j.1525-1497.1998.00101.x
  3. HAINER BL, GIBSON MV. Vaginitis. Am Fam Physician [online] 2011 Apr 1, 83(7):807-15 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524046
  4. SURESH A, RAJESH A, BHAT RM, RAI Y. Cytolytic vaginosis: A review Indian J Sex Transm Dis [online] 2009, 30(1):48-50 [viewed 27 August 2014] Available from: doi:10.4103/0253-7184.55490
  5. KELLY K.G. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 179-Tests on Vaginal Discharge. [web] [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK288/
  6. CHANDEYING V, SKOV S, KEMAPUNMANUS M, LAW M, GEATER A, ROWE P. Evaluation of two clinical protocols for the management of women with vaginal discharge in southern Thailand. Sex Transm Infect [online] 1998 Jun, 74(3):194-201 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9849555
  7. BLANDER DANIEL S, ZIMMERN PHILIPPE E, LEMACK GARY E, SAGALOWSKY ARTHUR I. Transvaginal repair of postcystectomy peritoneovaginal fistulae. Urology [online] 2000 August, 56(2):320-321 [viewed 27 August 2014] Available from: doi:10.1016/S0090-4295(00)00569-0
  8. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.65400
  9. BHATLA N, MUKHOPADHYAY A, KRIPLANI A, PANDEY RM, GRAVITT PE, SHAH KV, IYER VK, VERMA K. Evaluation of adjunctive tests for cervical cancer screening in low resource settings. Indian J Cancer [online] 2007 Apr-Jun, 44(2):51-5 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17938481
  10. KARIMI ZARCHI M, MOUSAVI A, MALEKZADEH M, DEHGHANI A, BEHNAMFAR Z, GODARZI A. Conservative treatment in young patients with cervical cancer: a review. Asian Pac J Cancer Prev [online] 2010, 11(3):589-94 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21039021

Investigations - for Diagnosis

Fact Explanation
Three-swab test The diagnostic investigation for ureterovaginal fistula. [1, 2, 3]
Double dye test It is a confirmatory test for vesicovaginal fistula, this involves inserting a urinary catheter, filling the bladder with dye, clamping the catheter, and observing if the dye leaks through the vagina via the fistula. [4, 5]
Cystoscopy Can be used to view site, size, number of fistulae. [6, 7]
Magnetic Resonance Imaging Indicated when there is a suspicion of neoplasm causing multiple fistulae or there is bizzarre anatomy and closer study of it is necessary before closing the fistula. [8, 9, 10]
References
  1. NERLI RB, REDDY M. Transvesicoscopic Repair of Vesicovaginal Fistula Diagn Ther Endosc [online] 2010:760348 [viewed 26 August 2014] Available from: doi:10.1155/2010/760348
  2. RANDAWA A, KHALID L, ABBAS A. Diagnosis and Management of Ureterovaginal Fistula in a Resource-Constrained Setting: Experience at a District Hospital in Northern Nigeria Libyan J Med [online] , 4(1):41-43 [viewed 26 August 2014] Available from: doi:10.4176/081101
  3. KAMAT NAGESH. Vesico-vaginal fistula. BJU Int [online] 2005 July, 96(1):192-192 [viewed 26 August 2014] Available from: doi:10.1111/j.1464-410X.2005.05656_4.x
  4. TAYLER-SMITH K, ZACHARIAH R, MANZI M, VAN DEN BOOGAARD W, VANDEBORNE A, BISHINGA A, DE PLECKER E, LAMBERT V, CHRISTIAENS B, SINABAJIJE G, TRELLES M, GOETGHEBUER S, REID T, HARRIES A. Obstetric Fistula in Burundi: a comprehensive approach to managing women with this neglected disease BMC Pregnancy Childbirth [online] :164 [viewed 26 August 2014] Available from: doi:10.1186/1471-2393-13-164
  5. HANASH KAMAL A., AL ZAHRANI HASSAN, MOKHTAR ALAA A., ASLAM MUHAMMAD. Retrograde Vaginal Methylene Blue Injection for Localization of Complex Urinary Fistulas. Journal of Endourology [online] 2003 December, 17(10):941-943 [viewed 26 August 2014] Available from: doi:10.1089/089277903772036334
  6. KUMAR S, KEKRE NS, GOPALAKRISHNAN G. Vesicovaginal fistula: An update Indian J Urol [online] 2007, 23(2):187-191 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.32073
  7. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.65400
  8. MOON SG, KIM SH, LEE HJ, MOON MH, MYUNG JS. Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings Korean J Radiol [online] 2001, 2(2):97-104 [viewed 26 August 2014] Available from: doi:10.3348/kjr.2001.2.2.97
  9. ABOU-EL-GHAR ME, EL-ASSMY AM, REFAIE HF, EL-DIASTY TA. Radiological diagnosis of vesicouterine fistula: role of magnetic resonance imaging. J Magn Reson Imaging [online] 2012 Aug, 36(2):438-42 [viewed 26 August 2014] Available from: doi:10.1002/jmri.23667
  10. ARBOE MD, TEITELBAUM DH, DILLMAN JR. Combined 3D rotational fluoroscopic-MRI cloacagram procedure defines luminal and extraluminal pelvic anatomy prior to surgical reconstruction of cloacal and other complex pelvic malformations. Pediatr Surg Int [online] 2012 Aug, 28(8):757-63 [viewed 26 August 2014] Available from: doi:10.1007/s00383-012-3122-6

Investigations - Fitness for Management

Fact Explanation
Complete blood count To exclude anemia, infection and thrombocytopenia before the surgical management option. [1, 2]
References
  1. APIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65
  2. BLUMENREICH MS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition [web]; Chapter 153, The White Blood Cell and Differential Count. [viewed 08 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/

Management - General Measures

Fact Explanation
Awaiting spontaneous closure of the fistula For smaller vesicovaginal defects. Meanwhile drainage of the bladder with catheters should be done. [1]
Patient education and reassuring Plays a major role since effortless urinary incontinence can affect a woman's life badly. Reassurance that the defect can be corrected and the course of the healing should be done. [2, 3, 4, 5, 6, 7]
References
  1. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 26 August 2014] Available from: doi:10.4103/0970-1591.65400
  2. DAVITS R. J. A. M., MIRANDA S. I.. Conservative Treatment of Vesicovaginal Fistulas by Bladder Drainage Alone. [online] 1991 August, 68(2):155-156 [viewed 26 August 2014] Available from: doi:10.1111/j.1464-410X.1991.tb15285.x
  3. HASSAN MA, EKELE BA. Vesicovaginal fistula: Do the patients know the cause?. Ann Afr Med [online] 2009 December [viewed 27 August 2014] Available from: doi:10.4103/1596-3519.56241
  4. JOSHI S, BHALERAO A, SOMALWAR S, CHAUDHARY S. A rare case of irreparable vesico-vaginal fistula of 45 years duration successfully managed by urinary diversion J Midlife Health [online] 2011, 2(1):37-39 [viewed 27 August 2014] Available from: doi:10.4103/0976-7800.83272
  5. SCHIMPF MO, MORGENSTERN JH, TULIKANGAS PK, WAGNER JR. Vesicovaginal Fistula Repair Without Intentional Cystotomy Using the Laparoscopic Robotic Approach: a Case Report JSLS [online] 2007, 11(3):378-380 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015832
  6. MOORE KATHLEEN N., GOLD MICHAEL A., MCMEEKIN D. SCOTT, ZORN KRISTIN K.. Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma. Gynecologic Oncology [online] 2007 September, 106(3):498-501 [viewed 27 August 2014] Available from: doi:10.1016/j.ygyno.2007.04.030
  7. WALL L LEWIS. Obstetric vesicovaginal fistula as an international public-health problem. The Lancet [online] 2006 September, 368(9542):1201-1209 [viewed 27 August 2014] Available from: doi:10.1016/S0140-6736(06)69476-2

Management - Specific Treatments

Fact Explanation
Glue injection Injecting platelet rich plasma and platelet rich fibrin glue in a transvesican or transvaginal route is a safe, effective and minimally invasive approach for the treatment of urinary tract fistulae which obviate the need for open surgery since it can be done by endoscopy also. Fibrin glue is attractive as a tissue sealant because it prevents fibrosis and promotes healing through its effects on fibroblasts and collagen synthesis. [1, 2, 3, 4, 5]
Tension free surgical repair The surgical correction should not be delayed unless there is an inflammation of infection present, since urinary incontinence can have devastating effect on a woman's life. The repair can be done in transabdominal or transvaginal route but the first has the highest success rate, but the latter is associated with rapid recovery. The principles of surgical correction are removal of debris and inflammatory material, creating a tension free flap (i.e. Latzko procedure, Martius flap) and promoting optimal conditions for wound healing. (i.e. correction of anemia) Laparoscopic repair has been known to present the success rate of transabdominal approach of open surgery. Rotational bladder flap can be used for multiple or large fistulae. [4, 5, 6, 7, 8, 9, 10]
References
  1. SHIRVAN MALIHEH KESHVARI, ALAMDARI DARYOUSH HAMIDI, GHOREIFI ALIREZA. A Novel Method for Iatrogenic Vesicovaginal Fistula Treatment: Autologous Platelet Rich Plasma Injection and Platelet Rich Fibrin Glue Interposition. The Journal of Urology [online] 2013 June, 189(6):2125-2129 [viewed 27 August 2014] Available from: doi:10.1016/j.juro.2012.12.064
  2. D'ARCY FRANK T., JAFFRY SYED. The treatment of vesicovaginal fıstula by endoscopic injection of fıbrin glue. The Surgeon [online] 2010 June, 8(3):174-176 [viewed 27 August 2014] Available from: doi:10.1016/j.surge.2009.10.018
  3. SHARMA SAMEER K., PERRY KENT T., TURK THOMAS M.T.. Endoscopic Injection of Fibrin Glue for the Treatment of Urinary-Tract Pathology. Journal of Endourology [online] 2005 April, 19(3):419-423 [viewed 27 August 2014] Available from: doi:10.1089/end.2005.19.419
  4. GOPALAKRISHNAN GANESH, KUMAR SANTOSH, KEKRE NITINS. Vesicovaginal fistula: An update. Indian J Urol [online] 2007 December [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.32073
  5. MIRANDA EDUARDO PAULA, RIBEIRO GUSTAVO PINTO, ALMEIDA DIEGO COSTA, SCAFURI ARIEL GUSTAVO. Percutaneous injection of fibrin glue resolves persistent nephrocutaneous fistula complicating colonic perforation after percutaneous nephrolithotripsy. Clinics [online] 2009 December, 64(7):711-713 [viewed 27 August 2014] Available from: doi:10.1590/S1807-59322009000700017
  6. GARTHWAITE M, HARRIS N. Vesicovaginal fistulae Indian J Urol [online] 2010, 26(2):253-256 [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.65400
  7. KAPOOR R, ANSARI MS, SINGH P, GUPTA P, KHURANA N, MANDHANI A, DUBEY D, SRIVASTAVA A, KUMAR A. Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach Indian J Urol [online] 2007, 23(4):372-376 [viewed 27 August 2014] Available from: doi:10.4103/0970-1591.36709
  8. BLAIVAS JERRY G., HERITZ DIANNE M., ROMANZI LAURI J.. Early Versus Late Repair of Vesicovaginal Fistulas: Vaginal and Abdominal Approaches. The Journal of Urology [online] 1995 April, 153(4):1110-1113 [viewed 27 August 2014] Available from: doi:10.1016/S0022-5347(01)67522-0
  9. EZZAT MAHMOUD, EZZAT MOHAMMED M., TRAN VIET Q., ABOSEIF SHERIF R.. Repair of Giant Vesicovaginal Fistulas. The Journal of Urology [online] 2009 March, 181(3):1184-1188 [viewed 27 August 2014] Available from: doi:10.1016/j.juro.2008.10.152
  10. ANGIOLI ROBERTO, PENALVER MANUEL, MUZII LUDOVICO, MENDEZ LUIS, MIRHASHEMI RAMIN, BELLATI FILIPPO, CROCè CLARA, PANICI PIERLUIGI BENEDETTI. Guidelines of how to manage vesicovaginal fistula. Critical Reviews in Oncology/Hematology [online] 2003 December, 48(3):295-304 [viewed 27 August 2014] Available from: doi:10.1016/S1040-8428(03)00123-9