Vesicovaginal fistula
Vesicovaginal fistula is an abnormal epithelialized tract between the bladder and vagina that produces continuous, painless leakage of urine from the vagina, most often after pelvic surgery (especially hysterectomy) in resource-rich settings or prolonged obstructed labor in resource-limited settings. Small fistulas found early may heal with prolonged bladder (Foley) catheter drainage; established fistulas require surgical closure, timed to let inflammation resolve.
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What this article covers
- Overview
Definition: a vesicovaginal fistula is an abnormal epithelialized tract connecting the bladder to the vagina, allowing urine to drain continuously through the vagina instead of the urethra.
- Epidemiology
Bimodal cause pattern: the same result, a bladder-vagina communication, arises from two mechanisms depending on setting: iatrogenic pelvic surgical injury where operative gynecologic care is routine…
- Risk factors
Pelvic surgery, especially hysterectomy: prior pelvic surgery is an established driver of later urogenital tract injury; unrecognized bladder injury during hysterectomy is the leading iatrogenic cause.
- Pathophysiology
Direct surgical injury: an unrecognized bladder laceration or suture through the bladder wall during hysterectomy or other pelvic surgery breaks down over the following days as compromised tissue…
- Clinical features
Continuous, painless leakage of urine from the vagina: the hallmark and most reliable feature; unlike stress or urge incontinence, the leakage is unrelenting, present at all times and in all positions, day and night.
- Differential diagnosis
Stress urinary incontinence: leakage occurs only with increased intra-abdominal pressure (cough, sneeze, lifting) and stops between events, unlike the nonstop leak of a fistula.
- Diagnosis
This is confirmed by directly demonstrating urine passing through an abnormal tract into the vagina: the clinching basis is visualizing dye-stained fluid communicating between the bladder and vagina…
- Management
First, drain the bladder continuously with a Foley catheter and reassess in several weeks: for a small fistula identified early (recognized intraoperatively or diagnosed within days of injury)…
- Complications
Recurrence or failure of repair: the most feared complication; operating on inflamed or infected tissue, or repairing too soon after injury, raises the risk of breakdown and recurrence.
- Prognosis
Most fistulas close successfully with appropriately timed surgical repair: definitive closure, performed after inflammation resolves and with a well-vascularized tissue interposition when indicated…
- Prevention
Recognize and repair bladder injury intraoperatively: meticulous bladder dissection during hysterectomy and other pelvic surgery, with a high index of suspicion whenever dissection is difficult…
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