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Vesicovaginal fistula (VVF)

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Vesicovaginal fistula (VVF)

What Is It ?

Vesicovaginal fistula (VVF) is the most common acquired fistula of the urinary tract and has been known since ancient times. This is an abnormal communication between the urinary bladder and vagina leading to continuous leakage of urine.

Symptoms

The most common complaint in patients with VVF is constant urine drainage per vagina. The amount of urine leakage can vary considerably from patient to patient and may be proportional to the size of the fistula. Patients may void a variable amount, depending on the size of the fistula and the volume of urine leakage. For example, when a large VVF is present, patients may not void at all and simply have continuous leakage of urine into the vagina. Small, pinpoint fistulas may present with intermittent wetness that is positional in nature.

In the supine position, when sleeping, the amount of leakage reported by the patient may be minimal; but on rising to a seated or standing position, the amount of leakage may increase precipitously.

Patients may also complain of perineal skin irritation due to constant wetness, vaginal fungal infections, or rarely pelvic pain.

VVF after hysterectomy or other surgical procedures may present on removal of the urethral catheter or 1 to 3 weeks later with urine drainage per vagina. It may be possible to identify some patients at high risk for VVF in the immediate postoperative period.

Signs and Tests

Vital Blue dye testing: The presence of a VVF may be confirmed by instillation of a vital blue dye into the bladder per urethra and observing for discolored vaginal drainage. Small or occult fistulas may be identified in this fashion.

Cystoscopy: An endoscopic examination should be performed in patients in whom a VVF is suspected.

Cystography or voiding cystourethrography: should be performed in patients being evaluated for a VVF. The cystogram may objectively determine the presence and location of the fistula. On filling of the bladder, contrast material often begins to opacify the vagina almost immediately, confirming the presence of a VVF.

Treatment

Treatment for VVF consists of both conservative and surgical management.

Conservative management: In case of small fistulas a trial of indwelling catheterization and anticholinergic medication for at least 2 to 3 weeks may be attempted with newly diagnosed VVF as spontaneous healing may result. This is especially applicable in those patients in whom the initial placement of the catheter immediately resolves the vaginal leakage. Fistulous tracks that remain open 3 weeks or more after adequate Foley drainage are unlikely to resolve without further intervention, especially those that appear completely epithelialized on examination.

Surgical management: Surgical management of VVF can be performed through various approaches namely vaginal or abdominal. The abdominal approach can be performed with open or laparoscopic approach.

 

Causes

The etiology of VVF varies in different parts of the world.

In the developing countries, where routine perinatal obstetric care may be limited, VVF most commonly results from prolonged obstructed labor, with resulting pressure necrosis to the anterior vaginal wall, bladder, bladder neck, and proximal urethra from the baby. The obstructed labor injury complex occurs largely in developing countries in certain cultures because of several factors, including marriage and conception at a very young age, which results in childbearing in a relatively small and immature pelvis; poor nutrition resulting in stunted skeletal (e.g., pelvic) growth in the mother; and absence of qualified prenatal and obstetric care. Patients may suffer with obstructed labor for days in a rural environment, eventually travelling to a distant health care facility only to have a stillborn fetus and a VVF. Risk factors include young or old maternal age and primigravida status.

While in the developed countries, the most common cause (>75%) of VVF is injury to the bladder at the time of gynecologic, urologic, or other pelvic surgery commonly occurs in the setting of hysterectomy and rest are related to general surgery procedures in the pelvis, anterior colporrhaphy or cystocele repair, anti-incontinence surgery, or other urologic procedures.

Other causes of VVF in the industrialized world include malignant disease, pelvic irradiation, and obstetric trauma including forceps lacerations and uterine rupture.
Other causes of VVF are urologic or gynecologic instrumentation, including percutaneous procedures, retroperitoneal, vascular, pelvic surgery; infectious and inflammatory diseases, foreign bodies, including neglected pessaries; congenital VVF, sexual trauma; vaginal laser procedures; and external violence .

The three most common locally advanced malignant neoplasms that result in VVF are

  • cervical
  • vaginal
  • Endometrial carcinomas.