Andrew Siegel MD 12/8/2018
The last few entries have been geared towards men. This week’s and next week’s entries address female urogenital maladies. Today I cover a specific type of fistula–an abnormal connection between two body parts that are normally not connected –specifically one that occurs between the bladder and the vagina and that often leads to miserable urinary leakage issues.
By BruceBlaus [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)%5D, from Wikimedia Commons
A vesico-vaginal fistula (VVF) is an abnormal hole or connection between the bladder and the vagina that causes continuous and persistent urinary leakage. Urine from the bladder drains from the fistula into the vagina, resulting in high-volume, continuous urinary leakage out of the vagina.
In the USA the most common cause is gynecological surgery, with abdominal hysterectomy accounting for the majority. Other causes are urological and pelvic surgery, pelvic cancers and radiation therapy. My most recent patient with a VVF had a retained (long forgotten about) pessary used to treat her pelvic organ prolapse, which eroded from the vagina into the urinary bladder creating the fistula.
However, on a worldwide basis, the most common cause of VVF is an obstetrical fistula that occurs in third-world nations, particularly in West Africa. This is the most extreme form of birth trauma, a not uncommon, horrific problem endemic in poverty-stricken countries where pregnant women have poor access to obstetric care. It happens after enduring days of “obstructed” labor, with the baby’s head persistently pushing against the mother’s pelvic bones during labor contractions. This prevents pelvic blood flow and causes tissue death, resulting in a fistula between the vagina and the bladder and/or vagina and rectum. These fistulas are often huge and are totally different entities compared to the fistulas resulting from hysterectomies that are seen in first-world nations. When birth finally occurs, the baby is often stillborn. The long-term consequences for the mother are severe urinary and bowel incontinence, shame and social isolation.
Fistulas can vary in size from tiny, pinpoint fistulas to those that are several centimeters in diameter. A simple fistula is solitary and small in diameter; complex fistulas include those that are large, multiple, recurrent after previous repairs and those associated with pelvic radiation. Most fistulas occur because of tissue “necrosis” (tissue death) and do not cause symptoms for several days to several weeks following the initial instigating surgery. The tissue necrosis is often caused by sutures inadvertently placed in the bladder wall in an effort to control pelvic bleeding.
The classic presentation of a VVF is urinary leakage from the vagina that occurs a few days to a few weeks following a hysterectomy. Evaluation is via pelvic examination in conjunction with cystoscopy (using a small lighted instrument to visualize the bladder) and vaginoscopy (using a small lighted instrument to visualize the vagina). The location, size and number of fistulas present are determined as well as the extent of inflammation associated with the VVF.
Small fistulas may occasionally heal spontaneously with prolonged urinary catheter drainage. Tiny fistulas can sometimes be dealt with via cauterization (searing them with electrical current), although most fistulas will be need to be repaired with surgery.
Surgical repair of a VVF can be via a vaginal or abdominal approach depending on circumstances and surgeon preference. In general, simple fistulas involving the more superficial vagina can be treated using vaginal approaches. Advantages of the vaginal approach are avoiding opening the bladder, minimal blood loss and less post-operative discomfort and the ability to do the procedure on an outpatient basis.
Complex fistulas that involve the deeper vagina can be repaired vaginally, although the abdominal approach is often preferred. Vaginal repair can be facilitated with the use of either a flap of the labial fat pad (Martius repair) or alternatively, with the use of a flap of muscle tissue attached to its blood supply (often gracilis muscle). Nowadays, the abdominal approach is often a robotic-assisted laparoscopic technique that has numerous advantages over the older, open technique.
In either case, important principles of surgical repair of a VVF are the following:
- Waiting a sufficient time period after diagnosis to allow the inflammation and tissue swelling to subside to optimize tissue health and suppleness. The repair should not be attempted if devitalized tissues, infection, inflammation or encrusted deposits on the tissues are present. The timing needs to find middle ground between optimal conditions for closure and the desire to minimize the duration of the annoying and distressing constant urinary leakage.
- Any urinary infection needs to be treated with antibiotics in advance of the surgery
- Topical estrogen can be used to optimize vaginal tissue integrity
- Careful tension-free closure of the VVF in several non-overlapping suture lines (bladder layer and vaginal layer) often with interposition of additional tissue (interposition flaps include omentum or peritoneum for abdominal repairs; peritoneum or labial fat for vaginal repairs) between the bladder and vaginal walls to buttress the repair. A flap of vaginal wall is advanced to cover the repair.
- Urinary catheter for several weeks after the repair for purposes of continuous urinary drainage to facilitate the healing process by keeping the bladder decompressed of urine
- Bladder relaxant medication post-operatively to minimize involuntary bladder contractions
- Post-operative antibiotics
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx
New video on female pelvic floor exercises: Learn about your pelvic floor
Tags: Andrew Siegel MD, fistula, obstetric trauma, urinary incontinence, vesico-vaginal fistula, vesico-vaginal fistula repair
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