Complete article 72 pages for VVF repair click here

Vesicovaginal fistula (VVF)
 

A fistula is an abnormal communication between two epithelial surfaces,
in the case of a VVF, between the bladder and vagina. In 10% of patients
there is a coexisting ureterovaginal fi stula.
 

Etiology
 

In developing countries, most cases are associated with obstructed or
prolonged childbirth, causing tissue pressure necrosis between the vagina
and bladder. In developed countries, 75% of cases follow hysterectomy
(0.1–0.2% risk).
Other causes include pelvic surgery (e.g., bowel resection); radiotherapy;
pessaries; advanced pelvic malignancy (cervical carcinoma); pelvic
endometriosis; inflammatory bowel disease; trauma (pelvic fracture);
childbirth (5%); low estrogen states; infection (urinary TB); and congenital
abnormalities.

Symptoms
 

These include immediate or delayed onset of urinary leakage from the
vagina postoperatively, prolonged bowel ileus (due to leak of urine into
the peritoneal cavity as well as through the vagina), and suprapubic pain
or flank pain.
 

Examination
 

• Vaginal examination may demonstrate the VVF, if large (the examining
finger can reach inside the bladder).

• 3-swab test—oral phenazopyridine turns urine orange. After 1 hour,
place 3 swabs into the vagina and instill methylene blue into the
bladder. If the proximal swab turns blue, it indicates VVF; if it is orange,
it suggests ureterovaginal fistula.
 

• Cystogram (or voiding cystourethrography [VCUG]). This is the best
test for identifying fistulae.
 

• Fistula track may be seen at  cystoscopy  and can help in determining its
proximity to the ureteric orifices. Biopsy the tract if there is a history
of malignancy.
 

• IVP and/or bilateral retrograde pyelograms are essential to assess
ureteral involvement.
 

Management
 

Most cases require surgery. Conservative methods include urethral
catheterization combined with anticholinergics and antibiotics for small,
uncomplicated VVF.

Alternatively, de-epithelization of the tract can be
attempted with silver nitrate or electrocoagulation.
If there is a coexisting ureterovaginal fistula, a ureteric stent alone is
often successful.
 

Surgery
 

Early repair (within 2–3 weeks) is advocated in simple cases, but traditionally,
surgery is delayed 3–6 months.

The transvaginal approach has success
rates of 82–100%. The fistula tract is closed with two layers of sutures and
covered by an anterior vaginal wall flap.

Additionally, interpositional tissue grafts should be mobilized between
the bladder and vagina (Martius fat pad graft from labia majora; peritoneal
flap; gracilis flap).
 

The abdominal approach is reserved for complex cases. The bladder is
bisected to the level of the fistula tract, which is then completely excised
(85–90% success). The bladder is closed and an interpositional omentum
graft created.

In complex cases, urinary diversion procedures may
be needed.
 

Postoperatively, maximal urinary drainage is prudent using a large-bore
Foley catheter and possibly a suprapubic catheter and/or ureteral catheter.
Antibiotic coverage and anticholinergics are maintained for 2 weeks
until catheters are removed.

A VCUG should be performed to document
the absence of extravasation. Give estrogen replacement to postmenopausal
women.

Patients should avoid use of tampons or sexual intercourse
for 2–3 months.
 

Postoperative complications include vaginal bleeding; infection; bladder
pain; dyspareunia due to vaginal stenosis; graft ischemia; ureteric injury;
and recurrence.