A 33-year old woman presented with urinary leakage for 4 months following an emergency C-section and hysterectomy. She developed leakage after her catheter was removed, using 10 diapers per day. Examination found a urinary fistula opening in her vagina. Tests showed a urinary tract infection and imaging located a 3cm fistula above her right ureter. She was diagnosed with a vesicovaginal fistula likely caused by her previous surgeries.

1. Case Presentation
33 year old Lactating female came with
C/o Urinary Leak since 4 months

2. History of Presenting Illness
• Patient was apparently alright 4 months back,
when she underwent Emergency LSCS +
Hysterectomy in her 9th month of pregnancy
(Ind: Placenta Previa)
• Post Procedure she was on catheter for 21
days.
• No urinary complaints during that time.

3. • After catheter removal she C/o urinary leak
- Intermittent
- Increases on minor posture change, standing,
coughing
- H/o Diapers use (~10/day)
- No urge to pass urine
- No H/o regular voiding
• These symptoms persisted for 15 days,
following which the patient underwent re-
catheterisation.

4. • Urinary leak decreased post catheterisation
- Intermittent, on standing and walking
- H/o Sanitary Pad use 4-5/day
• No H/o Urinary leak per rectum
• No H/o Fecal Incontinence/Constipation
• No H/o Fever
• No H/o dysuria
• No H/o Loin Pain

5. Past H/o
LSCS- 8 years back
No H/o DM, HTN, TB, Asthma
No H/o Urinary complaints in the past
Obstetric History - P2L2
Menstrual History - Past Cycles normal and
regular
Family History- nothing significant

6. Personal History – Appetite
Mixed Diet
Normal Bowel Habits
Normal Sleep Pattern

7. General Examination
• Moderately built and well nourished
• No pallor, Icterus, cyanosis, clubbing,
lymphadenopathy or pedal edema.
Vitals-
Pulse Rate- 84 bpm
Blood Pressure- 130/80 mm Hg
Temperature -98.4 F

8. Systemic Examination
Abdomen
Inspection
• Umbilicus is inverted, centrally placed
• All quadrants moving equally with respiration
• Transverse midline scar present in lower
abdomen
Palpation
• Soft, non-tender
• Bladder not palpable

9. Pelvic Examination
Inspection – 16 Fr Catheter in situ
Urethral meatus normal in location
Vaginal mucosa normal
No cystocele/rectocele
Pooling of urine in vagina +
PV urinary leak + on coughing

10. P/V - Opening palpated on right side of fornix
with surrounding Induration
- No fornicial tenderness
- No Adnexal mass palpated
DRE – Perineal sensation intact
Anal tone –Normal
No induration/ opening felt
CVS – S1 S2 +, no abnormal sounds
RS- Normal Breath Sounds +
CNS- No abnormality detected

11. Investigations
Hb- 11.5 g/dl
S. Creatinine – 0.75 mg/dl
Urine Culture – Klebsiella Species growth +
Colony Count > 100,000 col/ml

12. IVP

13. Cystoscopy Findings:
• Fistulous Opening of the size 3cm seen
supratrigonal just above the right ureteric
orifice.
• Trigone deformed with left ureteric orifice
pulled to the right side.
• Scar tissue seen at the right posterior wall
around the opening, close to the right orifice.
• Methylene Blue Dye instillated in bladder,
staining the vaginal pack.

14. CT Urogram

15. Delayed