1. Vesicovaginal fistula is an abnormal connection between the bladder and vagina that causes continuous urinary incontinence. 2. It is most commonly caused by prolonged obstructed labor in developing countries, while medical/surgical procedures are more common causes in developed nations. 3. Clinical features include continuous urinary leakage from the vagina. Examination involves identifying the fistula location, size, and involvement of surrounding structures.

1. VESICO-VAGINAL FISTULA
DR. SEEMA NISHAD
MODERATOR- UNIT 1

2. • Definition
• Classification
• Vesicovaginal fistula
• Epidemiology
• Pathophysiology
• Etiology
• Etiopathogenesis
• Classification of VVF
• Symptoms
• Examination findings
• Differential diagnosis
• Investigation
• Prevention
• management

3. FISTULA
• An abnormal passage or communication that
leads from one hollow organ to another.
• Urogenital fistula- abnormal communication
between the urinary (ureters, bladder,
urethra) and the genital (uterus, cervix,
vagina) systems.
• Vesicovaginal fistula is the commonest of all
types.

4. Types of fistulas
1) Congenital- (rare) Due to abnormal fusion of
ureteric bud and the Mullerian duct with the
urogenital sinus or due to abnormal
development of the urorectal septum.
2) Acquired- (based on anatomical site of
communication)- as vesicovaginal,
urethrovaginal, ureterovaginal,
ureterouterine etc.

5. Anatomical communications of various
Urogenital Fistula
URETER BLADDER URETHRA
VAGINA URETERO-
VAGINAL
VESICO-
URETERO-
VAGINAL
VESICO-
VAGINAL
URETHRO-
VAGINAL
CERVIX URETERO-
CERVICAL
VESICO-
CERVICAL
URETHRO-
CERVICAL
UTERUS URETERO-
UTERINE
VESICO-UTERINE NOT REPORTED

7. VESICOVAGINAL FISTULA
• Communication between bladder and vagina,
causing true urinary incontinence.
• Finding of vesicovaginal fistula (VVF) have
been identified in the mummified remains
from ancient Egypt in 1923.
• Most common type of urogenital fistula.

8. Epidemiology
• In Asia and Africa, up to 100000 new cases of
obstetrical genitourinary fistula are added
each year to the estimated pool of 2 million
women with unrepaired fistulas (WHO- 2014)
• The incidence is approximately 0.2-1 % in
developing countries by retrograde data
collection method.
• India lacks prevalence and incidence data on
obstetric fistula.

9. PATHOPHYSIOLOGY
TISSUE DAMAGE AND NECROSIS AFTER INJURY CAUSES INFLAMMATION
PROCESS OF CELL REGENERATION BEGINS
ANGIO-GENESIS STARTS FIRST
FIBROBLASTS PROLIFERATE AND SUBSEQUENTLY SYNTHESIZE AND DEPOSIT
EXTRACELLULAR MATRIX, PARTICULARLY COLLAGEN (FIBROSIS PHASE)
COLLAGEN DEPOSITION PEAKS APPROXIMATELY 7 DAYS AFTER INJURY
AND CONTINUES FOR SEVERAL WEEKS
SUBSEQUENTLY SCAR FORMATION AND ORGANIZATION
(REMODELLING) AUGMENTS WOUND STRENGTH
ANY DISRUPTION IN THIS SEQUENCE EVENTUALLY MAY CREATE A FISTULA
1-3 WEEKS AFTER TISSUE INJURY IS MOST VULNERABLE TIME TO ALTERATION IN HEALING
ENVIRONMENT AS HYPOXIA, ISCHEMIA, MALNUTRITION, RADIATION OR CHEMOTHERAPY.
EDGES OF WOUND EPITHELIALIZE TO FORM CHRONIC FISTULOUS TRACT

10. Etiology of Uro-genital fistula
OBSTETRIC CONDITION
OR PROCEDURES
GYNAECOLOGICAL AND URO-
GYNAECOLOGIC PROCEDURES
PELVIC/MEDICAL
CONDITIONS
• PROLONGED,
OBSTRUCTED LABOR
• PLACENTA PERCRETA
• CESAREAN SECTION
(ESPECIALLY REPEAT
CESAREANS)
• CESAREAN
HYSTERECTOMY
• OPERATIVE VAGINAL
DELIVERY
• CERVICAL CERCLAGE
• GISHRI CUT
• HYSTERECTOMY
• MYOMECTOMY
• LOOP EXCISION OF CERVIX
• VOLUNTARY INTERRUPTION
OF PREGNANCY
• SUBURETHRAL SLINGS
• ANTERIOR COLPORRAPHY
• PERIURETHRAL BULKING
• BURCH COLPOSUSPENSION
• URETHRAL DIVERTICULUM
REPAIR
• URETERAL WALL STENT
• ENDOMETRIOSIS
• GYNAECOLOGIC CANCERS
• PELVIC IRRADIATION
• INFECTION
(SCHISTOSOMIASIS,
TUBERCULOSIS,
LYMPHOURANULOMA
VENERUM)
• INTRAUTERINE DEVICE
• NEGLECTED PESSARY
• RETENTION OF OTHER
VAGINAL FOREIGN OBJECT
• ACCIDENTAL TRAUMA
• SEXUAL TRAUMA
• MITOMYCIN C
INSTILLATION
• BLADDER STONE

11. Etio-pathogenesis
• In developing countries, most common (70 %)
cause is obstetrical due to ischemia or trauma.
• Ischemia result from-
Prolonged compression on the bladder base
between fetal head and symphysis pubis in
obstructed labor Ischemic necrosis
infection sloughing fistula develops in 3-5
days of delivery.
• Traumatic- caused during instrumental vaginal
delivery as forceps application or destructive
operation (craniotomy) or may occur during
cesarean or cesarean hysterectomy.

13. • Gynaecological causes are more common in
developed countries.
• In post-operative cases, rate of fistula formation
with procedure type and its indication, as highest
chance with radical hysterectomy for cervical
cancer and lowest with vaginal hysterectomy for
prolapse.
• Risk factors include cancer stage, intra-operative
bladder injury, diabetes and post-operative
surgical site infection.
• Vaginal cancer shows a high likelihood of fistula
formation (both vesicovaginal and rectovaginal)
with no association with radiotherapy.

14. Obstetric classification system (Elkin 1999)
• High risk vesico-vaginal fistula –
1. Size > 4-5 cm in diameter
2. Involvement of urethra, ureter(s) or rectum
3. Juxta-cervical location
4. Inability to visualize the superior edge
5. Reformation following a failed repair

15. Types of VVF based on complexity (Elkins 1999)
FISTULA SIMPLE COMPLICATED
SIZE ≤ 3 cm > 3 cm
LOCATION HIGH VAGINAL MID VAGINAL
BLADDER
INVOLVEMENT
SUPRA-TRIGONAL TRIGONAL AREA
PELVIC
MALIGNANCY
ABSENT PRESENT
PRIOR RADIATION
THERAPY
ABSENT PRESENT
VAGINAL LENGTH NORMAL SHORTENED

16. Types based on location
TYPE OF FISTULA CHARACTERSTICS
HIGH VAGINAL / JUXTA-CERVICAL /
VAULT FISTULA
PROXIMALLY IN VAGINAL VAULT,
COMMUNICATION WITH SUPRATRIGONAL
AREA
MID-VAGINAL FISTULA PRESENT CENTRALLY IN VAGINA,
COMMUNICATION WITH BASE OR
TRIGONE AREA OF BLADDER
LOW VAGINAL / JUXTA-URETHRAL
FISTULA
COMMUNICATION BETWEEN THE
BLADDER NECK (OR UPPER URETHRA)
AND VAGINA
LOW VAGINAL / SUB-SYMPHYSEAL
FISTULA
CIRCUMFERENTIAL LOSS OF TISSUE IN
THE REGION OF BLADDER NECK AND
URETHRA. THE FISTULA MARGIN IS FIXED
TO THE BONE.

18. Surgical classification (Goh 2004)
• Integrates-
a) fistula distance from the external urethral
meatus
b) fistula size
c) degree of surrounding tissue fibrosis
d) extent of vaginal length reduction
• Good inter- and intra-observer reproducibility
• Efficacy in predicting which patients are at risk
of post-fistula urinary incontinence and failure
of closure.

19. BASIS CHARACTERSTICS
DISTANCE OF DISTAL
EDGE OF FISTULA
FROM THE
EXTERNAL
URETHRAL MEATUS
(IN cm)
TYPE 1: > 3.5 cm
TYPE 2: 2.5 - 3.5 cm
TYPE 3: 1.5 - 2.5 cm
TYPE 4: < 1.5 cm
FISTULA SIZE IN
LARGEST DIAMETER
(IN cm)
(a) SIZE < 1.5 cm
(b) SIZE 1.5 – 3.0 cm
(c) SIZE > 3 cm
DEGREE OF
SURROUNDING
TISSUE FIBROSIS
AND EXTENT OF
VAGINAL LENGTH
REDUCTION
(i) NONE OR ONLY MILD FIBROSIS (AROUND FISTULA &/OR
VAGINA) &/OR VAGINAL LENGTH > 6 cm, NORMAL
CAPACITY.
(ii) MODERATE OR SEVERE FIBROSIS (AROUND FISTULA &/OR
VAGINA) &/OR REDUCED VAGINAL LENGTH &/OR
CAPACITY
(iii) SPECIAL CONSIDERATION, e.g. POST-RADIATION, URETERIC
INVOLVEMENT, CIRCUMFERENTIAL FISTULA OR PREVIOUS
REPAIR

20. Symptoms
• Classical symptom- unexplained continuous
urinary leakage from vagina after a recent
operation or difficult vaginal delivery or local
trauma.
• If fistula is small, escape of urine occurs in certain
positions and patient can also pass urine
normally.
• Urine leakage occurs from 1st postoperative day if
caused by direct surgical injury.
• Urinary leakage starts after 7-14 days of obstetric
injury.
• After laparoscopic surgery, it may present after
days to weeks.

21. • The patient may present with recurrent
cystitis or pyelonephritis; unexplained fever;
hematuria; flank, vaginal or suprapubic pain;
and abnormal urinary stream.
• Irritation of the vagina, vulvar mucosa, and
perineum follows, and women report a foul
ammoniacal odor.
• If urine leakage persists, severe perineal
dermatitis may result due to exposure of skin
to ammonia.

22. • As urea is split by vaginal flora, the vaginal pH
becomes alkaline, which precipitates greenish-
gray phosphate crystals in the vagina and on the
vulva. These crystals serve to further irritate what
already may be compromised tissue.
• Large vaginal encrustations are seen with fistulae
secondary to neglected vaginal foreign bodies.
• This constant leakage of urine may make the
patient a social recluse; disrupt sexual relations;
and lead to depression, low self-esteem, and
insomnia.

23. On examination
• Local examination-
a) Extra-urethral urine leakage i.e. Escape of
ammonia smelling watery discharge through
vagina
b) Sodden and excoriated vulvar skin
c) Varying degree of perineal tears
• Vaginal fluid’s creatinine content (> 17 mg/dl) can
differentiate urine from vaginal discharge.

25. • Per speculum examination-
1) Site, size and number of fistula.
2) If small fistula, only a puckered area is seen
on anterior vaginal wall mucosa.
3) Complete perineal tear and recto-vaginal
fistula can be present.
4) Metal catheter can be passed through the
external urethral meatus into the bladder and
if it comes out through the fistula, it confirms
VVF and patency of urethra.

26. • Associated clinical features like foot drop (due
to prolonged compression of the sacral nerve
roots by fetal head during labor), complete
perineal tear or rectovaginal fistula may be
present.

27. Differential diagnosis
1. Uro-genital fistula
2. Stress incontinence
3. Urge incontinence
4. Overflow incontinence
5. Vaginal discharge
6. Erosion of mesh

28. To confirm the diagnosis-
1. Examination under anaesthesia- may be
needed for better visualization.
2. Sim’s or knee chest position during
examination are helpful.
3. Metal catheter can be passed through the
external urethral meatus into the bladder
and if it comes out through the fistula, it
confirms VVF and patency of urethra.
4. Dye test
5. 3 swab (tampon) test

30. Investigation
• Cystourethroscopy- confirms the diagnosis. The
added information are – exact level, number and
location of the fistula and its relation to ureteric
orifices and bladder neck.
• Intravenous urography- for diagnosis of
ureterovaginal fistula.
• Retrograde pyelography-for diagnosis of exact
site of ureterovaginal fistula.
• Voiding cystourethrography- can detect leak in
vagina.

31. Diagnosis
• Age
• Parity
• Comorbidities (DM, HTN, post-
hysterectomy/post-cesarean)
• Simple/complex
• Size
• Position
• Type

32. PREVENTION

33. Primary prevention (preventing a cystotomy)
• Avoid blunt dissection at the time of mobilization
of bladder during hysterectomy or anterior repair,
especially when the vesicovaginal space is scarred
from the prior cesarean section or other surgery.
• The precise direction of force cannot be
controlled accurately when blunt dissection is
used, when compared with sharp dissection.
• Gentle traction and countertraction are helpful in
dissecting the correct plane and thereby
preventing direct bladder injury.

34. • Direct trauma by retractors, particularly
during vaginal hysterectomy may occur. So,
retractors should always be used with
appropriate caution.
• Detrimental effect of using monopolar
electrocautery may be the cause, so one
should consider its use in vesicovaginal space
only after carefully considering the risk and
benefits.

35. Secondary prevention (early detection and repair)
• Suspicion of bladder injury per-operatively
occurs when-
1. New onset gross hematuria, while the
bladder is catheterized.
2. Visualization of fluid in operative field.
• Routine cystoscopy is not recommended by
any guideline but should be done in
suspicious cases per-operatively.

36. • Cystotomy repair-
1. Evaluate cystoscopically and vaginally to
assess the size, location in relation to ureter
and trigone and quality of injured tissue.
2. Ureteral catheterization is needed if injury
close to ureters.
3. Bladder should be catheterized with trans
urethral catheter (folley’s)
4. Use of fine surgical techniques, delicate
tissue handling and use of suction and
irrigation during optimizing visualization.

37. 5. Avoid prolonged clamping of injured tissue
during repair and avoid electro-cautery near
the injury.
6. Sharply dissect the vesico-vaginal space
sufficiently to allow tension free closure.
7. Close the urothelial layer with interrupted or
running fine 3-0 delayed absorbable suture.
8. Re-appoximate the muscular layer with
running or interrupted 2-0 or 3-0 delayed
absorbable suture. Ensure haemostasis.
9. Reinforce repair with third layer of
peritoneum using interrupted 3-0 delayed
absorbable suture.

38. 10. Ensure integrity of repair and ensure intra-
vesical hemostasis. Cystoscopy should be
done with minimum bladder filling.
11. Close vaginal injury separately making
certain that bladder is not incorporated with
vaginal repair.
12. Transurethral or suprapubic bladder
drainage to prevent bladder filling to avoid
tension on suture line.
13. Determine how long bladder catheterization
is needed and ensure orders are written to
avoid inadvertent routine catheter removal on
the following day.

39. MANAGEMENT

40. Non-surgical management
1. Trans-urethral bladder drainage- particularly
used for small fistulas (< 1 cm) that present
early (< 3 weeks) and have no evidence of
epithelialization of fistula tract. Drainage is
done for 4 – 6 weeks.
2. Optimizing nutrition, correcting anemia and
improving vaginal estrogenization.
3. Use of collection devices for temporary relief
from constant urinary leakage till permanent
solution.

41. Conservative surgical management
1. Cystoscopic laser treatment- very limited
success and only in small (2-4 mm)
supratrigonal fistulas.
2. Fibrin glue- first attempted in 1979 with
success. Since then it is used successfully.
3. Autologous platelet-rich plasma- most
recent. It was injected trans-vaginally with
interposition of platelet rich fibrin to
successfully treat 11 out of 12 iatrogenic VVF.

42. Surgical management
• Indication – when conservative therapy fails or patient
is not a candidate for conservative therapy.
• Principles of surgery-
1. Correct pre-operative assessment and preparation
2. Timely repair
3. Perfect asepsis and good exposure of fistula
4. Excision (minimal) of scar tissue at margins
5. Presence of healthy vascular margin
6. Mobilization of bladder wall from the vagina
7. Tension free repair in 2 layers
8. Fine suture material
9. Minimal use of electrocautery
10. Post-operative bladder drainage

43. Preoperative assessment
• Fistula status- site, size, number, mobility,
extent of fibrosis at margins
• Urethral involvement
• Position of ureteric openings in relation to big
fistula by cystoscopy
• Exclude associated rectovaginal fistula or
complete perineal tear.
• Complete hemogram and kidney function
tests.

44. Criteria for successful repair (WHO 2006)
CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSIS
NUMBER OF FISTULA SINGLE MULTIPLE
SITE VESICOVAGINAL FISTULA RECTOVAGINAL FISTULA
(RVF), MIXED (VVF AND
RVF)
SIZE < 4 CM >4 CM
URETHRAL INVOLVEMENT ABSENT PRESENT
VAGINAL SCARRING ABSENT PRESENT
TISSUE LOSS MINIMAL EXTENSIVE
URETER INVOLVEMENT URETERO-VAGINAL
FISTULA PRESENT
NO URETERO-VAGINAL
FISTULA
CIRCUMFERENTIAL DEFECT
(URETHRA SEPARATED
FROM BLADDER)
ABSENT PRESENT

45. Preoperative preparation
• Improvement of general condition and anemia
• Ensure good nutrition
• Treat local infection in vulva and vagina
• Treatment of urinary infection. May give urinary
antiseptics at least 3-5 days prior to surgery.
• To clean the area with vinegar to dissolve and
remove phosphate crystals and then application
of zinc oxide ointment for healing of excoriation
at vulva.

46. Various routes of fistula repair
1. Abdominal
2. Vaginal
3. Trans-peritoneal
4. Trans-vesical
5. Laparoscopic
Indication for Trans-peritoneal and Trans-vesical
approaches-
A. Fistula located high up and vagina is narrow
B. Fistula close to ureteric openings
C. Previous failed repair
D. Large or complex fistula
E. When an interposition graft is needed.

47. Vaginal approach
Latzko technique- steps are as follows-
1. Stay sutures are placed to help stabilize and
bring the fistula distally towards the operating
surgeon
2. Vaginal epithelium sharply dissected and excised
circumferentially about the fistula
3. completed epithelial excision around the fistula
4. Fistulous tract is imbricated into the bladder
cavity with sequential layers of interrupted 3-0
or 4-0 delayed absorbable suture.
5. First extra-mucosal layer closure of vagina
6. Closure of the vaginal epithelium.

49. Saucerisation:
1. Evolution of surgical management of urogenital
fistula was made by Morison Sims in 19th
century.
2. Original Marion Sims’ technique used for a very
small fistula, particularly for residual fistula after
previous surgery.
3. A bevelled cut through the vagina to the small
visceral aperture should clear scar tissue to
allow healthy tissues for apposition.

51. Abdominal approach
Retro-pubic intra-vesical VVF repair-
1. Retroperitoneal anterior bladder incision
2. Fistula is identified and circumscribed and
vesico-vaginal space is dissected radially.
3. First layer incorporates the vaginal epithelium in
a vertical closure using interrupted sutures.
4. Bladder muscularis is closed with interrupted
suture in a horizontal orientation.
5. Urothelium is closed with fine interrupted
suture to complete the repair.
6. The anterior bladder incision is closed in layers.

53. Trans-peritoneal trans-vesical VVF repair-
1. The bladder is incised midline from its anterior
portion back posteriorly until the fistula is
reached, the fistula is excised and ureters are
protected.
2. Dissection of vesico-vaginal space distal to the
fistula to allow tension free closure in layers.
3. Vagina is closed transversely with the
interrupted delayed absorbable suture with the
knots located inside the vagina. A second layer
of vaginal closure is done to imbricate the first
layer.

56. 4. The dependant portion of the bladder is usually
closed side to side with the interrupted double-
layer closure of the bladder without tension.
5. The rest of the bladder incision is closed with
running suture in 2 layers.
6. Prior to complete closure of bladder, a
suprapubic catheter is placed through a separate
stab incision.
7. Omental flap (partially detached by severing its
vasculature on the left along the curvature of
stomach) is anchored in vesico-vaginal space.
8. Cystoscopy is done to verify watertight closure
and ensure intravesical hemostasis.

57. Martius (bulbocavernosus) fat pad
transposition-
1. An incision is made over the labial fat pad
dissected bluntly and with electrocautery
ensuring adequate hemostasis and a
continued blood supply from the chosen
pedicle (anteriorly from external pudendal
and posteriorly from internal pudendal
artery).
2. A submucosal tunnel is created and enlarged
to ensure adequate blood flow to the tip of
the graft.

58. • The graft is carefully pulled through the tunnel
to the area needed and sutured in place.
• Hemostasis of donor site is verified and then
skin and vaginal mucosa incisions are closed.

60. Post-operative care
1. Urinary antiseptics
2. Continuous bladder drainage for about 10-14
days.
3. Nursing care for fluid balance, urine output and
to detect any catheter block
4. 1 hourly urine output charting
5. Check pH of urine twice daily.
6. Always keep urine acidic to avoid crystalization
of phosphate and stone formation.
7. Early ambulation to prevent DVT
8. Pelvic rest for 12 weeks
9. Prevention of constipation

61. Advice on discharge
• To pass urine more frequently.
• To avoid intercourse for at least 3 months
• To defer pregnancy for at least 1 year.
• If conception occurs, mandatory antenatal
checkups and hospital delivery by cesarean
section.

62. In case of repair failure
• Repair should again be attempted after 3
months.