Vesicouterine fistulae are uncommon, with most units reporting 1–5 cases over 5–15 year periods. To date there has been a paucity of case reports regarding this problem and only a few case series. In this report we outline the presentation and management of a vesicouterine fistula complicating a repeat Cesarean delivery, specifically describing the role of transvaginal ultrasound.

1. Ultrasound Obstet Gynecol 2005; 26: 183–185
Published online 5 July 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.1925
Vesicouterine fistula following Cesarean
delivery – ultrasound diagnosis and surgical management
M. ALKATIB, A. V. M. FRANCO and M. M. FYNES
Department of Pelvic Reconstructive Surgery and Urogynaecology, St George’s Hospital Medical School, London, UK
KEYWORDS: Cesarean section; ultrasound; vesicouterine fistula
ABSTRACT
Vesicouterine fistulae are uncommon, with most units
reporting 1–5 cases over 5–15-year periods. To date there
has been a paucity of case reports regarding this problem
and only a few case series. In this report we outline the
presentation and management of a vesicouterine fistula
complicating a repeat Cesarean delivery, specifically
describing the role of transvaginal ultrasound. Copyright
 2005 ISUOG. Published by John Wiley & Sons, Ltd.
CASE REPORT
A 33-year-old multiparous patient underwent a repeat
lower segment Cesarean section at 41 + 4 weeks’ gesta-
tion for fetal distress at 8 cm dilatation. Delivery was
uneventful although marked edema of the bladder, which
was adherent to the lower uterine segment, was noted. A
Foley catheter was inserted at the time of the Cesarean
and removed the following day. The patient then reported
urinary urgency, frequency, small volumes of urine, supra-
pubic pain and occasional urge incontinence. Based on
these findings and a positive mid-stream urine (MSU)
culture a urinary infection was diagnosed, antibiotics
commenced, and the patient discharged.
Following discharge, the patient had continuing
urinary symptoms and began to feel unwell. Ten days
postoperation she presented to the acute gynecology unit
with urinary frequency, urgency, hematuria, suprapubic
discomfort and urinary incontinence. On examination,
the patient was apyrexial. There was edema around the
Cesarean incision and a serous exudate but no evidence
of cellulitis. The abdomen was distended and tender but
with no peritonism. Bowel sounds were normal, the uterus
was well contracted and the bladder was not palpable.
Vaginal examination was unremarkable, with red-stained
serous lochia.
Transvaginal sonography using a 5-MHz probe
(GE200 base system; GE Medical Systems, Bedford,
UK) demonstrated free fluid in the pouch of Douglas
(68 × 44 mm) (Figure 1), a bladder containing a large
amount of debris, fluid in the uterine cavity and a
communicating tract measuring 3.15 mm in diameter
between the posterior bladder wall and the lower uterine
segment (Figure 2). These findings suggested that urine
was leaking from the bladder into the uterine and
peritoneal cavities with possible exudation through the
abdominal incision. A diagnosis of a vesicouterine fistula
was made. Methylene blue was injected into the bladder
through a catheter and dye was observed leaking through
the cervix. An MSU sample and wound and high vaginal
swabs were sent for culture. Intravenous urography
demonstrated the fistula and an undiagnosed duplex
system on the left, with no evidence of hydronephrosis or
ureteric injury.
A urethral catheter was left on free drainage for 14 days.
As wound swabs grew multi-resistant Staphylococcus
aureus, appropriate antibiotics were started and a repeat
evaluation was delayed for a further 14 days. At this
time the patient was reviewed at the urogynecology unit.
Repeat ultrasonography demonstrated a persistent fistula.
A cystometrogram using urografin demonstrated leakage
of contrast per vaginam and confirmed a 3.4-mm fistula
tract (Figure 3). Renal function was normal.
A laparotomy revealed free fluid within the abdominal
cavity, a bulky and erythematous uterus and a bladder
adherent to the lower uterine segment over the previous
Cesarean incision. A 4-cm cystotomy was performed
postero-inferior to the dome of the bladder. The vesical
portion of the fistula was identified on the posterior
wall of the bladder 3–4 cm superior to the interureteric
ridge and appeared to run obliquely through the bladder
wall surrounded by an area of induration. Ureteric
catheters were inserted. The peritoneal aspect of the
Correspondence to: Dr M. M. Fynes, Department of Pelvic Reconstructive Surgery and Urogynaecology, 4th Floor Lanesborough Wing, St
George’s Hospital, Tooting, London SW17 0RE, UK (e-mail: michellefynes@yahoo.co.uk)
Accepted: 17 March 2005
Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd. CASE REPORT

2. 184 Alkatib et al.
Figure 1 Transvaginal ultrasound scan (6.5-MHz) showing free
fluid in the pouch of Douglas (POD).
Figure 2 Transvaginal ultrasound scan (6.5-MHz) demonstrating a
large amount of debris within the bladder and a communicating
tract indicated by the arrow between the posterior bladder wall and
the lower uterine segment. The soft tissue of the fistula tract
measures 3.15 mm in diameter.
Figure 3 Cystogram demonstrating the fistula tract. (a) Coronal
view; (b) sagittal view.
bladder wall was dissected off the uterine wall. At
the site of the uterine Cesarean incision, the fistula
tract was identified surrounded by an area of necrotic
myometrium. A wide dissection was performed, necrotic
tissue excised and the uterus closed in two layers. The
vesical portion of the fistula tract was then excised with
the indurated bladder tissue and sent to histopathology.
The ureteric catheters were removed and the bladder
closed in two layers. An omental graft was anchored
without tension between the bladder and the uterine
closure sites and a urethral catheter was left on free
drainage for 14 days. Uroflowmetry and residual volume
tests performed subsequently were normal.
Histopathology demonstrated normal bladder tissue
containing a sinus tract lined by inflammatory cells,
histiocytes, and numerous well-formed epithelioid gran-
ulomata containing central necrosis and foreign material
which were consistent with transfixion of the bladder with
suture material at the time of the Cesarean section. The
patient was followed up 3 and 6 months after surgery and
has no symptoms of urinary leakage, voiding difficulty or
any other irritative symptoms.
DISCUSSION
Injury to the lower urinary tract is an uncommon
(0.1–0.3%) but significant complication associated with
Cesarean delivery1,2
. Unrecognized bladder injury may
resolve spontaneously with catheterization or persist,
leading to fistula formation. Vesicouterine fistulae
represent 1–4% of all reported urogenital fistulae3
. Most
units report 1–5 cases over 5–15-year periods4–7
. To
date, there is a paucity of reports regarding this problem.
With rising Cesarean section rates across Europe, the
management of this complication is important from both
clinical and medicolegal aspects.
The causes of peripartum bladder and uterine injury
resulting in fistula formation are nearly always iatrogenic.
Risk factors include delivery in the late first or second
stages of labor wherein injury may arise because of
difficulty or inadequate reflection of the bladder from
the lower uterine segment. Excessive intraoperative
bleeding may also cause injury from attempts to achieve
hemostasis, and may involve the distal ureter. Other risk
factors include severe dystocia, forceps delivery, manual
removal of the placenta, placenta percreta, uterine rupture
and previous Cesarean section3–9
. In an analysis of 24
vesicouterine fistulae, 87.5% followed operative delivery,
of which two-thirds had had a previous section7
. The
development of fistulae is believed to relate to higher
attachment of the bladder relative to the lower segment
secondary to scarring from previous surgery. With an
unrecognized bladder injury or suture transfixion of the
bladder, a tract may develop between the bladder and
uterine incision. With previous surgery, poor blood supply
may predispose to defective tissue healing.
Women presenting with vesicouterine fistulae in the
early postpartum period complain of voiding difficulty
and/or urinary incontinence. Low-grade pyrexia and
urinary sepsis are often present. If unrecognized, women
with the condition may develop menouria with the passage
of lochia or, at a later stage, menstrual blood; the latter
Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2005; 26: 183–185.

3. Vesicouterine fistula following Cesarean delivery 185
was first described by Youssef in 19579
. Hematuria can
be difficult to diagnose in the early postpartum period as
urine is often contaminated by lochia. In the present case,
the patient presented with irritative bladder symptoms
and incontinence immediately postdelivery. An early
abdominal ultrasound scan was performed and significant
amounts of fluid were noted in the peritoneal cavity in the
presence of an empty bladder. These should have raised
the suspicion of a fistula, and a contrast urogram may
have been indicated at this point.
The diagnosis of fistula is based on clinical examina-
tion and radiological investigations. In this case the serous
wound exudate, edema around the incision and abdomi-
nal distension were suspicious but not diagnostic findings.
Radiological investigations remain the ‘gold standard’ for
diagnosis, particularly the use of contrast techniques such
as an intravenous urogram or cystometrogram. However,
apart from the inherent risk associated with radiation,
the introduction of contrast may be uncomfortable and
associated with a risk of anaphylaxis.
Ultrasonography has been suggested as an alternative
diagnostic technique, but there is a paucity of data
supporting its use. Czaplicki et al., reporting on 11
cases of vesicouterine fistula, visualized the fistula
sonographically in 5 of 6 cases10
. A case report
by Park et al. delineated a vesicouterine fistula using
both ultrasound and sonohysterography11. Adetiloye
and Dare reported on a series of 22 women with 24
vesicovaginal fistulae diagnosed by contrast radiography
who subsequently underwent transabdominal ultrasound
examination12
. Identification of the fistula was possible
in only 29% of cases. The reduced pick-up by
ultrasonography was related to poor bladder filling with
large fistulae (> 3 cm) resulting in the absence of an
acoustic window, poor resolution in women with a very
small fistula tract (< 0.9 cm) despite adequate bladder
filling, or poor imaging because of body habitus.
Data are limited on the role of transvaginal sonography
in the diagnosis of postpartum vesicouterine fistulae
but with improvements in imaging technology this
approach requires further evaluation. In our report,
transvaginal imaging allowed accurate identification of
a small fistula tract. This was aided by the presence
of fluid within the bladder and endometrial cavity. The
measurements on ultrasonography correlated well with
those on cystography and surgery. Another supportive
finding included the presence of fluid in the pouch
of Douglas. Although this is common after Cesarean
delivery, the amount in this case was excessive considering
the duration since delivery. It may be argued that contrast
radiography could have been avoided as the diagnosis
was confirmed by a methylene blue test, and upper
renal tract involvement could have been evaluated by
ultrasonography.
In cases of small fistulae identified postpartum, free
drainage and antibiotics for 14–28 days may result
in spontaneous closure. Where conservative treatment
fails or in the presence of a large fistula, surgical
closure is required. Both transabdominal and transvesical
approaches have been described. The latter normally
involves fulguration of the vesical opening8. However, as
these fistulae are normally associated with tissue ischemia,
failure or recurrence rates are high. Transabdominal
correction gives superior results and usually involves
excision of the tract8. In our case we excised the tract and,
to minimize the risk of failure or recurrence, reinforced
the repair with a graft.
Despite successful fistula closure, many women com-
plain of ongoing irritable bladder symptoms or inconti-
nence. These may arise because of widespread detrusor
injury or excision of large portions of the detrusor to
facilitate the closure of healthy tissue. In this case, the
patient made a full recovery and has no ongoing bladder
symptoms. Careful monitoring will be required in subse-
quent pregnancies as there is a small but potential risk of
scar dehiscence and/or recurrent fistula.
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