Vesicovaginal fistula

Genitourinary fistula, an abnormal communication between the urinary (ureters, bladder, urethra) and the genital (uterus, cervix, vagina) systems is a serious problem that is associated with quality of life issues, hygiene, social outcasting, has legal ramifications, and potential exposure for additional surgery. Although the true incidence of genitourinary fistulae is unknown, the general consensus is approximately 0.1-2%. The clinical presentation varies, but most present with continuous leakage within days to weeks after the initial insult. The cause is due to obstetric trauma in developing countries and surgical injury in developed parts of the world. The diagnosis is achieved from a thorough history and physical. In addition to the 'tampon' test, radiologic tests provide confirmation, localization and characterization of the fistula. A trial of conservative management including continuous urinary catheter drainage is warranted, especially if the fistula is small and diagnosed early. Surgical management varies and may be approached laparoscopically, vaginally, or abdominally depending on the characteristics of the fistula and expertise of the surgeon. The optimal route of repair has not been determined. However, the basic principles remain the same: hemostasis, layered closure, tension-free repair and continuous post-operative bladder drainage.