Obstetric and Gynecologic Genitourinary Fistulas - BINASSS
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CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 64, Number 2, 321–330
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Obstetric and
Gynecologic
Genitourinary Fistulas
MEGAN ABRAMS, MD, MPH,*
and RACHEL POPE, MD, MPH†
*Department of Female Pelvic Medicine and Reconstructive
Surgery, University Hospitals Cleveland Medical Center;
and †Urology Institute, University Hospitals Cleveland Medical
Center, Cleveland, Ohio
Abstract: Urinary incontinence shortly after childbirth can be multifactorial and confusing to the
or gynecologic surgery can be the result of obstetric or unsuspecting medical provider. While ves-
iatrogenic fistula formation. This can be a confusing and
challenging diagnosis for medical providers. While the icovaginal fistulas are rare, they occur after
number of iatrogenic fistula cases is rising worldwide, 0.08% of hysterectomies in the United
obstetric fistulas are an issue uniquely particular to States.1 Ureteral injury which may result
resource poor settings. Appropriate treatment of genito- in ureterovaginal fistulas occur in 0.02% to
urinary fistulas spans beyond surgical intervention of 0.33% of hysterectomies.2 Globally, genito-
leakage, and includes re-integration into the community,
widespread education and counseling, and battling social urinary fistulas occur at much higher rates.
stigma and cultural biases. Current and future research Approximately 2 million women cur-
must focus on rigorous, unified efforts to set evidence- rently live with an obstetric-related urinary
based practices to help the millions of women affected. fistula. One systematic review found an
Key words: obstetric fistula, vesicovaginal fistula, incidence of up to 4 cases of obstetric fistula
iatrogenic fistula
per 1000 deliveries and a prevalence of up to
81 obstetric fistula cases per 1000 women.3
While these estimates are on the higher end,
there is a lack of robust data on incidence
Introduction and prevalence.
Urinary incontinence presenting shortly As the quality of obstetric care increases
after childbirth or gynecologic surgery globally through the improved access to
cesarean deliveries, iatrogenic fistulas ap-
Correspondence: Rachel Pope, MD, MPH, Urology pear to increase. However, because of the
Institute, University Hospitals Cleveland Medical Cen-
ter, Cleveland, OH. E-mail: rachel.pope@uhhospitals. lack of data on fistulas in general, we do not
org know if iatrogenic cases outnumber obstet-
The authors declare that they have nothing to disclose. ric cases. Therefore, improved access to
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 64 / NUMBER 2 / JUNE 2021
www.clinicalobgyn.com | 321
Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.
322 Abrams and Pope
surgery and enhanced surgical technique are intraoperative ureteral injuries, including
necessary across the board. lacerations, transection, crushing, avul-
sion, suture ligation, or ischemia, lead to
urinomas, and potential drainage from
Gynecologic Genitourinary the vaginal cuff, leading to a ureterovagi-
nal fistula. This is most often the lower
Fistulas third of the ureter, and may be the result
While obstetric fistulas are relatively un- of bleeding intraoperatively which ob-
known in resource-rich settings, iatrogenic scures the operative field, a markedly
genitourinary fistulas are known complica- enlarged uterus, or pelvic adhesions be-
tion of gynecologic surgeries, and recent cause of prior surgery.
studies have shown a growing incidence of Diagnosing an iatrogenic fistula requires
iatrogenic fistula throughout the world.4 a thorough history, physical exam, and a
Genitorurinary fistulas can occur during ob- high level of suspicion. Timing and presen-
stetric or gynecologic surgery because of the tation vary widely from patient to patient
close proximity of the bladder, ureters, uterus, and is dependent on etiology and location of
and vagina and cause an abnormal commu- the injury. Some fistulas present immedi-
nication between the bladder or ureter and ately after inciting trauma with leakage of
the uterus, cervix, or vagina. While any urine from the vagina; however, iatrogenic
surgery carries the risk of injury to nearby fistulas resulting from surgical intervention
structures, fistula formation is a known may take up to 30 days postoperatively to
complication of several obstetric and gyneco- present.5 This is because of the slower
logic procedures. Common obstetric and process of devascularization as a result
gynecologic procedures, which may result in suture, clamp, or thermal injury, which
genitourinary fistulas include cesarean deliv- leads to necrosis and tract formation over
ery, uterine rupture, and hysterectomy.4 time. Iatrogenic fistulas because of other
Postsurgical fistulas tend to be small, causes, like radiation therapy, may take
isolated, and surrounded by healthy tis- months or years to develop. The evaluation
sue. In the United States, 80% of vesico- of size, number, and exact location of the
vaginal fistulas are caused by benign fistula is important for diagnosis and surgi-
gynecologic surgeries.5 Urinary tract in- cal planning.
juries occur in ∼3/1000 gynecologic
surgeries.5 Other risk-factors include a DIAGNOSING VESICOVAGINAL AND
history of pelvic irradiation, gynecologic URETEROVAGINAL FISTULAS
malignancy, endometriosis, pelvic inflam- Patients with a vesicovaginal and ureter-
matory disease, infection, trauma, foreign ovaginal fistulas typically present several
bodies, or history of pelvic surgery.6 days to months after a pelvic operation with
Possible mechanisms of fistula devel- continuous leakage of urine through the
opment include direct injury to the tissue vagina. This warrants a prompt physical
during a surgical procedure or suboptimal exam. Using a speculum, the vagina should
placement or use of surgical instruments be carefully inspected. If a hole or defect is
while dissecting or clamping. Sutures identified, the surrounding mucosa may be
placed too close to the bladder or ureter erythematous or inflamed. Patient rarely
may also lead to necrosis and fistula cannot tolerate office exam and require
formation. Though rare, fistula formation anesthesia. A careful physical exam is nec-
has also been reported after uterine per- essary to evaluate for acute inflammation,
foration at the time of dilation and cur- edema, necrosis, or other bladder pathol-
retage or hysteroscopy or after procedures ogy, any of which may delay surgery.
utilizing synthetic mesh.6 Unrecognized Evidence of scarring, fixation to adjacent
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organs, or postirradiation involvement may and inspected to identify suspected vesico-
alter the surgical approach. If a vesicovagi- vaginal, ureterovaginal, or both vesico and
nal fistula is identified, one must also ureterovaginal fistulas. Figure 2 displays
evaluate to ensure there is not a concom- several possible outcomes of the double
itant ureteral injury. dye tampon test. A dry, colorless tampon
The standard office test for diagnosis of a suggests that there is not a fistula and other
suspected fistula is the double dye tampon sources of incontinence should be consid-
test. This allows the surgeon to identify if the ered. If only the distal edge of the tampon is
patient has a vesicovaginal fistula, ureter- blue and the top is dry, stress incontinence
ovaginal fistula, or both in the office setting. or transurethral urine leakage should be
The patient is given 200 mg oral phenazo- considered (as in first image). A damp,
pyridine at least 30 minutes before test to colorless tampon suggests a peritoneal fis-
dye the urine orange. The bladder is then tula or even cuff dehiscence if a hysterec-
retrograde filled with ∼250 mL of saline tomy was performed during the original
dyed blue with methylene blue or indigo surgery. A damp, blue tampon (last image)
carmine. For large vesicovaginal fistulas, suggests a vesicovaginal fistula. If the tam-
blue dye can often be seen pooling in the pon is orange, a diagnosis of ureterovaginal
vagina immediately (Fig. 1). After removal fistula is likely, while a damp tampon with
of the catheter, a tampon is placed into the both blue and orange dyes suggests that
vagina, and the patient is allowed to ambu- patient may have both a vesicovaginal and
late for 30 minutes without voiding. It is ureterovaginal fistula. If either a vesicova-
important that the patient not void during ginal or ureterovaginal fistula is suspected
the test as urine can wick on the tampon and referral to urogyneoclogy or urology is
obscure the results. The tampon is removed appropriate.
A myriad of other tests and imaging may
be utilized to further characterize and/or
confirm lower urinary tract fistulas. Cysto-
scopy is often performed to evaluate the size
and location of the fistulous tract, its rela-
tionship to the ureteral orifices, and the
health of the surrounding urothelium, all
of which guide the surgeon in when and
how to repair the fistula. Leukocytosis may
be seen on complete blood count. If there is
fluid pooling in the posterior vagina, it can
be sent for creatinine and compared with
serum creatinine levels. Markedly higher
levels of creatinine in the vaginal fluid than
serum suggest urine can confirm urinary
leakage; however, it does not differentiate
bladder and ureteral fistulas. A study by
Thayalan et al remarked that these addi-
tional tests often incurred high expense
while not yielding useful additional infor-
mation after a physical exam and double
dye test have established the presence of a
vesicovaginal fistula.7 Additional imaging
should be ordered with discretion by the
FIGURE 1. Dye test with methylene blue.
diagnosing physician to evaluate other
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FIGURE 2. Tampon dye test.
pelvic abnormalities and the ureters. surgery is optimal for patient outcomes
When additional imaging is ordered, we and decreases litigation. Intraoperative
recommend computed tomography (CT) cystoscopy has a 97% detection rate for
urogram rather than CT with intravenous lower urinary tract injury at the time of
contrast or ultrasound. To accurately eval- hysterectomy and should be done rou-
uate to the distal ureter, the delayed images tinely after hysterectomy.8 Cystoscopy is
obtained with urography are essential. A also associated with better litigation out-
CT with intravenous contrast or ultrasound comes. Unfortunately, however, not all
can miss a distal ureteral injury. This will lower urinary tract injuries can or will be
avoid delay of diagnosis and referral to a identified at the time of surgery and may
urogynecologic surgeon or urologist. go on to fistulize.
When disease of the upper urinary tracts
is suspected, CT urogram or magnetic TREATMENT OF VESICOVAGINAL
resonance imaging is used to further char- FISTULA
acterize the fistula. Retrograde pyelography Most posthysterectomy vesicovaginal fistu-
and voiding cystourethrogam may demon- las are repaired primarily, but multiple
strate ureteral abnormalities. Findings on repairs are sometimes necessary. Small ves-
imaging that may suggest ureteric fistula icovaginal fistulas may resolve with place-
include extravasation of dye, hydronephro- ment of an indwelling bladder catheter for 4
sis, or a persistent column of contrast in the to 6 weeks. Most experts recommend im-
ureter. CT findings may include contrast mediate early repair if the fistula is identified
within the vagina, detection of air/fluid in in the first 7 to 10 days after the initial
the vagina, or the fistulous tract itself. surgery; however, if the vesicovaginal fistula
Imaging may also identify radiation or is diagnosed after this time frame, repair
anatomic changes, pelvic masses, or adher- should be postponed for ∼6 weeks and until
ent thickened bowel, any of which will affect the surrounding vaginal epithelium and
surgical planning. urothelium appear healthy.
Vesicovaginal fistulas can be repaired
MANAGEMENT OF GENITOURINARY using transvaginal or minimally invasive
FISTULAS abdominal routes of access. Regardless,
Identification and management of a gen- several important principles apply. It is
itourinary injury at the time of the initial essential to have adequate visualization of
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the fistula and excellent mobilization of surgery; and 1 had a 1-year delay in
the fistula from surrounding tissues. A diagnosis. Therefore, in the majority of
two-layer closure is typically performed women who sustain ureterovaginal fistu-
ensuring the repair is not left under any las after hysterectomy, ureteral stenting is
tension. If the surrounding tissues do not an effective first line therapy.
have adequate vascular supply, surgeons When endourologic management of
often consider placement of vascular in- ureterovaginal fistula is not successful or
terposition flaps (omentum if the repair is appropriate, surgical intervention is nec-
abdominal and martius graft if it is essary. This may be accomplished by
vaginal). Prolonged bladder drainage for reimplanting the ureter into the bladder
2 to 3 weeks is recommended. or reanastomosis of the injured ureter.
Given that damage is most commonly in
TREATMENT OF URETEROVAGINAL the lower 1/3 of the ureter after gyneco-
FISTULA logic surgery, ureteral reimplantation
Treatment of ureterovaginal fistula revolves through ureteroneocystotomy is the most
around resolution of urinary leakage, pre- effective surgical correction. In this cir-
vention of urosepsis, and preservation of cumstance, the ureter is identified at the
renal function.9 Partial ureteral obstruction pelvic brim and mobilized to the fistula
is commonly present, and therefore drainage site. The distal end of the ureter is trans-
of the affected upper urinary tract is essential. ected, and any scarring or devitalized
If a surgical subspecialist is not available, tissue excised. The ureter is spatulated
gynecologists can consider referral to inter- and reimplanted into the posterior blad-
ventional radiology for temporary manage- der near the dome under no tension.
ment. Interventional radiologist can place a Adjuvant procedures, such as a psoas
percutaneous nephrostomy tube and/or ante- hitch or Boari flap, may be utilized to
rograde ureteral stent.10 facilitate ureteroneocystotomy repair
Expert opinion regarding optimal without tension.9 In the rare instance
management of ureterovaginal fistulas where direct reimplantation is not feasi-
varies with some recommending surgical ble, end-to-end or end-to-side anastomo-
repair or ureteral reimplanation11–13 and ses of ureteral segments may be
others advocating for endourologic man- considered to repair the defect.
agement as first line treatment.9,10 Most
commonly, the patient will initially be
taken to the operating room for retro- Obstetric Fistulas
grade pyelography and ureteral stent Obstetric fistulas occur rarely in devel-
placement. We recommend evaluating oped countries, but are prevalent in re-
both ureters and kidneys. A recent case source poor areas of the world. In much
series reported outcomes of 19 cases of of sub-Saharan Africa and south Asia,
ureterovaginal fistula after obstetric or women deliver infants in facilities that
gynecologic surgery (18 after hysterec- lack electricity, basic surgical instruments
tomy and 1 after cesarean delivery) at a and materials, and personnel to provide
single academic center.9 Twelve of the timely and high-quality obstetric inter-
ureterovaginal fistulas were managed ventions such as a cesarean delivery in
with initial ureteral stenting, which was the case of obstructed labor. The result is
successful in 92% of the patients. Primary often death of the neonate and at times,
ureteral reimplantation was selected in 6 the mother. Those who survive the diffi-
patients for the following reasons: 3 had a cult childbirth may develop a vesicovagi-
concomitant vesicovaginal fistula, 2 were nal fistula because of the fetal head
identified intraoperatively at the index applying constant pressure on the pelvic
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.326 Abrams and Pope
tissues, interrupting the normal blood cutting, have been attributed to increasing
supply. The tissues under pressure will the risk for developing a fistula. However,
eventually necrose and slough off, leaving if these individuals receive access to intra-
the fistula usually between the bladder or partum obstetric services, they would
bladder neck and the vagina. In the worst likely not develop fistulas. While child
cases, this connection continues into the marriage and genital cutting should come
rectum, and resulting in urinary and rectal to an end to protect the rights of girls and
fistulas. women, obstetric fistula will only come to
These patients present with uncontrol- an end if poor women are prioritized in
lable urinary leakage and often do under- improving access to health care and if
stand its mechanism. In an effort to obstetric interventions are improved
reduce the urinary leakage, women often worldwide.
avoid drinking water, which in turn
causes the urine to have a more concen- MEDICAL SEQUELAE
trated putrid odor. For these women, Obstetric fistula can be seen as a larger
even the most understanding partners injury “complex,” incorporating vesico-
and family members find it difficult to vaginal fistula, rectovaginal fistula, stress
share close quarters with them. As coping incontinence, renal involvement, secon-
with the incontinence is often not possible dary infertility, vaginal stenosis, and foot-
while working, many women experience a drop, and other physical ailments that
lifetime of disability and social isolation. often accompany obstetric fistulas.15 Sim-
Obstetric fistula has been described as ilarly, psychosocial effects and economic
“the worst problem you have never heard detriment have also been documented, all
of,” (http://www.operationfistula.org). Co- contributing to the injury complex. Ap-
lloquially shortened to “fistula,” it is a proximately 90% of all births during
problem often overlooked that leads to which obstetric fistulas occurs are accom-
deep social embarrassment. The women panied by stillbirth.16 Wilson et al17 found
affected either limit their interactions in that women with fistulas are more likely
their communities or spend most of their to be depressed, experience post-trau-
lives hiding their incontinence. In some matic stress disorder, have somatic com-
contexts where fistula exists, communities plaints, and lack a social network.
blame the woman for her child dying, and Community qualitative studies have dem-
then she is blamed for the subsequent onstrated a deep layer of secrecy sur-
uncontrollable leakage of urine. rounding obstetric fistulas and surgical
Obstetric fistulas in low-resource set- repair. Barriers to accessing repair con-
tings are largely caused by obstructed tinue to be unveiled in multiple countries.
labor and could be prevented by high Baker et al18 found that financial barriers
quality and skilled monitoring of labor were the most frequently mentioned
and timely operative delivery. The women (65%).
affected by fistula are generally of low
socioeconomic status, with little to no
education and often experience social Treatment of Obstetric Fistulas
isolation and stigma as a result of the
fistula. Browning et al14 examined phys- CATHETER PREVENTION
ical attributes as risks for fistula and In 1841, Ryan in London described spon-
found those affected are significantly taneously closing fistulas by keeping pa-
shorter and have a smaller pelvic inter- tients on their face or side, tying a catheter
tuberous space. Cultural patterns, such into the bladder and tamponing the vag-
as young age of marriage and genital ina with oiled lint. We still recommended
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prolonged catheter drainage to facilitate junior surgeons, and visiting surgeons
spontaneous vesicovaginal fistula healing, take into consideration the additional
especially when the fistula is recognized trauma a failed repair presents to a
soon after it develops. Prolonged catheter woman who has been suffering from
drainage can be utilized for prevention in incontinence and also consider the de-
individuals at high risk of developing a creased chance for healing with subse-
fistula. Waaldijk reports healing rates of quent attempts before choosing to take on
15% with prolonged, early catheterization the surgery and not refer to a surgeon
as conservative management of obstetric experienced in closing complex obstetric
fistuas.19 fistulas.
REPAIRING VESICOVAGINAL CLASSIFICATION
FISTULAS Frajzyngier et al23 examined prognostic
Traditionally, surgeons have waited three values of classification systems and found
months from delivery to operate on wom- them to be “poor to fair.” Bengtson et al24
en with vesicovaginal fistulas so that any looked for prediction of incontinence
spontaneous closure may occur, and after surgery using Goh’s classification.
granulation tissue is no longer present. Using a scoring algorithm based on clin-
Some surgeons, however, advocate for ical and demographic characteristics, they
operating on “fresh fistulas” rather than found age above 50 years, length of time
waiting. In cases of newly identified fistu- with a fistula above 20 years, previous
las, Waaldjik19 published on immediate surgical attempts, advanced Goh classifi-
surgery after catheterization for 3 months. cation relative to the urethra, moderate to
The catheter is kept until the fistula edge severe scarring, circumferential fistula,
is no longer necrotic at which time the and urethral length of 1.5 cm or less were
fistula is repaired. Outcomes using this all highly associated with residual incon-
timing for repair were highly successful at tinence. The authors suggest using the
91.8% (n = 156). Short interval from fis- scoring tool before surgery to guide diag-
tula development to repair could greatly nostic purposes and to assist with refer-
decrease stigma and the social consequen- ring complex patients to expert-level
ces of living with an obstetric fistula. surgeons.
PREDICTORS FOR SUCCESS and REPAIR TECHNIQUE
FAILURE Vaginal approach to vesicovaginal fistula
Reported rates of successful surgical clo- closer is generally described in the liter-
sure of obstetric fistulas are high (84% to ature and preferred by most surgeons.25
94%), but increasingly complex fistulas The type of suture and number of layers
are less likely to heal.20,21 Repair out- of closure have not been studied in a
comes are associated with duration of the systematic way, but retrospective data
fistula before surgery, fistula size, circum- demonstrates no superiority of 2 layers
ferential fistulas or those with urethral when controlled for bladder size.26 Cir-
involvement, and moderate to severe vag- cumferential fistulas appear to occur after
inal scarring.21 Women with large fistulas longer and potentially more severely ob-
( > 3 cm) are 6 times more likely to fail structed labor (see Fig. 3). More bladder
repair (P < 0.01).22 Previously failed at- tissue is lost and vaginal scarring is often
tempts suggest that patients may not be also more severe with circumferential
properly triaged or referred to surgeons fistulas resulting in residual incontinence
with expertise in repairing complex cases. more frequently.27 Repeat procedures are
It is imperative that training programs, common after failed closure, and some
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Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved.328 Abrams and Pope
FIGURE 3. Circumferential fistula.
authors argue that an interpositional increase in diameter of fistula].30 Kopp
layer with a new vascular supply in the et al31 examined 346 women after repair to
form of a gracilis flap should be used as determine a significant pad weight for
the Martius graft has not demonstrated incontinence. They determined that a
improvements in patient outcomes.28,29 1-hour pad weight after catheter removal
The first attempt is still widely considered of > 1.5 g had a positive predictive value of
to be the best chance for success and 94% (confidence interval: 90.0-96.9) in pre-
therefore, triaging cases according to dicting ongoing continence. Sexual dysfunc-
surgical skill would optimize outcomes. tion is a challenge for a significant
proportion of patients after surgery. Of
RISKS FOR ONGOING INCONTINENCE 102 patients interviewed, 23 (22.5%) re-
and SOLUTIONS ported not being able to engage in penetra-
Defining “cure” after obstetric fistula repair tive vaginal intercourse and 12 (52%) of
is not straight forward as many of these these patients ascribed this to a “narrow”
women have severe transurethral urine leak- vagina.32 Reconstructive techniques to im-
age after the fistula is repaired. While a dye prove the quality of vaginal reconstruction
tampon test can help differentiate between a and sexual function are imperative to im-
healed fistula and urethral leakage, not all prove quality of life.33
surgeons perform dye tests at the time of
catheter removal. Browning reported that
persistent urinary leakage after obstetric Conclusion
fistula repair was associated with the follow- Genitourinary fistulas in developed coun-
ing: fistula involving the urethra [odds ratio tries are uncommon and most often a
(OR): 8.4 (3.9-17.9)], small bladder (< 5 cm sequalae of pelvic surgery and hysterec-
depth from external ureteral orifice) [OR: tomy. Early identification and manage-
4.1 (1.2-13.8)], vaginal scarring [OR: 2.4 ment are essential to optimize outcomes
(1.5-4.0)], and larger fistula size [increase for patients and minimize litigation.
OR: 1.3 (1.16-1.56) with each centimeter In contrast, genitourinary fistulas in
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developing countries are often related to 14. Browning A, Lewis A, Whiteside S. Predicting
obstetrics and obstructed labor. women at risk for developing obstetric fistula: a
fistula index? An observational study comparison
of two cohorts. BJOG. 2014;121:604–609.
15. Arrowsmith S, Hamlin EC, Wall LL. Obstructed
labor injury complex: obstetric fistula formation
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