An abnormal opening of, or connection to, a urinary tract organ is called a fistula. There are many types of fistulas, but all types are devastating as they lead to increased morbidity and diminished physical activity. The vesicouterine fistula occurs between the uterus and the bladder and is between the vagina and the urinary tract. The urethrovaginal fistula is between the ureter and the vagina and the rectovaginal fistula occurs between the rectum and vagina. Fistulas are almost always caused by injury, such as a car accident, or during surgery such as a cesarean section. In developed countries, urinary fistulas may occur after hysterectomies, but in underdeveloped countries, obstetric trauma is usually responsible for the problem. Fistulas are very rare, and occur in less than 1% of patients who undergo a hysterectomy. They usually only develop in more complex hysterectomies or in instances of severe blood loss during the surgery.
Symptoms from fistulas vary dramatically. Some fistulas cause constant urine leakage from the vagina, frequent urinary tract infections, diarrhea, fever, vomiting, or nausea. A doctor will want to examine a patient believed to have a fistula, and may find the fistula during a physical exam. In order to visualize the fistula after the initial doctor’s visit, the physician will likely order an MRI or a retrograde cystogram, both of which visualize the internal organs. Patients with a fistula will often complain of side and abdominal pain and occasionally of unusual discharge or liquid from the vagina. Examinations may be painful and patients may have to be placed under general anesthesia to be evaluated for further treatment.
While some small, early fistulas can be treated with a catheter, most fistulas will require surgery. Surgical repair can fix the undesired opening or connection between two organs. Transabdominal surgery is the most common surgery. While it is safer for the patient if the surgeon were to gain access to the fistula through the vagina, it can be very difficult to do so. The main goal of vesicovaginal fistula surgery is to separate the two organs and create a watertight closure to keep the vagina and bladder separate.
Following surgery for fistulas, the patient will be given intravenous antibiotics and will be monitored until he or she can keep food down. The patient will be given anticholinergics to prevent bladder spasms. Bladder drains will be removed prior to the patient returning home. Two weeks after surgery, the patient is monitored by a cystogram, and the suprapubic tubes are removed.
In some instances, physicians may use fibrin glue to seal vesicovaginal fistulas instead of subjecting the patient to a surgical procedure. Patients should rest after such a procedure and should not attempt physical activity for 4-6 weeks after the procedure.
Risks of the fibrin glue treatment include failure to repair the fistula, infection, bladder or rectal injury and bleeding. Because of the severity of the condition and the dangers that it presents, surgery is necessary for almost every patient with a fistula.