Bladder–vaginal fistula

Disease Description (Causes and Symptoms)

• Definition: A vesicovaginal fistula is a condition in which an abnormal connection (fistula) forms between the bladder and vagina, causing urine to continuously leak through the vagina.
• Main causes:
  • Obstetric causes: obstructed labor (especially pressure necrosis due to prolonged labor) — common in low-resource settings
  • Gynecologic surgery: bladder injury during surgery such as hysterectomy (the most common cause in modern medical settings)
  • Pelvic radiation therapy (caused by tissue necrosis after cancer treatment)
  • Malignant tumors, pelvic trauma, infection, etc.
• Pathophysiology: Ischemia, necrosis, or trauma to the tissue creates a defect between the bladder wall and vaginal wall, allowing urine to flow backward and be discharged through the vagina during urination. Once a connection forms between the bladder mucosa and muscular layer and the vaginal mucosa, continuous leakage and secondary inflammation occur.
• Main symptoms:
  • Continuous urine leakage unrelated to activity or urinary urgency (a constantly wet feeling throughout the day)
  • Foul-smelling vaginal discharge, perineal irritation, and dermatitis
  • Recurrent urinary tract infections, frequent urination, and bladder irritation symptoms (in some cases)
  • Sexual dysfunction (pain or discomfort) and social and psychological effects

Treatment Methods

• Conservative treatment:
  • Continuous drainage with a urethral catheter (generally for about 4–6 weeks) — attempted for small fistulas or when the fistula has developed recently and there is little tissue inflammation
  • Antibiotics to control infection and urinary symptoms (according to culture results), and local care (perineal hygiene)
  • Endoscopic treatment: limited indications, such as electrocautery or injection of an adhesive (fibrin glue) for small fistulas
• Surgical treatment (standard treatment):
  • Selection: Determined according to the fistula’s size, location, and cause (including whether there is a history of radiation therapy), as well as the condition of the tissue
  • Approaches: Transvaginal (when a vaginal approach is possible), laparoscopic/robot-assisted laparoscopic, or open abdominal approach
  • Procedure: Excision of the fistula followed by multilayer closure; when necessary, an interposition flap made of well-vascularized tissue, such as a Martius fascia-fat pad, is inserted between the tissues to prevent recurrence
  • Timing of surgery: If there is acute inflammation or infection, surgery is recommended after treatment, once the tissue condition has stabilized (usually after several weeks to several months). Radiation damage affects surgical outcomes → the procedure is more complex and reconstruction is more difficult
• Pre- and postoperative care:
  • Optimization before surgery, including treatment of urinary tract infections, improvement of nutritional status, smoking cessation, and blood glucose control
  • Maintaining the urethral catheter for a certain period after surgery (during the healing period of the closure)
• Prognosis:
  • Varies depending on the cause, size, location, and history of radiation therapy. In general, appropriate surgery has a high healing rate, but radiation-related fistulas and extensive tissue damage increase the risk of recurrence
• Precautions (including self-care):
  • Keep the wound and perineal area clean, avoid sexual intercourse (until healing is complete), and limit lifting heavy objects and strenuous exercise
  • Prevent constipation (to suppress increases in intra-abdominal pressure during bowel movements) — consume fiber and fluids, and use laxatives if necessary
  • Improve general health, including smoking cessation and diabetes control

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare:
  • A list of current medications, including anticoagulants and steroids
  • Records of previous surgeries (if possible, the name and date of the surgery), and whether there is a history of radiation therapy
  • Recent test results (urinalysis/urine culture, ultrasound, CT, cystography, etc.) or copies of outpatient or inpatient records
  • Symptom diary: when leakage began, amount (number of pads used), aggravating factors, and whether there is accompanying pain or fever
• Preparation for examination and testing:
  • If possible, prepare a urine sample (for urinalysis and culture)
  • If necessary, prepare photographs or video recordings during urination (helpful for diagnosis)
• Questions that may be asked during the outpatient visit (by the doctor):
  • When did the symptoms begin? Have they gradually worsened?
  • Have you recently given birth or undergone surgery or radiation therapy?
  • How much and how often does urine leak (how many pads do you use)?
  • Do you have symptoms such as pain, blood in the urine, or fever?
• Materials that are useful for the patient to provide to the doctor first:
  • Number of pads used per day, urination diary, and previous test results

Examples of General Questions to Ask the Doctor

• “What do you think is the cause of this condition? What is the likely cause in my case?”
• “What are the advantages and disadvantages and success rates of the treatment options (conservative versus surgical)?”
• “If surgery is needed, what approach (transvaginal/laparoscopic/open) will be used, and how long is the expected recovery period?”
• “What should I prepare before surgery, such as stopping medications, quitting smoking, or improving nutrition?”
• “What is the risk of recurrence after surgery, and what additional treatment options are available if it recurs?”

Examples of Condition-Specific Questions

• “Based on the size and location of my fistula, is a transvaginal approach (transvaginal surgery) possible, or would an abdominal (or robotic) approach be more appropriate?”
• “I have heard that the success rate of surgery is lower in people with a history of radiation therapy. What is the prognosis in my case? Will additional measures be needed for reconstruction?”