Urogenital fistula

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation.^[1] Urogenital fistulas vary in etiology (medical cause). Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation.^[1] Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented.^[2] Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.^[2]: 673

Urogenital fistula
Other names	Urogenital fistulas, urogenital fistulae

Classification

Abnormal passageways or fistulas can exist between the vagina and bladder, ureters, uterus, and rectum with the resulting passage of urine from the vagina, or intestinal gas and feces into the vagina, in the case of a vaginal–rectal fistula.^[1] These vaginal fistulas are named according to the origin of the defect:

• vesicovaginal
• urethrovaginal
• ureterovaginal
• vesicocervical
• vesicouterine^[2][3]
• vesicouretovaginal^[2]
• uterocervical
• vesicocervical
• uretercervical
• ureteruterine

The vagina is susceptible to fistula formation because the gastrointestinal tract and urinary system are relatively close to the vagina.^[4] A small number of vaginal fistulas are congenital.^[5] The presence of a vaginal fistula has a profound effect on the quality of life since there is little control over the passage of urine and feces through the vagina.^[6][7]

Urogenital fistulas are often classified according to their cause: obstetric fistula, congenital fistula and iatrogenic fistula. Urogenital fistulas can be classified by size and more specific anatomical location such as 'upper vagina' or 'posterior vaginal wall'.^{[citation needed]}

Causes

In developed countries, the causes of fistulas are iatrogenic (caused by surgical accidents). Physician error and lack of training contribute to the unsuccessful treatment of obstetric fistulas in developing countries.^[8][6] Injuries to pelvic organs are a cause of fistulas.^[8][4] Most of those not caused by obstructed labor develop from injuries. An example of this would be the improper placement of an instrument during a hysterectomy.^[9] Fistulas can form after long-term pessary use,^[10] hysterectomies, malignant disease and pelvic irradiation,^[4][11][1] pelvic surgery, cancer or a pelvic fracture.^[4][12] Fistulas are sometimes found after a cesarean section.^[8] Providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery. The more training the physician has had, the less likely a uro-vaginal fistula will occur. Some women develop more than one fistula.^[8][6]

Treatment

Surgery is often needed to correct a fistula leading to the vagina. Conservative treatment with an in-dwelling catheter can be effective for small and recently formed urinary fistulas. It has a success rate of 93%.^[1][4] Collagen plugs are used but have been found not to be successful.^[6] The surgical treatment to correct can be approached in different ways. Surgery through the vagina is successful 90% of the time. Surgical correction can be accomplished by abdominal surgery, by laparoscopic and robot-assisted laparoscopic surgery.^[13] The various treatments vary in frequency. The transvaginal approach is used 39% of the time, transabdominal/transvesical approach is used 36% of the time, the laparoscopic/robotic approach is used to treat 15% of urogenital fistulas and a combination of transabdominal-transvaginal approach is used 3% of the time.^[1]

Epidemiology

Globally, 75 percent of urogenital fistulas are obstructive labor fistulas. The average age of a woman who develops a fistula due to prolonged labor is 28 years old. The average age of a woman who develops a fistula from other causes is 42 years old.^[8] Women with a small pelvis are more likely to develop a fistula. Though rare, a fistula can form after the minimally invasive oocyte retrieval part of infertility treatment.^[14] Urogenital fistulas (vesicovaginal) caused by surgical complications occur at a frequency of 0.8 per 1000.^[1]

Rectovaginal fistulas

Main article: Rectovaginal fistula

Abnormal passage of stool through the vagina is caused by a rectovaginal fistula.^[15] Treatment is often surgical with the use of tissue grafts.^[15][16] The presence of bowel disease increases the risk of a rectovaginal fistula.^[15] An entero-vaginal fistula can form between the bowel and the vagina.^[17] Rectovaginal fistulae result from inflammatory bowel disease, Chrohn's disease trauma, or iatrogenic injury and diversions to other organs.^[6][18] Episiotomies can cause the formation of a rectovaginal fistula.^[18]

See also

• Reproductive organs
• Urinary system
• Urogenital triangle
• Vaginal cysts

References

1. Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K (2017-02-22). "Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis". PLOS ONE. 12 (2): e0171554. Bibcode:2017PLoSO..1271554B. doi:10.1371/journal.pone.0171554. PMC 5321457. PMID 28225769.
2. Hoffman B, Schorge J, Schaffer J, Halvorson L, Bradshaw K, Cunningham F (2012). Williams Gynecology (2nd ed.). New York: McGraw-Hill Medical. pp. 677–683. ISBN 9780071716727. OCLC 779244257.
3. Wong MJ, Wong K, Rezvan A, Tate A, Bhatia NN, Yazdany T (March 2012). "Urogenital fistula". Female Pelvic Medicine & Reconstructive Surgery. 18 (2): 71–8, quiz 78. doi:10.1097/spv.0b013e318249bd20. ISSN 2151-8378. PMID 22453314. S2CID 5759825.
4. Priyadarshi V, Singh JP, Bera MK, Kundu AK, Pal DK (June 2016). "Genitourinary Fistula: An Indian Perspective". Journal of Obstetrics and Gynaecology of India. 66 (3): 180–84. doi:10.1007/s13224-015-0672-2. PMC 4870662. PMID 27298528.
5. Fernández Fernández JÁ, Parodi Hueck L (September 2015). "[Congenital recto-vaginal fistula associated with a normal anus (type H fistula) and rectal atresia in a patient. Report of a case and a brief revision of the literature]". Investigacion Clinica. 56 (3): 301–307. PMID 26710545.
6. Maslekar S, Sagar PM, Harji D, Bruce C, Griffiths B (December 2012). "The challenge of pouch-vaginal fistulas: a systematic review". Techniques in Coloproctology. 16 (6): 405–14. doi:10.1007/s10151-012-0885-7. PMID 22956207. S2CID 22813363.
7. Cowgill KD, Bishop J, Norgaard AK, Rubens CE, Gravett MG (August 2015). "Obstetric fistula in low-resource countries: an under-valued and under-studied problem--systematic review of its incidence, prevalence, and association with stillbirth". BMC Pregnancy and Childbirth. 15: 193. doi:10.1186/s12884-015-0592-2. PMC 4550077. PMID 26306705. Women with OF also suffer significant psychosocial repercussions, including isolation, divorce, loss of social roles—including the role of mother, for those whose infants are stillborn, loss of income, stigmatization, shame and diminished self-esteem.
8. Raassen TJ, Ngongo CJ, Mahendeka MM (December 2014). "Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries". International Urogynecology Journal. 25 (12): 1699–706. doi:10.1007/s00192-014-2445-3. PMC 4234894. PMID 25062654.
9. Cron J. "Lessons From the Developing World: Obstructed Labor and the Vesico-Vaginal Fistula". Medscape. Retrieved 2018-01-13.
10. Abdulaziz M, Stothers L, Lazare D, Macnab A (May–June 2015). "An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse". Canadian Urological Association Journal. 9 (5–6): E400-6. doi:10.5489/cuaj.2783. PMC 4479661. PMID 26225188.
11. Mellano EM, Tarnay CM (October 2014). "Management of genitourinary fistula". Current Opinion in Obstetrics and Gynecology. 26 (5): 415–23. doi:10.1097/gco.0000000000000095. PMID 25105561. S2CID 428688.
12. Patel DN, Fok CS, Webster GD, Anger JT (December 2017). "Female urethral injuries associated with pelvic fracture: a systematic review of the literature". BJU International. 120 (6): 766–773. doi:10.1111/bju.13989. PMID 28805298.
13. Tenggardjaja CF, Goldman HB (June 2013). "Advances in minimally invasive repair of vesicovaginal fistulas". Current Urology Reports. 14 (3): 253–61. doi:10.1007/s11934-013-0316-y. PMID 23475747. S2CID 27012043.
14. Spencer ES, Hoff HS, Steiner AZ, Coward RM (2017). "Immediate ureterovaginal fistula following oocyte retrieval: A case and systematic review of the literature". Urology Annals. 9 (2): 125–130. doi:10.4103/UA.UA_122_16. PMC 5405653. PMID 28479761.
15. Köckerling F, Alam NN, Narang SK, Daniels IR, Smart NJ (2015). "Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique". Frontiers in Surgery. 2: 55. doi:10.3389/fsurg.2015.00055. PMC 4607815. PMID 26528482.
16. Taylor D (2017-04-24). "Rectovaginal Fistula Treatment & Management: Approach Considerations, Medical Therapy, Surgical Therapy". Medscape.
17. Kraemer M, Kara D (2016). "Laparoscopic surgery of benign entero-vesical or entero-vaginal fistulae". International Journal of Colorectal Disease. 31 (1): 19–22. doi:10.1007/s00384-015-2395-3. PMC 4701784. PMID 26423060.
18. Das B, Snyder M (March 2016). "Rectovaginal Fistulae". Clinics in Colon and Rectal Surgery. 29 (1): 50–6. doi:10.1055/s-0035-1570393. PMC 4755772. PMID 26929752.