Vesicovaginal and other urinary fistulae

It is a Tuesday morning in the urogynaecology clinic. A 34-year-old teacher sits down in wet clothes and says, without preamble, "I leak all day and all night — since my hysterectomy eight weeks ago." She has been wearing pads continuously. Her MSU is sterile. Her previous surgeon told her it was "just stress incontinence." It is not stress incontinence — it is a vesicovaginal fistula until proven otherwise, and the next steps are an examination, a dye test, an upper-tract image, and a date for repair in about 3 months' time. The art is to recognise the pattern, name the operation you will offer, and not waste the first attempt.[4][11]

Overview and definition

A genitourinary fistula is an abnormal communication between the urinary tract (bladder, ureter, urethra) and the female genital tract. The vast majority are vesicovaginal fistulae (VVF) — a tract from the bladder to the vagina through which urine leaks continuously. A ureterovaginal fistula (UVF) connects a ureter to the vagina and is the second commonest; urethrovaginal and vesicouterine fistulae are uncommon.[4][11]

The clinical signature is continuous urinary leakage per vagina, day and night, with no dry interval between voids — the bladder is no longer a closed reservoir, and any rise in intravesical pressure (cough, walk, supine) drives urine through the tract. The pad is soaked continuously; the underlying bedding is wet; the woman smells of urine despite multiple pad changes a day.[4][11]

VVF is broadly two diseases:[2][4][11][15]

• Obstetric fistula — the global burden; caused by prolonged obstructed labour with pressure necrosis of the bladder base, urethra and anterior vaginal wall. Predominant in low- and middle-income countries (LMIC) where women labour without access to caesarean section. Often very large, with urethral destruction, scarring and a cohort of psychosocial morbidity (stillbirth, divorce, social isolation).[2][15]
• Iatrogenic fistula — the dominant mechanism in high-income countries (HIC); caused by pelvic surgery, most commonly total abdominal hysterectomy (TAH), laparoscopic hysterectomy, radical hysterectomy for cervical cancer, or anterior colporrhaphy. Often small, accessible in the vault, and the operative field is clean.[4][11]

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11. [11]Klemm J, Stelzl DR, Schulz RJ, et al. Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review Int Urogynecol J, 2024.PMID 38733321
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