Vesicovaginal Fistula

A 42-year-old woman presented to the emergency department with urinary incontinence. She underwent a total hysterectomy 18 days prior, during which an intraoperative bladder injury occurred and was repaired. The patient reported incontinence despite having a urethral Foley catheter placed during the surgical procedure. Pelvic examination revealed a thin yellow liquid in the vaginal vault. Computed tomographic cystographic images revealed a vesicovaginal fistula with contrast tracking posteriorly into the vaginal vault (images A and B, arrows). Conservative treatment with a Foley catheter and repeated cystoscopy 2 weeks later was recommended. Because her symptoms did not improve, ureteral reimplantation was performed using a modified O'Connor technique, which resulted in resolution of the symptoms.

Vesicovaginal fistula (VVF) is a passage that connects the bladder to the vagina and allows discharge of urine into the vaginal vault.¹ The most common cause of VVF worldwide is prolonged obstructed labor.¹ In industrialized cultures, however, it is associated with iatrogenic bladder injury, most notably during gynecologic procedures.¹ Approximately 0.8 of 1000 hysterectomies are complicated by a VVF.¹ In cases of small VVFs, conservative treatment can be used.^1,2 Surgical intervention via a transvesical or extravesical approach has been successful when conservative treatment fails.³