CLINICAL OBSTETRICS AND GYNECOLOGY Volume 64, Number 2, 321–330 Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. Obstetric and Gynecologic Genitourinary Fistulas MEGAN ABRAMS, MD, MPH,* and RACHEL POPE, MD, MPH† *Department of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center; and †Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio Abstract: Urinary incontinence shortly after childbirth can be multifactorial and confusing to the or gynecologic surgery can be the result of obstetric or unsuspecting medical provider. While ves- iatrogenic fistula formation. This can be a confusing and challenging diagnosis for medical providers. While the icovaginal fistulas are rare, they occur after number of iatrogenic fistula cases is rising worldwide, 0.08% of hysterectomies in the United obstetric fistulas are an issue uniquely particular to States.1 Ureteral injury which may result resource poor settings. Appropriate treatment of genito- in ureterovaginal fistulas occur in 0.02% to urinary fistulas spans beyond surgical intervention of 0.33% of hysterectomies.2 Globally, genito- leakage, and includes re-integration into the community, widespread education and counseling, and battling social urinary fistulas occur at much higher rates. stigma and cultural biases. Current and future research Approximately 2 million women cur- must focus on rigorous, unified efforts to set evidence- rently live with an obstetric-related urinary based practices to help the millions of women affected. fistula. One systematic review found an Key words: obstetric fistula, vesicovaginal fistula, incidence of up to 4 cases of obstetric fistula iatrogenic fistula per 1000 deliveries and a prevalence of up to 81 obstetric fistula cases per 1000 women.3 While these estimates are on the higher end, there is a lack of robust data on incidence Introduction and prevalence. Urinary incontinence presenting shortly As the quality of obstetric care increases after childbirth or gynecologic surgery globally through the improved access to cesarean deliveries, iatrogenic fistulas ap- Correspondence: Rachel Pope, MD, MPH, Urology pear to increase. However, because of the Institute, University Hospitals Cleveland Medical Cen- ter, Cleveland, OH. E-mail: rachel.pope@uhhospitals. lack of data on fistulas in general, we do not org know if iatrogenic cases outnumber obstet- The authors declare that they have nothing to disclose. ric cases. Therefore, improved access to CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 64 / NUMBER 2 / JUNE 2021 www.clinicalobgyn.com | 321 Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved. 322 Abrams and Pope surgery and enhanced surgical technique are intraoperative ureteral injuries, including necessary across the board. lacerations, transection, crushing, avul- sion, suture ligation, or ischemia, lead to urinomas, and potential drainage from Gynecologic Genitourinary the vaginal cuff, leading to a ureterovagi- nal fistula. This is most often the lower Fistulas third of the ureter, and may be the result While obstetric fistulas are relatively un- of bleeding intraoperatively which ob- known in resource-rich settings, iatrogenic scures the operative field, a markedly genitourinary fistulas are known complica- enlarged uterus, or pelvic adhesions be- tion of gynecologic surgeries, and recent cause of prior surgery. studies have shown a growing incidence of Diagnosing an iatrogenic fistula requires iatrogenic fistula throughout the world.4 a thorough history, physical exam, and a Genitorurinary fistulas can occur during ob- high level of suspicion. Timing and presen- stetric or gynecologic surgery because of the tation vary widely from patient to patient close proximity of the bladder, ureters, uterus, and is dependent on etiology and location of and vagina and cause an abnormal commu- the injury. Some fistulas present immedi- nication between the bladder or ureter and ately after inciting trauma with leakage of the uterus, cervix, or vagina. While any urine from the vagina; however, iatrogenic surgery carries the risk of injury to nearby fistulas resulting from surgical intervention structures, fistula formation is a known maytakeupto30dayspostoperativelyto complication of several obstetric and gyneco- present.5 This is because of the slower logic procedures. Common obstetric and process of devascularization as a result gynecologic procedures, which may result in suture,clamp,orthermalinjury,which genitourinary fistulas include cesarean deliv- leads to necrosis and tract formation over ery, uterine rupture, and hysterectomy.4 time. Iatrogenic fistulas because of other Postsurgical fistulas tend to be small, causes, like radiation therapy, may take isolated, and surrounded by healthy tis- months or years to develop. The evaluation sue. In the United States, 80% of vesico- of size, number, and exact location of the vaginal fistulas are caused by benign fistula is important for diagnosis and surgi- gynecologic surgeries.5 Urinary tract in- cal planning. juries occur in ∼3/1000 gynecologic surgeries.5 Other risk-factors include a DIAGNOSING VESICOVAGINAL AND history of pelvic irradiation, gynecologic URETEROVAGINAL FISTULAS malignancy, endometriosis, pelvic inflam- Patients with a vesicovaginal and ureter- matory disease, infection, trauma, foreign ovaginal fistulas typically present several bodies, or history of pelvic surgery.6 days to months after a pelvic operation with Possible mechanisms of fistula devel- continuous leakage of urine through the opment include direct injury to the tissue vagina. This warrants a prompt physical during a surgical procedure or suboptimal exam. Using a speculum, the vagina should placement or use of surgical instruments be carefully inspected. If a hole or defect is while dissecting or clamping. Sutures identified, the surrounding mucosa may be placed too close to the bladder or ureter erythematous or inflamed. Patient rarely may also lead to necrosis and fistula cannot tolerate office exam and require formation. Though rare, fistula formation anesthesia. A careful physical exam is nec- has also been reported after uterine per- essary to evaluate for acute inflammation, foration at the time of dilation and cur- edema, necrosis, or other bladder pathol- retage or hysteroscopy or after procedures ogy, any of which may delay surgery. utilizing synthetic mesh.6 Unrecognized Evidence of scarring, fixation to adjacent www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. All rights reserved. Obstetric and Gynecologic Fistulas 323 organs, or postirradiation involvement may and inspected to identify suspected vesico- alter the surgical approach. If a vesicovagi- vaginal, ureterovaginal, or both vesico and nal fistula is identified, one must also ureterovaginal fistulas. Figure 2 displays evaluate to ensure there is not a concom- several possible outcomes of the double itant ureteral injury. dye tampon test. A dry, colorless tampon The standard office test for diagnosis of a suggests that there is not a fistula and other suspected fistula is the double dye tampon sources of incontinence should be consid- test. This allows the surgeon to identify if the ered. If only the distal edge of the tampon is patient has a vesicovaginal fistula, ureter- blue and the top is dry, stress incontinence ovaginal fistula, or both in the office setting. or transurethral urine leakage should be The patient is given 200 mg oral phenazo- considered (as in first image). A damp, pyridine at least 30 minutes before test to colorless tampon suggests a peritoneal fis- dye the urine orange. The bladder is then tula or even cuff dehiscence if a hysterec- retrograde filled with ∼250 mL of saline tomy was performed during the original dyed blue with methylene blue or indigo surgery. A damp, blue tampon (last image) carmine. For large vesicovaginal fistulas, suggests a vesicovaginal fistula. If the tam- blue dye can often be seen pooling in the pon is orange, a diagnosis of ureterovaginal vagina immediately (Fig. 1). After removal fistula is likely, while a damp tampon with of the catheter, a tampon is placed into the both blue and orange dyes suggests that vagina, and the patient is allowed to ambu- patient may have both a vesicovaginal and late for 30 minutes without voiding. It is ureterovaginal fistula. If either a vesicova- important that the patient not void during ginal or ureterovaginal fistula is suspected thetestasurinecanwickonthetamponand referral to urogyneoclogy or urology is obscure the results. The tampon is removed appropriate. A myriad of other tests and imaging may be utilized to further characterize and/or confirm lower urinary tract fistulas. Cysto- scopy is often performed to evaluate the size and location of the fistulous tract, its rela- tionship to the ureteral orifices, and the health of the surrounding urothelium, all of which guide the surgeon in when and how to repair the fistula. Leukocytosis may be seen on complete blood count. If there is fluid pooling in the posterior vagina, it can be sent for creatinine and compared with serum creatinine levels. Markedly higher levels of creatinine in the vaginal fluid than serum suggest urine can confirm urinary leakage; however, it does not differentiate bladder and ureteral fistulas. A study by Thayalan et al remarked that these addi- tional tests often incurred high expense while not yielding useful additional infor- mation after a physical exam and double dye test