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CASE REPORT |
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| Year : 2000 | Volume
: 16
| Issue : 2 | Page : 168-169 |
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Delayed spontaneous recurrence of vesicovaginal fistula
Sandeep Tiwari, D Dalela, H Chandra, Rajiv Agarwal
Departments of Urology, General Surgery and Plastic Surgery, K. G. Medical College, Lucknow, India
Correspondence Address:
D Dalela
Division of Urology, Department of Surgery, K.G. Medical College, Lucknow - 226 003
India
 Source of Support: None, Conflict of Interest: None  | Check |
Keywords: Vesicovaginal Fistula; Urinary Incontinence.
How to cite this article:
Tiwari S, Dalela D, Chandra H, Agarwal R. Delayed spontaneous recurrence of vesicovaginal fistula. Indian J Urol 2000;16:168-9 |
 Case Summary | |  |
A 32-year-old obese woman developed vesicovaginal fistula (VVF) following abdominal hysterectomy for fibromyoma of uterus. She used to void normally as well as leak per vaginum intermittently. Delay in voiding tended to manifest the leakage. Cystoscopy revealed a pin-headsize midline hole located well above the interureteric ridge. Vaginoscopy confirmed a 3 mm. size fistulous opening at midvaginal level. A narrow fistulous tract was demonstrated only when the bladder was filled upto 450 ml [Figure 1]. In reverse lithotomy position, the vesical hole was closed by two purse-strings and vaginal side was closed by interrupted 3-0 polygalactin sutures.
After 2 weeks of uneventful recovery she voided with total continence. She remained asymptomatic for 10 weeks after which she started dribbling intermittently. On re-examination, the bladder hole was seen as before but the vaginal end was seen at the vault. The previous vaginal hole had completely healed. There was no history of any fever, lower abdominal pain, dysuria or sexual overindulgence, preceding the onset of urinary dribbling. The hole in bladder was cauterized by low-coagulating current resulting in complete healing. The patient is now totally continent and has been asymptomatic for over 14 months.
| Discussion | | |
Following the successful VVF repair, problems like stress urinary incontinence, dyspareunia and stone formation in bladder or vagina have been reported [1],[2],[3],[4] . The delayed recurrence has been rather rare and is described either following calculus erosion or urethral obstruction or subsequent obstetric insult. In our personal experience of managing over 78 cases in the past 10 years, we have only recently encountered this problem.
Earlier we had seen cases of post-hysterectomy VVF, which though small, had an oblique tract and leaked after a certain amount of bladder filling was achieved, which straightened and thereby activated the previously dormant oblique tract [Figure 2].
In the case described, it appears that though the vaginal end healed, the vesical hole persisted or gave way. Since the hole size was very small and activation of fistulous tract was volume dependent, the leak did not manifest immediately but formed a retrovesical collection, incremently increasing over 10 weeks which subsequently got extruded from the weak vault. Postoperatively the patient was advised to void at frequent intervals to avoid overfilling of urinary bladder. She followed the instructions initially for 7-8 weeks but later on she resorted to normal lifestyle. Probably the frequent voiding prevented overfilling of the urinary bladder and thus the leakage. Since there was no history suggestive of local infection or sexual trauma we fail to find any other explanation of the mishappening. It is therefore suggested that irrespective of the size of VVF, accurate closure of vesical end is the key to the successful repair. Meticulous layered closure through string and healthy detrusor is recommended and patient should be instructed to void frequently for a period of three months.
| References | | |
| 1. | Hassim AM, Lucas C. Reduction in the incidence of stress incontinence complicating fistula repair. Br. J Surg 1974; 61: 461-465.  |
| 2. | Dalela D, Arora R, Chandra H, Vatsal D. Vaginolith on a coated polygalactin suture: An unusual case of post VVF repair dyspareunia. Accepted for publication in Arch Esp de Urol 1993. |
| 3. | Elkins TE, Drescher C, Martey JO, Fort D. Vesicovaginal fistula revisited. Obstet Gynecol 1988; 72: 307-312. [PUBMED] |
| 4. | Bhandari M, Dalela D. Complexities of a vesicovaginal fistula. Arch Esp de Urol 1994; 47: 303-306. |
[Figure 1], [Figure 2]
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