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Urogenital fistulas: vesicovaginal and ureterovaginal
Continuous leakage of urine from the vagina after hysterectomy is a fistula until proved otherwise; a bladder fistula is told from a ureteric fistula by a dye test and imaging, and repair is surgical, tension-free, watertight and multilayer.
Why it matters in the exam
The exam shows a woman after hysterectomy — the commonest cause in developed countries — who complains days to weeks after surgery of much urine from the vagina, without urgency and sometimes with normal voiding. In developing countries the main cause is prolonged obstructed labour. Other causes: pelvic radiotherapy, tumours and caesarean sections. Further questions deal with distinguishing it from stress incontinence: in a fistula the leakage is continuous and not related to effort.
Evaluation: a "two-dye" test — methylene blue into the bladder and a tampon in the vagina; a blue tampon points to a bladder fistula, and if oral phenazopyridine is also given and the tip of the tampon is orange, a ureteric fistula is suspected. Cystoscopy defines the site of the opening, and CT urography is always needed because some patients also have a ureteric injury. In a fistula after radiotherapy or when a tumour is suspected, the edges are biopsied.
A small fresh fistula can sometimes close with prolonged catheter drainage. Surgical repair is vaginal (for example Latzko) or abdominal (O'Connor), according to the fistula site and the surgeon's experience, with tension-free closure in separate layers, and a tissue interposition (Martius, omentum or peritoneum) in a complex fistula or after radiotherapy. Early repair is possible when there is no inflammation or infection; after radiotherapy waiting is customary. A ureteric fistula is treated first with a stent, and if that fails — ureteric reimplantation into the bladder. A rectourethral fistula can follow prostatectomy or radiotherapy.
Key points
- Hysterectomy — the commonest cause in developed countries.
- Dye test: blue bladder, orange ureter.
- CT urography to exclude ureteric injury.
- Tension-free, watertight, multilayer repair.
- After radiotherapy — tissue interposition.
Summary table
| Type | Common cause | Diagnosis | Treatment |
|---|---|---|---|
| Vesicovaginal | Hysterectomy, obstructed labour | Blue tampon, cystoscopy | Catheter if small; vaginal or abdominal repair |
| Ureterovaginal | Hysterectomy | Orange tampon, CT urography, hydronephrosis | Stent; reimplantation |
| After radiotherapy | Pelvic radiotherapy | Biopsy to exclude tumour | Delayed repair with tissue interposition |
| Rectourethral | Prostatectomy, radiotherapy | Air in urine, urine per rectum | Faecal diversion and repair |
A free exam question
אצל יילוד בן יומיים אובחנה Vesico-Umbilical Fistula . מהו המבנה העוברי שחל בו פגם התפתחותי במקור מום זה? (the question as examined, in Hebrew)
- א. Allantois
- ב. Pronephros
- ג. Ureteric bud
- ד. Cloaca
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Sources
- EAU Guidelines on Non-neurogenic Female LUTS, 2025 edition — Urogenital fistula
- International Consultation on Incontinence: Fistula committee report, 7th edition (2023) — Diagnosis and repair of urogenital fistula
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Urinary Tract Fistulae
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.