Vesicovaginal Fistula
A vesicovaginal fistula is an abnormal connection (a hole) between your bladder and vagina, which allows the continuous leakage of urine through the vagina.
It is often a complication of surgery most commonly after hysterectomy or Caesarian Section, but can also occur following incontinence surgery, or due to treatment for cervical cancer or inflammatory diseases.
In the developing world vesicovaginal fistula are much more common, and result from difficulties (delayed second stage of) during labour.
Colovesical Fistula
A colovesical fistula is an abnormal connection (a hole) between the colon (large intestine) and the bladder. This can allow faecal matter from the colon to enter the bladder and urine to leak from the rectum, causing infections and other complications.
The majority of colovesical fistula occur as a consequence of are the result of diverticular disease of the large bowel which become inflamed and as a result attach and erode into the bladder. Other causes of colovesical fistula are colorectal cancer inflammatory bowel disease (particularly Crohn’s disease) and as a result of surgery that involves the colon or bladder.
What are the symptoms of vesicovaginal (bladder) fistula?
Bladder injury is sometimes recognised at the time of the initial surgery but on some occasions the hole develops (days to weeks) later. This is a result of impaired blood supply and tissue necrosis (death), which causes tissue breakdown, leaving a hole.
In cases where radiotherapy is involved fistulae may develop many years after the initial treatment.
Fistula causes continuous leaking of urine through the vagina. In addition to the medical effects of urine leakage, vesicovaginal fistulae cause huge emotional distress, and social isolation.
Mr Jeremy Ockrim
Consultant urologist Mr Jeremy Ockrim is one of very few experienced vesicovaginal / colo vesical fistula specialists in the UK, and is a member of the University College Hospital specialist centre, which treats complex incontinence, fistula and mesh complications.
Leading the London Fistula Service, he works with a multidisciplinary team of experts to ensure patients receive a personal, tailored treatment plan, which includes consultant colorectal surgeons, urology Clinical Nurse Specialists and specialist uroradiologists.
Diagnosis of a vesicovaginal (bladder) fistula
Diagnosis is usually made by clinical examination of the vagina. Radiological imaging is required to further assess the position of the fistula. This was previously done using X-rays but is now mostly commonly performed by MRI scanning to assess the bladder, and CT scanning to ensure that the ureters (draining the kidneys to the bladder) are not involved.
MRI
Water (urine) shows up white
Bladder and the vagina behind both filled with urine
Diagnosis of a colovesical (bladder) fistula
Diagnosis of a colovesical fistula is most commonly done by cystoscopy, during which the urologist uses a thin, flexible scope into your bladder. The camera relays images of the bladder so your doctor can see if there is a fistula. Radiological imaging is required to further assess the position of the fistula. This was previously done using barium X-rays but is now mostly commonly performed by CT scanning.
MRI
Water (urine) shows up white
Bladder and the colon behind both filled with urine
What Are The Treatment Options?
Catheterisation
A catheter is a small tube made of silicone or latex, which passes through your urethra (water-pipe) to keep the bladder empty and give the bladder a chance to heal. Occasionally, a vesicovaginal or colovesical fistula can heal by itself if a catheter is left in for several weeks, but in most cases this is not successful.
Surgical Repair of Bladder Fistulae
If the fistula is recognised early after surgery and the original surgery uncomplicated, then the fistula can sometimes be repaired early, within the first days. In most cases this is not the case. In such circumstances it is important that time is allowed for the tissue swelling and inflammation to be allowed to settle before a further surgical procedure is performed. Most specialists advocate a wait of at least 12 weeks (3 months) before surgical repair is performed.
Vesicovaginal repair can be performed through the vagina or through the abdomen. The success rates are generally equivalent (the same) for both approaches.
Vaginal Repair of vesicovaginal (bladder) Fistulae
The majority of fistulae (over 90%) can be repaired via the vagina.
This is the preferred route as it avoids another operation through tour abdomen (stomach), and recovery is rapid.
The bladder and vagina are separated to allow each to be sewn closed individually.
Urine (water) can find a route through the smallest of defects so in order to reduce the risk of the repair failing a flap of fat from one of your labia is tunnelled between the bladder and vagina repairs to form an interposition layer between the two lines of stitches. This is called a Martius fat pad.
Abdominal Repair of vesicovaginal (bladder) Fistulae
In a very small number of cases and abdominal operation is required (less than 10%)
If the fistula defect cannot be reached through the vagina, the defect is too large, or the ureter (kidney) drainage is affected then the operation can be performed through the abdomen (stomach).
This is usually performed through a Bikini line (Pfannensteil) incision, or laparoscopic (robotic) platform
The bladder and vagina are separated to allow each to be sewn closed individually. In abdominal repairs fat from your stomach – Omental interposition (1) and (3) – is brought down to separate the bladder and vagina layers.
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Laparascopic / robotic or open repair of colovaginal (bladder) fistulae
The type of surgery required to treat a colovesical fistula depends on the cause and location of the fistula. The most common surgery is a sigmoid colectomy. This surgery involves the removal of the affected length of colon, the fistula itself, and repair of the bladder defect.
The operation may be performed by the laparoscopic / robotic (keyhole) technique or open surgery through an incision in the abdomen depending on the cause and severity of the fistula.
Following Repair Surgery
Following both vaginal and abdominal repairs a urethral and or abdominal catheter is left in place for 3-4 weeks to give time for the fistula to heal. The catheters drain into a collection bag on tour thigh. After this time a Cystogram dye X-ray (see above) is performed to check that the fistula has healed, and the catheter is then removed.
Further Information
BAUS information sheets
Vaginal repair of a fistula between the bladder and vagina
Abdominal repair of a fistula between the bladder and vagina
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