Edward J. Gill
History of present illness
A 47-year-old gravida 4, para 2-0-2-2 woman presents on postoperative day 9 from a laparoscopic-assisted vaginal hysterectomy with a complaint of watery vaginal discharge.
The discharge is constant throughout the day and she is now wearing a pad daily. She denies dysuria or urinary urgency.
The indication for surgery was a history of pelvic pain, irregular bleeding and fibroids. Her surgery was uncompli- cated as she was discharged home on postoperative day 1.
She is a smoker and has had diabetes mellitus for 18 years.
The preoperative evaluation included a transvaginal ultra- sound, which showed an 11.0 × 8.3 × 6.6 cm uterus with several fibroids, the largest measuring 4.1 cm. Ovaries appeared normal with no other pathology seen. Her past history is significant for two Cesarean section deliveries.
Preoperative laboratory evaluation included Hb 10.2 g/dL and a HbA1c of 7.7.
Physical examination
General appearance:Well-appearing woman in no distress
Vital signs:
Temperature: 37.0°C Pulse: 95 beats/min
Blood pressure: 132/78 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air BMI: 38.8 kg/m2
Abdomen:Soft, nontender, incisions healing well, normoactive bowel sounds
External genitalia:Unremarkable
Vagina:Vaginal cuffhealing well, small amount of watery fluid pooled in vault
Cervix:Absent Uterus:Absent
Adnexa:Nontender, without masses Laboratory studies:
Urine analysis: pH 5.5; specific gravity 1.010; WBCs 20–40/high powerfield; RBCs 10–20/high powerfield Hb: 9.8 g/dL (normal 12.1–15.1 g/dL)
WBCs: 12 000/μL (normal 4500–10 000/μL) Glucose: 208 mg/dL
How would you manage this patient?
Due to the symptoms of a persistent watery vaginal discharge and examination findings of fluid-filling the vaginal vault, there is a high suspicion for a post-hysterectomy vesicovaginal fistula (VVF). A CT urogram was ordered and the diagnosis was confirmed (Fig. 86.1). A 4 mm VVF was identified at the superior portion of the vagina just left of the midline. She was initially managed with continuous bladder drainage with an indwelling transurethral Foley catheter for four weeks; how- ever, this failed to resolve the fistula. She then underwent surgical repair via a vaginal approach with a Latzko partial colpocleises. This surgery was uncomplicated and she was managed postoperatively with continuous bladder drainage via a transurethral Foley catheter for 10 days along with daily antibiotic suppression while the catheter remained in place.
A cystogram was performed to confirm integrity of the repair prior to catheter removal. At her six-week postoperative visit, her symptoms had completely resolved.
Post-hysterectomy vesicovaginal fistula
A vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes persistent and involuntary leakage of urine into the vagina. VVFs are the most common urogenital fistula encountered. Other less common types of urogenital fistula include ureterovaginal, urethrovaginal, vesivocervical, and vesicouterine fistulas. In developing countries VVF are most commonly caused by obstructed labor and obstetrical trauma. However, in developed areas such as the United States and Europe, over 90% of VVFs are caused by bladder injury at the time of hysterectomy. A majority of these bladder injuries are unrec- ognized at the time of surgery and lead to poor healing and fistula formation.
Performing a hysterectomy usually requires at least some dissection of the bladder off of the upper vagina and lower uterus to complete the procedure. In addition, the ureters run in close proximity to the lateral borders of the lower uterus and cervix and are at risk of injury during hysterectomy. Recent reports on the overall incidence of lower urinary tract (LUT) injury after hysterectomy range from 0.23 [1] to 4.8% [2].
Most series report that laparoscopic hysterectomy has the highest rate of LUT and subtotal (supracervical) and vaginal hysterectomies have the lowest reported rate of injury. How- ever, Vakili and colleagues reported a trend toward a higher
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
rate of bladder injury with vaginal hysterectomy with a rate of 6.3%, which is higher than previously reported [2]. Supracer- vical hysterectomy limits the amount of bladder dissection required and may explain the lower rate of injury to the LUT. It is unclear what effect the newer robotic approach to hysterectomy will have on LUT injury.
All hysterectomies have an inherent risk of LUT injury, but some conditions increase that risk. Ischemia, tissue hypoxia, infection, diabetes, prior pelvic radiation, and smoking are known risk factors for poorer healing. In patients with these conditions small injuries or needle injuries of the bladder are more likely to heal poorly and progress to fistula formation.
Any conditions that disrupt normal anatomy predispose to injury at the time of surgery and increase the risk of fistula formations. These conditions include leiomyomata (myomas or fibroids), endometriosis, prior pelvic infections, including pelvic inflammatory disease (PID), and prior pelvic surgery, especially prior Cesarean section(s) since this common oper- ation usually requires a similar bladder dissection as hysterec- tomy and can result in scar tissue formation in the direct path of hysterectomy surgery. Cesarean section was the most common identifiable risk factor associated with injury occur- ring in Tancer’s review [3].
VVF can present any time after surgery and depends on the size, location, and etiology of thefistula. Large anterior vaginal wall lacerations can present immediately postoperatively, while devascularization injuries can take up to 30 days to present.
Fistulas after pelvic radiation may not emerge for one year or longer. The most common symptom is leakage of urine or thin watery vaginal discharge. Leakage can be intermittent or con- tinuous. The patient may still retain normal voiding patterns in the face of a genitourinary (GU)fistula and this cannot be relied on to eliminate the possibility of a GUfistula. In add- ition, the patient may have dysuria, hematuria, cystitis,
abdominal, orflank pain. Some patients with a VVF will have no leakage offluid from the vagina.
The evaluation of VVF after hysterectomy requires a speculum examination looking for abnormal fluid in the vagina and a thorough search for a fistula opening. Post- hysterectomy VVF are often very small and can be difficult to visualize. Creatinine, blood urea nitrogen, and electrolytes can be ordered on any collected vaginal fluid to see if it consistent with urine. The urine analysis may show hematuria and/or pyuria. This may be from a UTI or from inflammation or bleeding at the site of injury. Urine culture is required to distinguish the two. In addition to urine analysis, consider- ation should be given to imaging both upper and LUT. A CT urogram with intravenous contrast is the preferred imaging modality as it can also detect unrecognized ureteric injury which can happen concomitantly in up to 12% of cases [4].
Cystourethroscopic examination will also eventually be required but is not mandatory in the initial evaluation and management of a postoperative GUfistula. Other tests that can be done in the outpatient setting to help identify a fistula include placing a pad or tampon in the vagina followed by maneuvers to color the urine to make it easier to identify and visualize any fluid leaking into the vagina. Examples include oral phenazopyridine hydrochloride (Pyridium®) (orange–
red), intravesical administration of methylene blue via trans- urethral catheter or intravenous indigo carmine dye. Under normal circumstances no coloredfluid should be seen on the vaginally placed tampon. Discoloration of the tampon vagin- ally should prompt a further search for urogenitalfistula.
Conservative treatment of a postoperative VVF includes treating any concurrent UTI and placement of an indwelling catheter to continually drain the bladder. With smallfistulas, conservative treatment with continuous bladder drainage has been curative without the need for surgery [5]. The outcomes
Bladder
Vagina
VVF
Rectum
Fig. 86.1 Superiorly located vesicovaginalfistula with a 4 mm neck just left of the midline with contrastfilling the bladder and vagina.
of this treatment are variable and success rates have been found to be highest when the fistula is identified in the first few days following the surgical injury. Injuries that are identi- fied weeks following surgery, those with largerfistulous open- ings or in women with risk factors for poor healing are less likely to resolve with continuous bladder drainage. At least 30 days of continuous bladder drainage is recommended for optimal healing and consideration of low-dose antibiotic prophylaxis with nitrofurantoin or trimethoprim should be given to prevent catheter-associated infection.
For those who fail continuous bladder drainage or are poor candidates for conservative management, surgical revision is necessary. Occasionally, when larger fistulas are recognized immediately and there is limited inflammation, they can be surgically repaired without delay. More commonly, surgery is delayed for at least six weeks when most inflammation has resolved. Surgical repair offistulas associated with pelvic radi- ation may not be repaired for up to one year. Any fistula associated with pelvic malignancy will require a biopsy of the fistula tract. The surgical approach tofistula repair depends on location, size, and surrounding tissue quality of the fistula.
When possible, a vaginal approach to repair offers a low morbidity and shorter recovery option compared to an abdominal approach. Consultation with Urogynecolgy or Urology would be appropriate for recommendations on surgi- cal approach and repair.
Following surgical repair, continuous bladder drainage for 7–14 days with a transurethral or suprapubic catheter is rec- ommended to promote healing. A cystogram is typically
performed to ensure integrity of the repair prior to catheter removal. For postmenopausal women, vaginal estrogen treat- ment may promote vaginal healing and by improving tissue vascularization. Patients are counseled to strictly adhere to pelvic rest with nothing inserted into the vagina for at least six weeks following surgical repair.
Key teaching points
Risk factors for vesicovaginalfistula (VVF) after
hysterectomy includes conditions that predispose to poor healing, including diabetes mellitus, smoking, prior pelvic radiation, and tissue hyopoxia. In addition, conditions that disrupt the anatomy, including leiomyomata, prior pelvic surgery, a history of prior pelvic infection including pelvic inflammatory disease, and endometriosis, also increase the risk of VVF.
The diagnosis of VVF requires a high index of suspicion in patients complaining of vaginal discharge after
hysterectomy and a thorough examination to investigate this complaint, including a speculum examination to search for afistula opening.
A CT urogram with intravenous contrast is the preferred imaging modality as it can also detect unrecognized ureteric injury which has been reported to occur in up to 12% of cases of VVF.
Smallerfistulas may respond to conservative treatment with an indwelling catheter, but largerfistulas and those with other risk factors will often require surgical repair.
References
1. Harkki-Siren P, Sjoberg J, Titner A.
Urinary tract injury after hysterectomy.
Obstet Gynecol1998;92(1)113–18.
2. Vakili B, Chesson RR, Kyle BL, et al.
The incidence of urinary tract injury after hysterectomy: A prospective analysis based on universal
cystoscopy.Am J Obstet Gynecol 2005;192(5):1599–604.
3. Tancer ML. Observations on prevalence and management of vesicovaginal fistulas after total hysterectomy.Surg Gynecol Obstet1992;175(6):501–6.
4. Goodwin WE, Scardino PT.
Vesicovaginal and ureterovaginal
fistulas: A summary of 25 years of experience.J Urol1980;123(3):
370–4.
5. Davits RJ, Miranda SI. Conservative treatment of vesicovaginalfistulas by bladder drainage alone.Br J Urol 1991;68(2):155–6.
Case 86: Urinary leakage following hysterectomy