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Urethrovaginal Fistula: Symptoms, Diagnosis and Treatment

Definition of a Urethrovaginal Fistula

A urethrovaginal fistula is an abnormal passageway between female urethra and vagina. The fistula most often develops after incontinence surgery, surgical treatment of urethral diverticula, prolonged labor, or obstetric interventions. Other causes include trauma (pelvic fractures, long-term catheterization), tumors, or complications of cancer treatment such as surgery and radiation.

Signs and Symptoms

Proximal fistulas present with urinary incontinence. Distal fistula cause irritative voiding symptoms and a splayed urinary stream with urine entering the vagina.

Diagnostic Workup of a Urethrovaginal Fistula

• Pelvic examination
• Cystoscopy
• Voiding cystourethrography
• Depending on etiology: biopsy of suspicious lesions, CT or MRI.

Surgical Treatment of a Urethrovaginal Fistula

Surgery for distal urethrovaginal fistulas:

If disturbing voiding symptoms are present, the distal urethra and anterior vaginal wall are incised into the fistula (extended meatotomy). This results in a hypospadias-like urethra with an improved urinary stream.

Surgery for proximal urethrovaginal fistulas:

An incision of the vaginal wall is done around the fistula. An additional U-shaped incision of the vaginal wall is done to dissect the urethra. Excision of the fistula and closure of the urethra is done. Surgery ends with preparation of a labial fat flap (Martius technique) covering the closed urethra and closure of the vaginal wall (Wang and Hadley, 1993).

If the urethra is deemed unsuitable for reconstruction due to severe damage of the soft tissue, a bladder flap may be raised to reconstruct a neourethra in one-stage or two-stage procedures (e.g., reverse Boari-flap). Severe urinary incontinence is often a postoperative problem despite fascial sling procedures. In complex cases or after failure, the alternative is the closure of the urethra and ileovesicostomy or a heterotopic continent urinary diversion using the bladder (Mitrofanoff appendicovesicostomy).

References

Wang und Hadley 1993 WANG, Y. ; HADLEY, H. R.: The use of rotated vascularized pedicle flaps for complex transvaginal procedures.
In: J Urol
149 (1993), Nr. 3, S. 590–2

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