A vesicovaginal fistula is an abnormal passageway between the bladder and the vagina that causes incontinence, allowing urine to drain directly into the vagina rather than through the urethra (the tube that conveys urine out of the body). The condition can be congenital or acquired through surgery or other physical trauma (e.g. childbirth). In developed countries, one of the most common causes is tissue damage from gynecological surgeries, such as a hysterectomy or urinary tract procedure. Treatment depends on fistula size and location.
Conservative Treatment for Vesicovaginal Fistula
The most common symptom of a vesicovaginal fistula is loss of bladder control or urinary incontinence. Conservative treatments of vesicovaginal fistula promote closure of the fistula and prevent urine from flowing through. These include:
- Foley catheter: A one-to-two month catheterization of the bladder ensures that urine is drained from the bladder through the urethra and gives the fistula time to close.
- Estrogen therapy: Estrogen therapy—via pill, patch, injection, vaginal cream, or ring—may help strengthen the vaginal wall and close the fistula.
Conservative treatment options are best for patients with a fistula smaller than 3mm in diameter. If these aren't successful, patients can move on to more invasive procedures.
Minimally Invasive Procedures for Vesicovaginal Fistula
Minimally invasive procedures for vesicovaginal fistula treatment destroy the lining of the fistula to try and block or occlude it. This can be done a number of different ways, including the use of electrocautery (burning), lasers, or occlusive agents such as fibrin glue. In these procedures, a cystoscope (thin tube with a camera) is inserted through the urethra and up to the bladder to get a visual of the fistula. Then, tools can be inserted through the tube and used to close the fistula.
Occlusion can be effective for fistulas smaller than 3mm. It is typically used when conservative treatment doesn't work. Occlusion can sometimes initially be effective but then fail later, necessitating additional procedures.
Surgical Procedures for Vesicovaginal Fistula
Surgical treatments for vesicovaginal fistula are generally not considered until three to six months after the fistula develops, as the condition can cause inflammation that must be treated before surgery can be performed. These methods are typically used when the fistula is greater than 3 mm and when other, more conservative interventions are not effective. Three surgical options exist:
- Transvaginal surgery: When a fistula is small and easily accessibly, it can be removed with a scalpel. Transvaginal surgery requires the surgeon to open the vagina with forceps, remove the fistula, then suture shut the layers of the vagina and bladder wall. This procedure may not be feasible if the fistula is located high in the vagina, or if narrowing of the vagina prevents access to the fistula.
- Laprascopic surgery: In this approach, a cystoscope is inserted into the vagina to visualize the fistula. A surgeon makes small incisions in the abdomen, then inserts surgical instruments and uses them to close the fistula and create a passageway that allows for appropriate urine drainage. This procedure can be used when the fistula is positioned high in the vagina, or when the fistula cannot be accessed through the vagina.
- Transabdominal surgery: For this method, which is often used when there are multiple fistulas, a surgeon makes an incision from the belly button into the abdomen. Once inside, he will separate the bladder and vagina and suture the fistulas closed.
Conservative approaches work best when the fistula is diagnosed quickly (within seven days of its formation), less than 1 cm in diameter, not complicated by cancer or radiation, and responds well to bladder drainage within the first four weeks.
In cases where prolonged bladder drainage fails to result in improvement, or when the abnormal passageway is large, complex, and stubborn, the fistula is not likely to resolve on its own and will require more invasive treatments. Even after surgical or minimally invasive measures have been taken, constant bladder drainage through a catheter is necessary for seven to 60 days to guarantee that the treated area is not stressed by the weight of urine. Taking pressure off of the repaired segment allows for proper healing.
When treating the fistula, success rates depend on the severity of the condition and how long it has been present. Those with fistulas smaller than 1 cm who undergo conservative and minimally invasive treatments have a recovery rate as high as 80 percent. With surgery, rates can be even higher: The transvaginal approach has success rates ranging from 82 to 100 percent, while abdominal approaches have success rates between 85 and 90 percent. If a fistula is large and fails to respond to initial surgery, multiple surgeries may be required for long-term success.
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