International Journal of Urology (2018) 25, 25--29
13419
Review Article
Changing trends in the etiology and management of vesicovaginal
fistula
Muhammad A Malik,1 Muhammad Sohail,1 Muhammad TB Malik,1 Nauman Khalid1 and
Adeen Akram2
1
Department of Urology, Madina Teaching Hospital, University Medical and Dental College, and 2Department of Gynecology, Allied
Hospital, Punjab Medical College, Faisalabad, Punjab, Pakistan
Abbreviations & Acronyms
VVF = vesicovaginal fistula
Correspondence: Muhammad
A Malik M.D., F.C.P.S.,
Department of Urology,
University Medical and Dental
College, Sargodha Road,
Faisalabad, Punjab 37250,
Pakistan.
Email: akrammlk@yahoo.com
Received 29 March 2017;
accepted 13 June 2017.
Online publication 1 August
2017
© 2017 The Japanese Urological Association
doi: 10.1111/iju.
Abstract: Vesicovaginal fistula has remained a scourge and of public health
importance, causing significant morbidity, and psychological and social problems to the
patient. Continuous wetness, odor and discomfort cause serious social issues. The
diagnosis has been traditionally based on clinical evaluation, dye testing, cystoscopic
examination and contrast studies. A successful repair of such fistulas requires an
accurate diagnosis and timely surgical intervention using techniques that are based on
basic surgical principles with or without the use of interpositional flaps. The method of
repair depends on the type and location of the fistula, and the surgeon’s training and
expertise. The main complications are recurrence and stress/urge incontinence.
Prevention must include universal education, improvement in the social and nutritional
status of women, discouraging early marriages, and the provision of improved accessible
healthcare services.
Key words: gynecological trauma, urogenital fistula vesicovaginal fistula, vesicovaginal
fistula management, vesicovaginal fistula repair.
Introduction
VVF is an abnormal communication between the bladder and vagina, which results in contin-
uous involuntary loss of urine through the vagina. It is among the most distressing and
socially devastating conditions among women, and occurs most commonly as a result of
obstetrical and gynecological injury. VVF comprises a major burden of obstetrical proce-
dures-related morbidity in developing countries, as well as having a drastic social impact on
quality of life. The first recorded reference to VVF was in 1950 BC. VVF has been a social
stigma for women for centuries. The occurrence of VVF goes back to more than 2000 BC,
when it was identified in 1935 in an Egyptian mummy.1 Avicenna first described the relation-
ship between VVF and obstructed labor or iatrogenic injury in 1037.2 While Derry in 1935,
noted a large VVF that he concluded was the consequence of obstructed labor.3
Incidence and etiology
The incidence of VVF is rare in the developed world; however, it has a drastically high
prevalence in developing and underdeveloped countries.4 VVF is stigmatized in many popula-
tions, making the true incidence and prevalence difficult to articulate. That notwithstanding, it
is common in most sub-Saharan countries, with an estimated 2 million women in sub-Saharan
Africa and south Asia living with VVF, while 50 000–100 000 new cases were recorded
annually as at 2008 – 30 000–130 000 in sub-Saharan Africa alone5 and approximately
33 000 new cases in West Africa.6,7 VVF fistula is one such long-term morbidity consequent
upon poor obstetric care. VVF has remained a scourge and of public health importance, not
just for the attendant medical and physical disabilities, but also for the inherent social, emo-
tional and psychological strain, and stress on the victims.8 It has been reported that at least
3 million women in underdeveloped poor countries have unrepaired VVF.9 Early marriage
and child bearing, poor socioeconomic status, low literacy rate, malnourishment, and inade-
quately developed infrastructure for antenatal care and emergency obstetric services are
important factors for this high prevalence in these nations.10
25
MA MALIK ET AL.
In the industrialized world, the most common causes of
VVF are gynecological or pelvic surgery, radiotherapy and
malignancy.11–13 In underdeveloped countries, the most com-
mon cause is obstructed labor.14,15 The impacted fetal head in
obstructed, and prolonged labor causes massive field injury
leading to VVF. On average, the Department of Urology,
Madina Teaching Hospital, University Medical and Dental
College, Faisalabad, Punjab, Pakistan, is carrying out 36–40
cases of VVF repair per year. Because of improved and acces-
sible antenatal and natal care, and strict rules regarding early
marriages, the number of cases of VVF as a result of obstructed
labor has markedly reduced. Gynecological surgery is the cause
of fistula in most of the cases. Hysterectomy is the most
common surgical procedure resulting in VVF formation in
developed countries, with an 80% incidence.11,12 Other gyne-
cological procedures account for up to 11%. However, the inci-
dence varies depending on the approach. The lowest is with
transvaginal (0.2:1000), followed by transabdominal (1:1000)
and laparoscopic procedures (2.2:1000).16 Contrary to the pre-
vious trend, a significant shift has been observed in Pakistan
regarding the etiology of female urogenital fistula. A study car-
ried out at Bahawal Victoria Hospital Bahawalpur found the
rate of obstetric fistula to be 38.46% compared with post-hys-
terectomy fistula, which was 61%.17 Another study at the same
center showed the rate of post-hysterectomy fistulas to be 55%,
as compared with that after obstructed labor, which was 40%.18
A similar study reported obstructed labor in 68% of cases
as the etiology of VVF, and gynecological surgery in 3% of
cases.19 Gynecological surgery is being reported to be the
main cause of VVF in our department nowadays (>90%).
Rare cases of VVF as a result of obstructed labor present to
us, and most of these cases occur in remote areas.
Classification
VVF can be classified in various ways. Simple fistulas are
small in size (<0.5 cm), and single in non-radiated patients
with no malignancy involvement. Complex fistulas are large
sized (≥2.5 cm), failed previous fistula repair, or are associ-
ated with chronic disease or post-irradiated. A fistula sized
0.5–2.5 cm is considered as intermediate.20
Clinical presentation
Total urinary incontinence with a history of recent gyneco-
logical or pelvic surgery, or obstructed labor is the classical
presentation of VVF. However, a post-radiation fistula can
present even after years of therapy.21
Diagnosis
The location, size and number of fistulas are important before
definite repair for a better outcome of the procedure. A high
suspicion of index for VVF arises when a patient has a postop-
erative (gynecological) urine leak between the 7th and 12th
day. This is probably as a result of necrosis followed by
obstructed prolonged labor and tissue taken up in stitches in
pelvic surgery. Diagnosis can be established by filling the
26
bladder with methylene blue, inserting a tampon in the vagina
and asking the patient to ambulate.22 Cystoscopy has prime
importance in accurate mapping of a fistula, which helps in the
future management plan. Physical examination of the site of the
fistula and its surroundings is also vitally important. Surgery
should be postponed if there are signs of acute inflammation,
edema, necrosis, or other pathology of the bladder or vagina.
In long-standing cases of VVF, or repeated recurrent cases,
bladder capacity reduces, and this might change the manage-
ment plans.
Contrast studies including intravenous urogram or cys-
togram might not be helpful in showing genital abnormality;
however, it is essential to rule out any associated ureterovagi-
nal fistula. The advanced and more costly techniques include
subtraction magnetic resonance fistulography, which proved
to be highly informative in 20 cases.23 The Moir test consists
of the patient first taking phenazopyridine in the clinic, three
cotton swabs are placed into the vagina and 100 mL of
methylene blue solution is inserted into the bladder through
the urethra.24
After removing the catheter, a tampon is inserted into the
vagina. Two hours later, the tampon is inspected; if stained
blue, it indicates VVF, and an orange stain indicates a
ureterovaginal fistula.
Most urologists rarely use this test, and they are more
comfortable with cystoscopic evaluation and contrast studies
for the diagnosis and management of genitourinary fistulas.
Treatment
Conservative management might be effective in small, non-
malignant and early-detected fistulas. Keeping a urethral
catheter for 0.5–2 months along with anticholinergics might
be helpful in spontaneous closure of these fistulae. If diagno-
sis is established late in small fistulas, electrocoagulation of
the mucosal layer along with catheterization for 2–4 weeks
could lead to closure of the fistula.25
Fibrin sealant and collagen as an additional plug has been
successfully used to treat VVF. This material can be placed
in the fistulous tract after electrocoagulation and draining the
catheter for several weeks. This gel-like material plugs the
tract until tissue ingrows from the edges.26
Unfortunately, in most cases, these conservative measures
fail and surgery is required.
The timing of surgery depends on the condition of the sur-
rounding tissue. Early repair might be carried out on healthy
tissue, while surgery should be delayed up to 2–3 months to
allow recovery from inflammation, edema, infection or necro-
sis. Based on experiments carried out on slaves in Mont-
gomery, USA, James Marion Sims established the
foundations of VVF repair in 1852, which included proper
exposure in the knee-chest position, the use of a weighted
vaginal retractor, silver wire sutures, tension-free closure of
the defect and proper postoperative drainage of the bladder.27
VVF can be best managed following basic surgical princi-
ples, such as adequate exposure, identification of structures,
wide mobilization, tension-free closure, good hemostasis and
uninterrupted bladder drainage.28,29
© 2017 The Japanese Urological Association

The choice of surgical repair of VVF depends on the sur-
geon’s experience, the location and size of the fistula, and the
patient’s preference.30
VVF is most commonly repaired transvaginally, as most
gynecologists find this approach more convenient.31 The
transabdominal route is mostly used by urologists.32,33
In general, simple fistulas are being managed by the vaginal
approach, whereas complex fistulas are either repaired through
the abdominal approach or vaginally using myocutaneous
flaps. Most gynecologists prefer the vaginal approach, which
has the merits of minimal blood loss, shorter hospital stay and
relatively less postoperative morbidity, and at the same time a
success rate comparable with the abdominal approach.34
Formation of dead space, where inflammation and infection
can develop along with vaginal shortening, might be associ-
ated with the vaginal approch.35
Severely indurated vaginal epithelium, vaginal stenosis,
improper exposure and repair requiring ureteric re-implanta-
tion are contraindications for the vaginal approch.36,37
The abdominal approach has been recommended for high
retracted fistulas with a narrow vagina, fistulas proximal to
ureters, associated pelvic pathology, and multiple and recur-
rent fistulas.38
The traditional O’Connor’s approach has been the most
accepted method of VVF repair for supratrigonal VVF to
date. The O’Connor’s approach provides excellent mobiliza-
tion of tissues and omental interposition. In this approach, a
long sagittal cystotomy (bivalving of the bladder) is carried
out until the fistula is reached. The fistulous tract is excised,
and two-layer closure is carried out with or without tissue
interposition.
A recent review by Dalela et al. from Lucknow, India,
described a transperitoneal modification of the O’Connor pro-
cedure that decreases the amount of bladder dissection and
operative time. It is also postulated to decrease the postopera-
tive voiding dysfunction and detrusor overactivity, which
occurs with a larger cystotomy and vesical dissection.
The modification involves a smaller, posterior cystotomy
that is carried out toward the edge of the fistula. The fistula
tract is excised, and the bladder defect is closed by advancing
the flap that has been created. The closure is completed in a
single, running, locking layer of monocryl suture. An omental
flap is utilized in all cases where the omentum is able to
reach this far.38
Our preferred abdominal approach is transvesical, in which
the bladder is opened by a vertical incision. After putting a
small-caliber Foley catheter into the fistula and filling the bal-
loon with saline, the fistula is pulled anteriorly. We routinely
inject diluted adrenaline submucosally around the tract to
minimize blood loss and to obtain a clear field while separat-
ing the vagina from the bladder. The vaginal wall and wall
of the bladder are separated by a sharp dissection with scis-
sors. The vagina and bladder are repaired separately without
any tissue interposition. Both ureters are stented with feeding
tubes for 4–5 days, and the bladder is drained with a 3-way
large caliber Foley catheter (22–24-Fr); slow irrigation is
usually carried out with saline fluid for 24 h to prevent any
clot retention. By this approach, our success rate is >95%
(Figs 1–3).
© 2017 The Japanese Urological Association
Vesicovaginal fistula
Step-1
Identification of fistula & canulation of ureteric orifices
(a) (b)
2
3
1 4
Fig. 1 (a) VVF on the posterior bladder wall. 1, canulated ureteric orifices;
2, fistulous tract; 3, posterior wall of urinary bladder. (b) Both ureters have
been stented with 5-Fr feeding tubes. 1, retracted muscles; 2, posterior wall
of urinary bladder; 3, fistulous tract; 4, canulated ureteric orifices.
In post-radiation VVF, repair should be carried out using a
pedicle flap, as the post-irradiation fistula site has a poor
blood supply.
Laparoscopic repair using intracorporeal suturing and
omental interpositioning is a feasible procedure in selected
patients. Laparoscopic repair in expert hands provides a high
success rate and low morbidity; however, it is not widely
practiced because of the costs and considerable learning
curves imposed by intracorporeal suturing.39,40
Successful robotic VVF repair was reported for the first
time in 2005.41 The advantages of the robotic technique
include 3-D visualization, wristed instrumentation reducing
the severe angulation required for laparoscopic VVF repair
and technically simpler intracorporeal knotting.
Transabdominal surgery can be carried out by laparoscopic
or robot-assisted laparoscopic approaches. Success rates in
large series are up to 86%. Difficulties, such as an increased
learning curve and vesicovaginal plane dissection, have been
overcome with innovations, such as the robotic platform and
cutting to the light with vaginoscopy. While still in its infancy
in VVF repair, single-site surgery has also been utilized with
reasonable success. Although minimally invasive surgery offers
numerous advantages, the most successful approach will still
be the surgery with which the VVF surgeon is most familiar.42
In patients seeking treatment after many years, the capacity
of the bladder decreases as a result of continuous leakage of
urine. The bladder has to be augmented by using a segment
of the intestine. Occasionally, such patients even require uri-
nary diversions to treat urinary leakage when augmentation
cystoplasty is not possible.
It is doubtful that a single procedure will emerge as an
optimal surgery for all VVF patients, given the variability of
the nature of the condition, the patient’s characteristics and
the expertise of the surgeon.
Postoperative care
Continuous bladder drainage through a Foley catheter is
mandatory. In patients with VVF involving the bladder neck,
27
MA MALIK ET AL.
Step-2
Traction of fistulous tract with Foley catheter balloon and
dissection around the fistula
(a) (b)
2 3
1 1
3
4
Fig. 2 Foley balloon shown inserted and inflated into VVF and traction
applied by Foley balloon. (a) 1, canulated ureteric orifice; 2, margins of fistu-
lous tract; 3, balloon of catheter raising the edges of the fistulous tract. (b) 1,
balloon of catheter raising the edges of the fistulous tract; 2, posterior wall of
urinary bladder; 3, canulated ureteric orifice; 4, margins of fistulous tract.
the balloon of the catheter should not be filled to avoid pressure
on the suture line; rather, it should be fixed by sutures. We usu-
ally use a 3-way 22-Fr catheter to irrigate for 1–2 days, as
catheter blockage is likely to cause failure of the procedure.
The patient should remain catheterized for 2–3 weeks. If there
is any doubt about the success of the repair, a cystogram should
be carried out before catheter removal, and the catheter should
remain in place for another 2–3 weeks if there is a minor leak.
Anticholinergics should be given to patients who have bladder
spasms, as these not only cause pain to patients, but might also
compromise healing. Antiseptic tampon/gauze should be
placed in the vagina for a day. Antibiotics coverage should be
given until removal of the catheter.43
Complications
Frequency, urgency, urge incontinence, stress incontinence
and failure are recognized complications of VVF repair.
Stress incontinence most likely occurs in obstetric fistula in
which injury involves the sphincter mechanism. Anticholiner-
gic drugs might be helpful in reducing the symptoms.
Failure of VVF repair and recurrence of fistula occurs in
30% of cases. Recurrent cases should be dealt with a gap of
at least 3 months from the previous attempt of repair. Inter-
position of flaps is considered to be protective for recurrent
cases.44
Conclusions
VVF is among the most distressing conditions for women.
It causes a great deal of social, emotional, and psychologi-
cal stress and strain on the patients. The diagnosis is based
on symptoms/signs, clinical tests and exact mapping by
cystoscopy. The best chance of successful surgical repair is
at the first attempt. Debate about the most appropriate
28
Step-3
Repair of vaginal & urinary bladder wall
(a) (b)
Fig. 3 (a) VVF repair completed with vicryl 3/0 in two layers. 1, canulated
ureteric orifice; 2, repaired fistulous tract. (b) Second layer repair shown
along with feeding tubes inserted into ureters and fixed. 1, repaired fistulous
tract; 2, posterior wall of urinary bladder; 3, canulated ureteric orifices.
route of repair continues; however, the role of interposi-
tioning grafts is viewed positively, especially in recurrent
and large fistulas. Laparoscopic and robot-assisted tech-
niques continue to develop; however, these are expensive
and require considerable learning curves. Measures for pre-
vention must include universal education, improvement in
the social and nutritional status of women, discouraging
early marriage, and the provision of improved easily acces-
sible healthcare services.
Conflict of interest
None declared.
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