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Clinical Images  |   December 2017
Vesicovaginal Fistula
Author Notes
  • From the Department of Emergency Medicine at the Duke Lifepoint Conemaugh Memorial Medical Center in Johnstown, Pennsylvania (Drs Taylor and Ashurst) and the Department of Gynecology at the Mayo Clinic in Phoenix, Arizona (Dr Wasson). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to John V. Ashurst, DO, MSc, Department of Emergency Medicine, Duke Lifepoint Conemaugh Memorial Medical Center, 1086 Franklin St, Johnstown, PA 15905-4305. E-mail: ashurst.john.32.research@gmail.com
     
Article Information
Imaging / Obstetrics and Gynecology / Urological Disorders / Clinical Images
Clinical Images   |   December 2017
Vesicovaginal Fistula
The Journal of the American Osteopathic Association, December 2017, Vol. 117, 789. doi:10.7556/jaoa.2017.154
The Journal of the American Osteopathic Association, December 2017, Vol. 117, 789. doi:10.7556/jaoa.2017.154
A 42-year-old woman presented to the emergency department with urinary incontinence. She underwent a total hysterectomy 18 days prior, during which an intraoperative bladder injury occurred and was repaired. The patient reported incontinence despite having a urethral Foley catheter placed during the surgical procedure. Pelvic examination revealed a thin yellow liquid in the vaginal vault. Computed tomographic cystographic images revealed a vesicovaginal fistula with contrast tracking posteriorly into the vaginal vault (images A and B, arrows). Conservative treatment with a Foley catheter and repeated cystoscopy 2 weeks later was recommended. Because her symptoms did not improve, ureteral reimplantation was performed using a modified O'Connor technique, which resulted in resolution of the symptoms. 
Vesicovaginal fistula (VVF) is a passage that connects the bladder to the vagina and allows discharge of urine into the vaginal vault.1 The most common cause of VVF worldwide is prolonged obstructed labor.1 In industrialized cultures, however, it is associated with iatrogenic bladder injury, most notably during gynecologic procedures.1 Approximately 0.8 of 1000 hysterectomies are complicated by a VVF.1 In cases of small VVFs, conservative treatment can be used.1,2 Surgical intervention via a transvesical or extravesical approach has been successful when conservative treatment fails.3 
References
Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K. Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: a systematic review and meta-analysis. PLoS One. 2017;12(2):e0171554. doi: 10.1371/journal.pone.0171554 [CrossRef] [PubMed]
Bazi T. Spontaneous closure of vesicovaginal fistula after bladder drainage alone: review of the evidence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):329-333. doi: 10.1007/s00192-006-0194-7 [CrossRef] [PubMed]
Miklos JR, Moore RD, Chinthakanan O. Laparoscopic and robotic assisted vesicovaginal fistula repair: a systematic review of the literature. J Minim Invasive Gynecol. 2015;22(5):727-736. doi: 10.1016/j.jmig.2015.03.001 [CrossRef] [PubMed]