Combined vesico-vaginal and vesico-cutaneous fistulae are exceptionally rare. We present a young woman who had combined vesico-vaginal fistula and vesico-cutaneous fistula following prolonged obstructed labour and caesarean section. The patient presented at three months of illness with total urine incontinence from the vagina and lower abdominal skin. One-stage surgical repair of both fistulae was done. The patient had a successful closure of the fistulae, regained full urinary continence, and remained continent at six months follow-up. We opine that one-stage repair of combined vesico-vaginal and vesico-cutaneous fistulae is feasible and preferred. Providers of pelvic surgery in low resource countries should be supervised and retrained accordingly, in order to prevent iatrogenic vesico-cutaneous fistula.
Urinary fistulae result from a breach in the integrity of the renal system. Urine then by-passes its pathway to surrounding structures which are devoid of sphincteric control. The result is incontinence of urine which has devastating physical, social and psychological consequences [
Obstetric fistula persists in low resource countries [
Globally, the prevalence of female genital fistula was estimated to be 3,000,000, while the incidence was estimated to be 130,000 in Africa [
Since VVF relegates its victims to a life of misery [
Our objective is to report a very rare case of combined vesico-vaginal fistula and vesico-cutaneous fistula, and the successful one-stage surgical treatment.
A 24 year old G1P1 presented with three-month history of urinary incontinence following caesarean delivery for prolonged obstructed labour. She leaked urine from the vagina and the lower anterior abdominal skin. She had no history of pelvic swelling, haematuria or pyouria.
On examination she was well hydrated but her clothes were wet with urine from her waist downwards. She had normal vital signs and her chest was clinically clear with normal vesicular breath sounds. There was a Pfannenstiel scar on her lower abdomen, part of which was wet. A defect was seen towards the middle of the Pfannenstiel scar from which urine was seen to be oozing when the lower abdomen was palpated. The uterus was normal sized and there was no pelvic mass or abdominal hernia.
Pelvic speculum examination revealed an obvious defect between the bladder and vagina through which urine leaked. When weak methylene blue solution was instilled into the bladder through a urethral catheter, the anterior vaginal wall and lower abdomen were directly observed (Direct dye test), the dye was seen to leak through the bladder defect to the vagina and the Pfannenstiel scar defect. A provisional diagnosis of combined vesico-vaginal fistula and vesico- cutaneous fistula was made.
Her packed cell volume was 35% and urea and creatinine were within normal limits. Pelvic ultrasound could not be done as it was not possible for urine to be retained within the bladder. Cystoscopy was not done as the bladder could be seen through the VVF defect.
The patient consented for an examination under anaesthesia and one-stage surgical repair of both fistulae under spinal anaesthesia. In the theatre, routine cleaning and draping were done under spinal anaesthesia. Examination under anaesthesia was done. The fistula defects were estimated to be 5 × 4 cm on the vagina (VVF) and 4 × 3 cm on the Pfannenstiel scar (VCF). The bladder was inspected from the vaginal defect, which revealed an empty bladder with both ureters actively spilling urine. A uterine sound passed from the VCF through the bladder, exited at the VVF (
The VVF was incised via an inverted “T” shaped incision and the bladder was sharply dissected from the anterior vaginal wall. The bladder margin of the fistula was excised and repaired with a tension free absorbable suture in one layer. The anterior vaginal wall was also repaired in one layer using absorbable suture. The margin of the VCF was then incised, trimmed and the bladder dissected off the anterior abdominal skin. Both structures were repaired with tension free absorbable sutures in separate layers. Post closure direct dye test with 200 mls of dye showed no dye leak from the vagina and anterior abdominal wall. The bladder was drained with an indwelling size 16 Foley’s catheter for fourteen days. After removal of the catheter, both fistulae had closed and the patient had regained continence and remained continent at six months follow up.
Obstetric fistula persists in low income countries decades after it was eradicated from the developed world [
Women with VVF have significant distress from urinary incontinence [
Abdominal ultrasonography was deferred because both fistulae were large, making it impossible to retain urine in the bladder. This could obscure ultrasonographic findings. Furthermore, the urea and creatinine resuls were normal and examination under anaesthesia revealed ureters that were actively spilling urine. The direct dye test and the examination under anaesthesia were therefore sufficient for diagnosis in our low-resource setup. In the management of vesi co-cutaneous fistula, others have used abdominal ultrasonography and CT
cystograms [
Although we could not find a combined VVF and VCF in published literature, one-stage repair of other types of combined fistulae have been reported with good outcome [
Surgical closure of VCF with interposition of omental flap has been reported [
One-stage surgical repair of combined fistulae could be challenging. Depending on the degree of tissue loss, bringing together the available bladder tissue for a tension free closure may be difficult. In this case, wide dissection enabled a tension free closure with a successful outcome. The rest of the management and follow up was uneventful and our patient regained full continence, thus confirming effectiveness of one-stage surgical repair of combined VVF and VCF.
Prevention of obstetric fistula is possible [
Combined vesico-vaginal and vesico-cutaneous fistula is exceptionally rare. One-stage surgical repair of combined VVF and VCF is feasible and preferred. Healthcare workers providing surgical services in low resource countries need to be supervised in order to prevent iatrogenic VCF.
A written informed consent was obtained from the patient for the publication of this article.
We declare no conflict of interest.
Lengmang, S.J., Oseni-Momodu, E., Ushie, P. and Chima, G.A.A. (2017) A Rare Case of Combined Vesico-Vaginal and Vesico-Cutaneous Fistulae Treated by One-Stage Surgical Repair. Open Journal of Obstetrics and Gynecology, 7, 702-706. https://doi.org/10.4236/ojog.2017.77070