Management of urethrovaginal

fistulaeDmitry Yu. Pushkar, Natalia M. Sumerova and Gevorg R. Kasyan

Department of Urology, Moscow StateMedical-Stomatological University (MSMSU),Moscow, Russia

Correspondence to D. Pushkar, 28-2-45 Tverskaya,Moscow 103050, RussiaTel: +7 903 1303250; e-mail: pushkardm@mail.ru

Current Opinion in Urology 2008, 18:389–394

Purpose of review

Urethrovaginal fistulae are a rare condition. It is a conceptual mistake to consider

urethrovaginal fistulae to be synonymous with vesicovaginal fistulae. Urethrovaginal

fistulae are a different entity requiring special attention and treatment. Due to the wide

variety and individuality of the clinical manifestations of these injuries, it is practically

impossible to find and create common guidelines for treatment. Taking into account the

difficulty of urethrovaginal fistula treatment, we decided to conduct a review of the

current literature on this subject.

Recent findings

Due to advances in obstetric care, urologists in the developed world encounter

urethrovaginal fistulae rarely, and many of the fistulae seen are secondary to vaginal

surgery. Surgical treatment procedures include direct primary anatomical repair and

interpositional tissue restorations, mainly by Martius flap. Successful direct anatomica

repair alone may result in the development of stress urinary incontinence or obstructed

voiding in up to 50% of patients. Synthetic tape should be removed during fistula repair

which may lead to the resumption of stress incontinence.

Summary

Prevention of urethrovaginal fistulae can be achieved through both improvements in

obstetric care and adequate training in vaginal surgery. The success of any surgical

treatment depends on careful patient selection, and assumes knowledge of all possible

treatment options. Potential work needs to be directed towards the application of the

newest molecular technologies.

Keywords

urethral loss, urethral surgery, urethrovaginal fistula, urinary incontinence

Curr Opin Urol 18:389–394� 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins0963-0643

IntroductionUrethrovaginal fistulae are a rare condition [1,2]. Fortu-

nately, the urethra is an anatomically well protected organ

in females. In adults, the majority of urethrovaginal

fistulae are a result of iatrogenic injuries [2–4]. It is a

conceptual mistake to consider urethrovaginal fistulae

synonymous with vesicovaginal fistulae. Urethrovaginal

fistulae are quite different in terms of the complications

because of the risk of sphincteric involvement in

vesicovaginal fistulae. The medical literature on this

particular subject is sparse, and limited to either clinical

cases, or a small series of patients.

Etiology and pathogenesisIn the developing world the vast majority of urethrova-

ginal fistulae result from obstructed labor [5–8]. In a

report from the USA [9] only 5% of genitourinary fistulae

were of obstetric origin, while studies from Nigeria [10],

India [11], and Pakistan [12��] indicate obstetric causes to

0963-0643 � 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

l

,

be responsible for 92, 81, and 68% of such fistulae,

respectively [13–15]. The United Nations Population

Fund estimates that there are more than 2 million women

currently living with fistulae in the sub-Sahara belt of

Africa and that another 50 000–100 000 join their ranks

each year [16]. Roenneburg and Wheeless [16] describe

the traumatic absence of the proximal urethra (TAPU)

occurring within context of various labor injuries in

Africa. In the developed world the more common causes

of urethral injury include trauma, iatrogenic injury at

urethral diverticulectomy, bladder neck suspension,

endoscopic surgery and gynecologic surgery, such as

vaginal hysterectomy or anterior vaginal repair. Urethral

erosion can result from synthetic materials used in these

procedures or from antiincontinence surgery, or it may be

due to long-term indwelling catheters in neurologically

impaired or comatose patients [17–22]. Urethral damage

is also a potential sequela of radiotherapy for pelvic

malignancy and related procedures [6,23]. The incidence

of urethral injury with pelvic fractures ranges from 0 to

390 Female urology

6% and is predominantly caused by high-speed motor

vehicle accidents. The reader should be aware that here

we are covering only urethrovaginal fistulae, as opposed

to acute urethral damage, which when treated requires a

different, specific approach.

Clinical presentationUrethrovaginal fistulae may present with a tiny pinpoint

lesion manifested by vaginal voiding, or as extensive

urethra damage with total urinary incontinence (Fig. 1).

The clinical presentation of urethrovaginal fistulae

depends on the location and the size of the fistula.

The patient may be continent and often minimally

symptomatic if the fistula is located in the distal third

of the urethra. These patients usually complain of urinary

drainage per vaginum during or after voiding. Intermit-

tent positional wetness is often present when a urethro-

vaginal fistula is localized in the middle or proximal

urethra. Other symptoms that present in these patients

are perineal skin irritation, recurrent urinary tract infec-

tions, and vaginal fungal infections. The time from initial

lesion to the onset of clinical symptoms depends on the

Figure 1 Large urethrovaginal fistula after synthetic sling

placement

etiology of the urethrovaginal fistula. Approximately 90%

of genitourinary fistulae associated with pelvic surgery

are symptomatic within 7–30 days postoperatively. An

anterior vaginal wall laceration associated with obstetric

fistulae typically (75%) presents within the first 24 h after

delivery. In contrast, radiation-induced urethrovaginal

fistulae are associated with slowly progressive devascu-

larization necrosis and may present 30 days to many years

later [3]. Some recent data show that urethrovaginal

fistulae associated with synthetic tape erosion may lead

to symptoms of urethritis and pelvic pain [24]. It is

important to realize that with all of these fistulae, there

is a significant risk of concomitant sphincteric damage,

particularly with mid-urethral fistulae. Some authors

unite urethrovaginal fistulae with urethral loss and other

urethral conditions [6]. We believe that these are separate

conditions with different clinical manifestations.

Figure 2 shows different types of urethrovaginal fistulae.

Larger fistulae may lead to extensive sphincter damage,

which can compromise subsequent continence even after

successful fistula closures.

Patient evaluationA proper evaluation of urethrovaginal fistulae is necessary

in order to plan effective therapy, particularly for recur-

rent cases which may demonstrate urethral stenosis due

to scarring and prolonged catheterization.

Several authors describe prolonged catheter management

in cases of noted and fixed urethral injuries, as well as in

cases where urethral damage was diagnosed shortly after

primary surgery. Usually fistulae form within 2 weeks of

injury. Taking into account that the patient with urethro-

vaginal fistulae suffers not just from a medical condition,

but a social condition [15], the specialist needs to try to

utilize as many diagnostic procedures as possible. Many of

these tests, however, may be unnecessary. A careful

vaginal exam, using different probes with simultaneous

cystoscopy, helps identify small or multiple fistulae. Larger

lesions can be seen easily during the vaginal exam. In cases

of extensive postdelivery damage, fistulae may be com-

bined – urethrovesicovaginal – so special care is required

to evaluate ureteric orifices. The possibility of stress or

urgency incontinence, resulting from sphincteric damage,

should also be considered, and directed testing should be

done to exclude these diagnoses [25]. Large fistulae can

be palpated manually. The identification of smaller fistu-

lae can be facilitated by distention of the bladder with

methylene blue-dyed saline. It is necessary to remember

that urethrovaginal fistulae may be associated with

vesicovaginal fistulae. Cystourethroscopy helps to identify

the location and size of the fistula tract and affords

evaluation of the bladder, which is important to exclude

involvement of the bladder neck and trigone. Even in the

Management of urethrovaginal fistulae Pushkar et al. 391

Figure 2 Probe shows multiple urethrovaginal fistulae in one patient

presence of a normal trigone, we recommend renal ultra-

sonography and intravenous pyelography screening exam-

inations to exclude occult upper tract abnormality. A

standard urinalysis is an essential part of preoperative

evaluation. We do not recommend cystometry as a

routine preoperative evaluation, but it may be helpful in

the presence of urinary urgency [3]. Many authors believe

that the most important aspects of the patient examination

are to evaluate the quality of the tissue, and define the

proper timing of repair [26]. This is especially true in

postradiation damage, although such cases are extremely

rare. Psychological counseling may be advised for patients

subject to social ostracism [15]. Some authors believe

bilateral retrograde pyelography should be used routinely

in patients with these types of fistulae.

Timing of surgery and treatment planFlisser and Blaivas, among others, advocate immediate

repair within 10 days of the onset of a fistula when

tissue quality permits [6,27��,28]. Others believe that

the tissue should be allowed to restore itself for

2–3 months prior to successful fistula repair. In the

majority of recurring cases, at least 2 months should pass

between fistula closures [13,29–31]. When considering a

treatment plan for each individual patient, the surgeon

should be prepared to use additional tissue. About 30% of

patients, however, benefit from simple primary anatomical

repair. Simple primary anatomical repair is performed over

a 14 or 16 Fr Foley catheter. Fine absorbable suture

materials, such as 3-0 or 4-0, are used for the majority of

repairs. A urethral catheter is left in place from 10 to 30 days

[3]. We believe that this duration should be determined

based on the size and localization of the fistula.

A suprapubic catheter is not routinely recommended,

although some authors use it for the vast majority of

cases [6,9,20,22,28,32]. While formulating the treatment

plan, the surgeon must take great care in determining

the possibility and necessity of performing a concomi-

tant antiincontinence procedure. In some cases it is

difficult to predict the development of secondary stress

incontinence, thus some authors do not recommend

performing simultaneous correction of stress inconti-

nence. At the same time, other authors prefer to

correct stress incontinence during fistula repair [32].

An autologous sling procedure is the most common

operation advised for these patients [6]. If the surgeon

decides to perform such a procedure, and an additional

graft should be used to cover the suture layer, the sling

should be placed overlying the graft [6]. Since it

is difficult to predict which patients will need an anti-

stress incontinence procedure and because of the

possibility of compromising the fistula repair, we do

not recommend concomitant repair of fistulae with

antistress procedures.

392 Female urology

Urethrovaginal fistulae, associated with extensive

urethral damage in patients after pelvic radiation, in some

cases may be considered noncurable [15]. Such patients

may be scheduled for diversion. Such patients should be

informed that they may require several operations with

subsequent continence restoration if required. Special

care should be taken in those cases where fistulae are

associated with synthetic materials. Although only a few

such cases have been described in the current medical

literature, and these are limited to clinical cases, the

surgeon should realize that the synthetic tape to be

removed during fistula repair might lead to the resump-

tion of stress incontinence and even though the fistula

may be successfully closed, the patient may perceive

the fistula repair as a failure because of the stress incon-

tinence. Therefore, the patient should be informed

accordingly. The majority of authors consider that the

subsequent antiincontinence procedure should be done

several months later and ought not to be performed with a

minimally invasive synthetic tape [17–19,33].

Hilton et al. showed that 15–20% of patients may

develop obstructive voiding due to urethral stenosis

and lower urinary tract symptoms [3,25]. Little can

be done to avoid this postoperatively. Therefore, before

initiating treatment the surgeon should inform the

patient accordingly.

Finally, it should be noted that the vast majority of

patients should be operated on vaginally in the dorsal

lithotomy or prone position [28]. Some rare, traumatic

lesions, or those associated with TAPU, can be treated

with combined vaginal and suprapubic approaches

[16].

Surgical treatment methodsBefore describing specific surgical treatment methods,

we would like to note that treatment procedures

are constantly evolving. Therefore we would like to

place special emphasis on the latest technical modifi-

cations.

Direct primary anatomical repair may be advised for the

patient with minimal anatomical disruption. Flisser and

Blaivas [6] have successfully closed 15 urethrovaginal

fistulae using this technique. This technique calls for

careful vaginal examination immediately prior to the

procedure, when the patient is already anesthetized, in

order to exclude multiple fistulae. Flisser and Blaivas

emphasize the crucial meaning of wide mobilization of

the urethral wall in order to provide tension-free closure,

preferably with two layers of absorbable sutures. Some

authors have recently recommended minimizing scar

formation postoperatively and facilitating subsequent

sling placement if necessary by creating a full-thickness

flap from the proximal urethra, or even the bladder, and

bringing it in to avoid any tissue tension [12��]. During

suture placement, the urethral mucosa should be

avoided. Noninterrupted sutures with fine monofilament

absorbable may be used. Once the first line of sutures is

completed, evaluation of the urethra with a metallic

urethral sound in place allows the surgeon to see small

defects in the suture line, which must also be closed. A

second suture line with the same suture material must

then be placed using periurethral and perivaginal tissues

to provide watertight closure. It should be emphasized

that one suture layer is not enough to secure the urethral

wall properly; two layers are required to avoid fistula

recurrence. The second layer can be either continuous

or interrupted sutures, but must cover the first layer as

completely as possible. Before final vaginal mucosa

closure, careful examination of the suture line with a

fine urethral probe should be attempted to detect unsu-

tured places [3,27��,34–37].

About 50% of patients after such a repair develop stress

urinary incontinence symptoms requiring antiinconti-

nence procedures. If the full-thickness urethral wall

has been used with no tissue tension for fistula closure,

tension-free synthetic tape may be considered as an

antistress procedure for these select patients [3]. Other-

wise, we believe that autologous slings for the correction

of subsequent stress incontinence offer good functional

results with fewer complications.

Interpositional tissue should be considered whenever the

closure lines or the vaginal tissues are of questionable

quality or if subsequent sling placement is being con-

sidered. When tissues are insufficient, a Martius flap

should be considered to secure the closure, which

necessitates careful mobilization of vaginal mucosa. In

contrast with vesicovaginal fistulas, where mobilization is

extended on the perivesical tissue, patients with urethro-

vaginal fistulae often present with minimal space

between urethral wall and the vagina [3]. The Martius

labial fat flap, introduced in 1928 by Martius [38], mainly

consists of fat and connective tissue and has a rich blood

supply [1,2,27��,39–41]. It has been widely accepted and

adopted for the repair of urethrovaginal, vesicovaginal

and rectovaginal fistulae [42,43], for damaged urethra

reconstruction, vaginal or rectal stenosis, and postradia-

tion rectal or vaginal fistulae, with success rates close to

100%. The blood supply of the Martius flap mainly

comes from the posterior labial artery. The labial

fat pad provides the area of reconstruction with an

additional blood supply and epithelization [12��].

Martius flap creation and its placement may be seen

schematically in Fig. 3.

The Martius flap is routinely used for urethrovaginal

fistula closure by Flisser and Blaivas [6]. They advocate

Management of urethrovaginal fistulae Pushkar et al. 393

Figure 3 Martius flap

Martius flap is created (a), and subsequently passed into periurethralarea (b).

single-stage vaginal flap reconstruction with a Martius

flap and concomitant pubovaginal sling. Mundy [44]

achieved anatomical success and continence in 93% of

a case series of 30 patients with an obstruction rate of

41%. Tancer [34] reports continence and anatomical

success in 82% of his series of 34 patients. Elkins et al.[45] report that 90% of their 20 underwent successful

anatomical repair with 50% continent and 10%

obstructed. Hamlin and Nicholson [46] describe 50

patients in whom obstetric trauma caused urethral injury.

They achieved an anatomical success rate of 98% and

continence in 80% of cases. Fall [47] describes vaginal

wall flap repair in 30 patients who often underwent

multiple procedures, including 91% who ultimately

achieved successful repair, and 70% who were continent.

These results emphasize the difficulties of reconstructive

surgery, since continence may be achieved at the cost of

obstruction [6]. Candiani et al. [48] describe a case of

recurrent urethrovaginal fistula closed by using a bulbo-

cavernous musculocutaneous flap. Patil et al. [49]

reported satisfactory surgical results by interposition of

viable gracilis muscle and labial fibrofatty tissue at the

repair site; the author used the modified Ingelman-Sund-

berg procedure. These random case reports, however, do

not allow for systematic review or discussion about this

technique. The same is true for the rectus abdominis

muscle flap procedure [31]. This technique has been

described for refractory urethrovaginal fistulae after failed

repair with Martius flap procedure.

Park and Hendren [50] show promising results using

buccal mucosa grafts for reconstructing difficult urethral

female problems. Potentially buccal mucosa may be

successfully used for the closure of extensive urethral

damage. These data need to be confirmed in a larger

sample group.

Recent surgical applicationsRecently many efforts have been made in the direction of

reconstructive urology. Primarily this has affected issues

such as tissue engineering, organ regeneration, and graft

fabrics [51]. Atala [52] started elegant work on tissue

engineering with a cell culture in order to create a

urethral tube. Unfortunately, it is too early to fully assess

the clinical data. Preliminary findings on fabrication of a

urethral graft using reinforced collagen-sponge tubes

show that urethral tissue regeneration depends not only

on the biomaterial composition, but also on the fabrica-

tion technique [53]. Guan et al. [54] state that human

vascular endothelial growth factor may be a suitable

approach to increase the blood supply in tissue engin-

eering for treatment of urethral damage.

ConclusionUrethrovaginal fistulae in the developed world result

primarily from complications of vaginal surgery for stress

incontinence, urethral diverticula repairs, vaginal vault

prolapse repairs and other vaginal surgeries. New tech-

nologies associated with the use of synthetic mesh must

be widely evaluated in randomized clinical trials [18,19].

All urologists planning to deal with the treatment of stress

urinary incontinence in female patients must familiarize

themselves with vaginal surgery in order to avoid such

complications as unnoticed urethral trauma [15].

The success of any surgical treatment depends on careful

patient selection, and assumes knowledge of all possible

treatment options. Potential work needs to be directed

towards the application of the newest molecular techno-

logies which may provide for artificial urethra creation.

The surgeon needs to remember that this area of recon-

structive surgery is not only anatomical, but also functional

[50]. Every effort directed at the restoration of the patient’s

anatomy should be undertaken only with the clear

understanding of the necessity of obtaining a functionally

satisfactory result with respect to the urethral sphincter

mechanism.

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Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 439).

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