Journal of the New Zealand Medical Association, 18-April-2008, Vol 121 No 1272
A rare cause of early post-partum haematuria secondary to uterovesical fistula
Tahrir Basheer, Dominic Lee, Warren Davis, Rahul Rindani
Uterovesical fistulae are uncommon, constituting 1–4% of all urogenital fistulae.6,8 Although the least common type of urogenital fistulae, they cannot be considered a rarity as there are about 800 published cases.11 Most Units report 1–5 cases over 5–15 year periods.3 Presentation is variable, ranging between 3–7 years post-delivery. There are few case reports about this condition following vaginal birth after caesarean (VBAC).8
In this article we outline the immediate diagnosis and the management of a case involving this complication.
A 26-year-old woman, Gravida 2 Para 1, underwent labour. She had a previous delivery by emergency lower-segment caesarean section at 40 weeks gestation after a failed attempt at vacuum delivery. There was no other significant past medical or surgical history.
The current pregnancy was complicated by intrauterine growth restriction (IUGR) and multiple presentations for management of possible antepartum haemorrhage in the last trimester. She was induced at 39 weeks by artificial rupture of membranes (ARM) and syntocin infusion. She had an epidural and in her third stage of labour she developed decelerations in her cardiotocograph (CTG), which became deeper and wider. She progressed to a vacuum-assisted and Wrigley’s forceps delivery. She had persistent frank haematuria post-delivery with haemodynamic instability but mild pain and generalised abdominal tenderness. A 50 ml saline bladder wash was performed; unexpectedly the saline discharged from the vagina.
Dehiscence of the previous caesarean scar with formation of a uterovesical fistula was the initial diagnosis. This was confirmed by cystogram, ultrasound scan, and cystoscopy after involvement of the Urology Team (see Figure 1). Conservative management with transurethral catheter was instituted which failed after 4 months with persistent intermittent urine leak per vaginum, and menouria.
Further discussion of surgical treatment by laparotomy was conducted; a total abdominal hysterectomy and bladder repair with omental patch was decided after considerable counselling.
Intraoperatively, dense fibrous adhesions were noted between the lower segment of the uterus and the bladder. A 2–3 cm fistula was located in the lower segment scar area towards the left side of the uterus. The trigone and ureters were not involved. The hysterectomy was completed and the bladder was repaired with an omental patch. A transurethral catheter was left in situ on free drainage for 2 weeks. At 6 weeks post-surgery, she was continent.
Figure 1. Uterovesical fistula (arrows) on ultrasound scan
While injury to the lower urinary tract is uncommon, occurring in only 0.1–0.3% of births,3 however it is expected to increase worldwide because of an increase in caesarean section rates. This complication is important from clinical, social, and medicolegal aspects.
The causes of peripartum bladder and uterine injury resulting in fistulae formation are nearly always iatrogenic. Risk factors include severe dystocia, instrumental deliveries, manual removal of the placenta, placenta accreta, uterine rupture, and previous caesarean section.3 Labour induction with prostaglandins, in particular ARM and IV syntocin, may be associated with an increased risk of scar dehiscence in comparison to a spontaneous onset of labour this should be emphasized in the consent process with women who have previously delivering via caesarean section.
The development of a fistula is believed to relate to higher attachment of the bladder relative to the lower segment, usually secondary to scarring from previous surgery. With an unrecognised bladder injury or suture transfixion of the bladder, a tract may develop between the bladder and uterine wall. Other risk factors associated with uterovesical fistula are malignancy, irradiation, and intrauterine devices.
Józwik and Józwik have proposed a classification for uterovesical fistula which is based on the route of menstrual flow.7 Type 1 (Youssef syndrome) is menouria, amenorrhoea, and complete continence of urine. Type 2 is dual direction menstrual flow via bladder and vagina. Type 3 is normal vaginal menses but lack of menouria. The management of vesicouterine fistula can be either conservative or surgical.
Conservative management is indicated when the fistula is diagnosed early and is small.1,2,10 Spontaneous healing is reported in 5% of women.1 Surgical treatment is indicated when conservative treatment has failed or in cases involving a large fistula. This is either through laparoscopy or laparotomy immediately after the diagnosis (in 48 hours) or 3–4 months after diagnosis.
The operation can be transperitoneal or retroperitoneal. Either repair of the uterus and the bladder with excision of the fistulous track; or total abdominal hysterectomy and repair of the bladder if the patient has completed her family; can be performed. A transvesical approach involving fulguration of vesical opening6 has also been described but with a high recurrence rate. The pregnancy rate after repair has been reported to be 31.25–37.5% with a rate of term deliveries of 25%.1,14
Fistulae are prevented by meticulous practice of surgical principles at caesarean section with investigations for intraoperative haematuria, caudal retraction of the bladder, and identification of the anatomical landmarks with suturing.
As authors, we recommend that the management should be tailored by the size of the fistula. With small fistulae, conservative management is recommended with expectation of spontaneous closure in 4 months, while big fistulae need surgical treatment.
Author information: Tahrir Basheer, Obstetrics Fellow; Dominic Lee, Urology Registrar; Warren Davis, Obstetrics and Gynaecology Specialist; Rahul Rindani, Urologist; Department of Obstetrics and Gynaecology, Department of Urology, The Wollongong Hospital, Wollongong, NSW, Australia
Correspondence: Dr Dominic Lee, Department of Obstetrics and Gynaecology, Department of Urology, The Wollongong Hospital, Crown Street, Wollongong, NSW, Australia. Email: email@example.com
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