Urinary Fistulae in Females & Males

Background

A fistula is an abnormal connection between organs that are naturally meant to be separate.  While there are many different kinds of fistulae (pleural of fistula) that involve various organ systems, we deal with fistulae that involve the urinary tract.  For example, vesicovaginal fistula is an abnormal connection between the bladder and vagina in a female.  Most fistulae involving the urinary tract result in profound symptoms and physical impairment due to incontinence, recurring infections, chemical irritation from contact with urine and passage of intestinal contents (gas or stool) through the urinary system.  For instance, colovesical fistula (abnormal connection between colon and bladder) may develop in men or women with inflammatory bowel disease or diverticulitis and can result in passage of gas or stool in the urine, frequent UTI's and even sepsis (severe infection that enters the bloodstream).

 

 

Causes

Most fistulae we see are the result of previous medical interventions such as surgery or radiation therapy for cancer (eg. prostate cancer in men, uterine or cervical cancer in women, colorectal cancer in both).  A fistula may also arise due to underlying diseases such as inflammatory bowel disease, diverticulitis or even cancer which can cause the colon to perforate and erode into the adjacent bladder wall.  Some fistulae are a consequence of congenital abnormalities (issue that one is born with) such as hypospadias or subsequent surgeries to address this.

The types of fistulae that we manage include the following:

Males

  • urethrocutaneous (abnormal opening anywhere along the course of the urethra)
  • rectoprostatic or rectourethral (communication between the rectum and prostate or urethra usually after radiation +/- surgery for prostate cancer)
  • colovesical (communication between colon and bladder)

Females

  • urethrovaginal (opening between the urethra and vagina, usually due to prior vaginal surgery, rarely due to difficult labour)
  • vesicovaginal (opening between the bladder and vagina, usually due to prior hysterectomy, rarely due to difficult labour)
  • ureterovaginal (opening between the ureter and vagina, usually due to prior hysterectomy or other pelvic surgery)
  • colovesical (communication between colon and bladder)

Diagnosis & Evaulation

The diagnosis is usually strongly suspected by completing a detailed medical history and physical examination.  Confirmation of the diagnosis usually requires cystscopy, dye testing (eg. placing dye in the bladder seeing it come out of the vagina confirms an fistula between those two organs) and imaging tests.  A detailed anatomical assessment of the fistula (ie. location, size, number) and the organ systems involved is required to plan treatment.

 

Treatment

In the vast majority of cases, surgery is required to repair urinary tract fistulae.  In very rare circumstances, simply providing drainage and treating underlying medical issues may provide resolution.  Surgery for fistulae requires that the fistula tract be identified and transected resulting in separation of the 2 organ systems beyond the borders of the fistula.  The fistula tract itself may be excised and the opening in each of the organ systems is repaired.  Often, healthy tissue from an nearby site (known as a flap) is brought in to separate the repaired organ systems and prevent reformation of another fistula tract.  Adequate drainage of the urinary tract through catheterization is required for a few weeks to optimize healing and divert urine away from the repair. 

The details of the surgical procedure and recovery period are specific to the type of fistula repair being done.  These details can be found in the procedures and surgery section.

 

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