Vaginal fistulas
A vaginal fistula is an abnormal connection between the vagina and a neighboring organ, usually the bladder or the rectum. Most fistulas can be repaired, and repairing them is part of what I do as a fellowship-trained urogynecologist. It is not a problem you have to live with.
Types
Fistulas are named for the two structures they connect:
- Vesicovaginal fistula: between the bladder and the vagina. This is the most common type and causes continuous leakage of urine into the vagina.
- Rectovaginal fistula: between the rectum and the vagina, which allows stool or gas to pass through the vagina.
- Urethrovaginal and ureterovaginal fistulas: less common connections involving the urethra or a ureter.
What causes them
In the United States, most vaginal fistulas are not caused by childbirth. The common causes here are:
- Pelvic surgery, especially hysterectomy
- Radiation therapy for pelvic cancers, which can cause fistulas that appear months or years later
- Severe obstetric tears (a leading cause of rectovaginal fistula)
- Inflammatory bowel disease, particularly Crohn’s disease, for rectovaginal fistulas
Worldwide, the leading cause is prolonged obstructed labor, which is why fistula care is a major focus of global women’s health.
Symptoms
The symptoms depend on which organs are connected:
- A bladder fistula causes constant, uncontrollable leakage of urine into the vagina, unrelated to activity or urge.
- A rectovaginal fistula causes passage of gas, discharge, or stool through the vagina, often with recurrent infections or irritation.
Continuous leakage that does not fit the usual pattern of stress or urge incontinence is a reason to be evaluated for a fistula.
How I diagnose it
Diagnosis starts with a careful pelvic exam. Depending on what I find, I may use:
- A dye test, where the bladder is filled with colored fluid to see where it leaks
- Cystoscopy, a camera exam of the bladder, to locate a bladder fistula and see its relationship to the ureters
- Imaging when the anatomy is complex or the fistula is hard to find
Getting the location, size, and cause right is what determines the repair.
Treatment
- Conservative management: a small, recently formed bladder fistula is sometimes given a trial of continuous catheter drainage, but this closes the fistula only a small percentage of the time, so most fistulas move on to repair.
- Timing: for fistulas after surgery, I often wait until the surrounding tissue inflammation settles before repairing, which improves the chance of a durable closure.
- Surgical repair: the approach is tailored to the fistula. Many bladder fistulas are repaired through the vagina with high success rates. Rectovaginal fistula repair depends on the location of the fistula and whether the anal sphincter is also injured, since the two are often repaired together.
- Tissue flaps: for complex, radiation-related, or previously failed repairs, healthy tissue can be brought in between the two organs to support healing.
When to see me
Consider an appointment if you have:
- Continuous, uncontrollable urine leakage, especially after pelvic surgery or radiation
- Passage of gas or stool through the vagina
- New leakage after a difficult delivery or a severe vaginal tear
- A fistula that was repaired before and has come back
References
- Goh, et al. An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas. Neurourology and Urodynamics. 2020. doi:10.1002/nau.24508
- Breen, et al. Controversies in the management of vesicovaginal fistula. Best Practice & Research Clinical Obstetrics and Gynaecology. 2018. doi:10.1016/j.bpobgyn.2018.06.005
- Dawes, et al. Rectovaginal fistulas secondary to obstetrical injury. Clinics in Colon and Rectal Surgery. 2021. doi:10.1055/s-0040-1714284