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Antenatal diagnosis of vesicouterine fistula
Antenatal diagnosis of vesicouterine fistula Colleen M. Kennedy, MD, David Peleg, MD, Craig Syrop, MD, and Ingrid Nygaard, MD Background: In pregnancy, vesicouterine fistulas usually are diagnosed postpartum after cesarean deliveries. Case: An 18-year-old woman, gravida 3, para 2, with two prior cesarean deliveries had pain and apparent rupture of membranes at 23 weeks’ gestation. At 26 weeks’ gestation, she developed increasing suprapubic pain and irregular contractions. Ultrasonographic findings included a small uterine defect and possible ballooning of membranes into her bladder. Cytoscopy showed ballooning of amnion into the bladder dome. A viable 900-g female infant was delivered by classic cesarean, the fistulous tract was excised, and the rupture sites were repaired. Conclusion: Vesicouterine fistulas might be diagnosed antenatally. With continued contractions and associated uterine rupture, cesarean delivery can be done with excision of the fistulous tract and repair of the rupture sites. (Obstet Gynecol 1999;94:808 –9. © 1999 by The American College of Obstetricians and Gynecologists.)
Vesicouterine fistulas rarely were diagnosed before the 1950s.1 In a comprehensive review of articles published between 1908 and 1986, Tancer1 found 92 cases. There were 18 reported cases from 1908 through 1946. Between 1947 and 1986, the number of reported cases increased to 74. Most occurred after cesarean deliveries, although other etiologies were also reported.2 Typically, vesicouterine fistulas present as constant urinary leakage in the early postoperative period, with cyclic hematuria. A case of a vesicouterine fistula diagnosed antenatally is presented. A MEDLINE search for articles published between 1986 and 1998 was done to update Tancer’s1 review. Searching using the key word “bladder fistula” yielded 420 articles, and each article’s abstract was reviewed. During this period, a total of 115 cases of vesicouterine fistulas were presented, with patients from 17 countries represented. No other cases of antenatally diagnosed vesicouterine fistula with delivery of a viable infant were found.
From the Department of Obstetrics and Gynecology, University of Iowa College of Medicine, Iowa City, Iowa, and Department of Obstetrics and Gynecology, Poriya Government Hospital, Tiberias, Israel.
808 0029-7844/99/$20.00 PII S0029-7844(99)00349-X
Figure 1. Abdominal ultrasound image showing a uterine defect (left arrow) and suggesting a vesicouterine fistula. The right arrow points to fetal membranes.
Case A 18-year-old woman, gravida 3, para 2, was hospitalized at 25 weeks and 1 day’s gestation for premature rupture of membranes. Two weeks before admission, she noted loss of clear fluid from her vagina and intense pelvic pain. The pain subsided in 24 hours and the leakage continued until admission. At that time, speculum examination confirmed rupture of membranes, and her condition was managed expectantly with betamethasone and tocolytics. Ultrasound showed concordant fetal growth and a decreased amount of amniotic fluid; the bladder was not evaluated. Obstetric history included two cesarean deliveries: a primary classic cesarean delivery at 26 weeks and 3 days’ gestation because of severe preeclampsia and a low transverse cesarean delivery at 37 weeks and 3 days’ gestation because of preeclampsia and the scar from the previous cesarean delivery. Otherwise, her medical and surgical histories were unremarkable. One week after admission, she had sharp suprapubic pain and irregular uterine contractions. Urinalysis results were negative and fetal heart tracing showed the heart rate pattern to be within normal limits. Because of the history of a classic cesarean delivery, ultrasound was done to assess uterine rupture, and a 1-cm defect in the lower uterine segment was seen, with what appeared to be amniotic membranes protruding into the bladder (Figure 1). Because of a suspected uterine rupture and increasing contractions, repeat cesarean delivery was done, with the woman’s desire for uterine preservation taken into account. Immediately before surgery, cystoscopy confirmed a vesicouterine fistula, with 2 cm of fetal membranes ballooning into the posterior bladder dome (Figure 2). The ureteral orifices were not involved. At laparotomy, no uterine rupture was seen initially, and the repeat classic cesarean delivery was done, with the incision made above the level of the bladder flap. A viable 900-g female infant was delivered. One- and 5-minute Apgar scores were 7 and 8, respectively. There was dense scar tissue between the
Obstetrics & Gynecology
Figure 2. Preoperative cystoscopic view showing ballooning of fetal membranes into the posterior dome of the bladder.
lower segment of the uterus and the bladder flap. After creation of a bladder flap, a 2-cm uterine defect was found at the right lower edge of the lower uterine segment. The defect appeared to be at the junction between the patient’s transverse and vertical scars. The bladder dome was opened to show a fistula in the right upper posterior dome, with partially epithelialized edges, suggesting a recent, but not acute, rupture. The fistulous tract was excised sharply from the uterus and bladder. The uterus was repaired with a single-running, locking layer of no. 0 polyglycolic acid suture. The bladder was repaired in two layers in a running fashion with no. 2-0 polyglycolic acid suture. Surgicel (Johnson & Johnson, Fort Washington, PA) was placed in the vesicouterine space and a suprapubic catheter was inserted. The woman was discharged home on postoperative day 3 with the suprapubic catheter in place. Her infant was discharged at 54 days of life in stable condition. On postoperative day 11, a cystogram showed a small, persistent bladder defect at the posterior dome, contiguous with the bladder, and suprapubic drainage was continued. On postoperative day 36, repeat cystography showed no vesicouterine fistula, and the suprapubic catheter was removed. Four months postoperatively, the patient reported no urinary leakage, menouria, or urinary tract infections.
Comment In 1954, Nourse and Wishard3 reported a case of a vesicouterine fistula diagnosed intrapartum when macerated fetal parts were seen in the external urethral meatus. In our MEDLINE search, we found no other cases of antenatal diagnosis involving a dead or a viable fetus. Treatments include conservative management and surgical intervention. Several case reports described successful conservative management, including urethral catheterization for bladder decompression, admin-
VOL. 94, NO. 5, PART 2, NOVEMBER 1999
istration of antibiotics, and menstrual cycle suppression to promote spontaneous healing.4,5 Surgical correction usually is required to repair the fistula, and some authors6,7 recommend that repair be delayed for 2–3 months to allow complete uterine involution and reduction of inflammation. Because of increasing contractions and the woman’s desire for more children, we chose to repair the uterine rupture at cesarean delivery, to avoid future surgical repair. Consideration was given to placing an omental J-flap. Uneventful vaginal and cesarean deliveries have been described in women who have undergone repair of vesicouterine fistulas with omental grafts.8 The persistent small defect on the first cystogram in our subject supports using such tissue to reinforce the repair. However, because the woman planned further pregnancies and would require repeat cesarean delivery, we were concerned that this step would increase significantly the risk of future injury to the bowel and omentum.
References 1. Tancer ML. Vesicouterine fistula—A review. Obstet Gynecol Surv 1986;41:743–53. 2. Mohan V, Gupta SK, Arora M. Cysto-uterine fistula. Br J Urol 1983;55:245– 6. 3. Nourse MH, Wishard WN. Uterovesical fistula with fetal parts presenting in external urethral meatus. J Urol 1954;72:374 –7. 4. Vu KK, Brittain PC, Fontenot JP, Harlass FE, Hawley-Bowland CG, Diaz-Ball F. Vesicouterine fistula after cesarean section. A case report. J Reprod Med 1995;40:221–2. 5. Rubino SM. Vesico-uterine fistula treated by amenorrhea induced with contraceptive steroids. Two case reports. Br J Obstet Gynaecol 1980;87:343– 4. 6. Lenkovsky Z, Pode D, Shapiro A, Caine M. Vesicouterine fistula: A rare complication of cesarean section. J Urol 1988;139:123–5. 7. Buckspan MB, Simha S, Klotz PG. Vesicouterine fistula: A rare complication of cesarean section. Obstet Gynecol 1983;62(suppl): 64S– 66S. 8. Kottasz S, Gergely I. Successful pregnancy after surgical repair of vesico-uterine fistula. Int Urol Nephrol 1986;18:289 –98.
Address reprint requests to:
Ingrid Nygaard, MD Department of Obstetrics and Gynecology University of Iowa College of Medicine 200 Hawkins Drive Iowa City, IA 52242 E-mail: [email protected]
Received January 11, 1999. Received in revised form March 12, 1999. Accepted March 18, 1999. Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Kennedy et al
Vesicouterine Fistula
809
Vesicouterine fistulas rarely were diagnosed before the 1950s.1 In a comprehensive review of articles published between 1908 and 1986, Tancer1 found 92 cases. There were 18 reported cases from 1908 through 1946. Between 1947 and 1986, the number of reported cases increased to 74. Most occurred after cesarean deliveries, although other etiologies were also reported.2 Typically, vesicouterine fistulas present as constant urinary leakage in the early postoperative period, with cyclic hematuria. A case of a vesicouterine fistula diagnosed antenatally is presented. A MEDLINE search for articles published between 1986 and 1998 was done to update Tancer’s1 review. Searching using the key word “bladder fistula” yielded 420 articles, and each article’s abstract was reviewed. During this period, a total of 115 cases of vesicouterine fistulas were presented, with patients from 17 countries represented. No other cases of antenatally diagnosed vesicouterine fistula with delivery of a viable infant were found.
From the Department of Obstetrics and Gynecology, University of Iowa College of Medicine, Iowa City, Iowa, and Department of Obstetrics and Gynecology, Poriya Government Hospital, Tiberias, Israel.
808 0029-7844/99/$20.00 PII S0029-7844(99)00349-X
Figure 1. Abdominal ultrasound image showing a uterine defect (left arrow) and suggesting a vesicouterine fistula. The right arrow points to fetal membranes.
Case A 18-year-old woman, gravida 3, para 2, was hospitalized at 25 weeks and 1 day’s gestation for premature rupture of membranes. Two weeks before admission, she noted loss of clear fluid from her vagina and intense pelvic pain. The pain subsided in 24 hours and the leakage continued until admission. At that time, speculum examination confirmed rupture of membranes, and her condition was managed expectantly with betamethasone and tocolytics. Ultrasound showed concordant fetal growth and a decreased amount of amniotic fluid; the bladder was not evaluated. Obstetric history included two cesarean deliveries: a primary classic cesarean delivery at 26 weeks and 3 days’ gestation because of severe preeclampsia and a low transverse cesarean delivery at 37 weeks and 3 days’ gestation because of preeclampsia and the scar from the previous cesarean delivery. Otherwise, her medical and surgical histories were unremarkable. One week after admission, she had sharp suprapubic pain and irregular uterine contractions. Urinalysis results were negative and fetal heart tracing showed the heart rate pattern to be within normal limits. Because of the history of a classic cesarean delivery, ultrasound was done to assess uterine rupture, and a 1-cm defect in the lower uterine segment was seen, with what appeared to be amniotic membranes protruding into the bladder (Figure 1). Because of a suspected uterine rupture and increasing contractions, repeat cesarean delivery was done, with the woman’s desire for uterine preservation taken into account. Immediately before surgery, cystoscopy confirmed a vesicouterine fistula, with 2 cm of fetal membranes ballooning into the posterior bladder dome (Figure 2). The ureteral orifices were not involved. At laparotomy, no uterine rupture was seen initially, and the repeat classic cesarean delivery was done, with the incision made above the level of the bladder flap. A viable 900-g female infant was delivered. One- and 5-minute Apgar scores were 7 and 8, respectively. There was dense scar tissue between the
Obstetrics & Gynecology
Figure 2. Preoperative cystoscopic view showing ballooning of fetal membranes into the posterior dome of the bladder.
lower segment of the uterus and the bladder flap. After creation of a bladder flap, a 2-cm uterine defect was found at the right lower edge of the lower uterine segment. The defect appeared to be at the junction between the patient’s transverse and vertical scars. The bladder dome was opened to show a fistula in the right upper posterior dome, with partially epithelialized edges, suggesting a recent, but not acute, rupture. The fistulous tract was excised sharply from the uterus and bladder. The uterus was repaired with a single-running, locking layer of no. 0 polyglycolic acid suture. The bladder was repaired in two layers in a running fashion with no. 2-0 polyglycolic acid suture. Surgicel (Johnson & Johnson, Fort Washington, PA) was placed in the vesicouterine space and a suprapubic catheter was inserted. The woman was discharged home on postoperative day 3 with the suprapubic catheter in place. Her infant was discharged at 54 days of life in stable condition. On postoperative day 11, a cystogram showed a small, persistent bladder defect at the posterior dome, contiguous with the bladder, and suprapubic drainage was continued. On postoperative day 36, repeat cystography showed no vesicouterine fistula, and the suprapubic catheter was removed. Four months postoperatively, the patient reported no urinary leakage, menouria, or urinary tract infections.
Comment In 1954, Nourse and Wishard3 reported a case of a vesicouterine fistula diagnosed intrapartum when macerated fetal parts were seen in the external urethral meatus. In our MEDLINE search, we found no other cases of antenatal diagnosis involving a dead or a viable fetus. Treatments include conservative management and surgical intervention. Several case reports described successful conservative management, including urethral catheterization for bladder decompression, admin-
VOL. 94, NO. 5, PART 2, NOVEMBER 1999
istration of antibiotics, and menstrual cycle suppression to promote spontaneous healing.4,5 Surgical correction usually is required to repair the fistula, and some authors6,7 recommend that repair be delayed for 2–3 months to allow complete uterine involution and reduction of inflammation. Because of increasing contractions and the woman’s desire for more children, we chose to repair the uterine rupture at cesarean delivery, to avoid future surgical repair. Consideration was given to placing an omental J-flap. Uneventful vaginal and cesarean deliveries have been described in women who have undergone repair of vesicouterine fistulas with omental grafts.8 The persistent small defect on the first cystogram in our subject supports using such tissue to reinforce the repair. However, because the woman planned further pregnancies and would require repeat cesarean delivery, we were concerned that this step would increase significantly the risk of future injury to the bowel and omentum.
References 1. Tancer ML. Vesicouterine fistula—A review. Obstet Gynecol Surv 1986;41:743–53. 2. Mohan V, Gupta SK, Arora M. Cysto-uterine fistula. Br J Urol 1983;55:245– 6. 3. Nourse MH, Wishard WN. Uterovesical fistula with fetal parts presenting in external urethral meatus. J Urol 1954;72:374 –7. 4. Vu KK, Brittain PC, Fontenot JP, Harlass FE, Hawley-Bowland CG, Diaz-Ball F. Vesicouterine fistula after cesarean section. A case report. J Reprod Med 1995;40:221–2. 5. Rubino SM. Vesico-uterine fistula treated by amenorrhea induced with contraceptive steroids. Two case reports. Br J Obstet Gynaecol 1980;87:343– 4. 6. Lenkovsky Z, Pode D, Shapiro A, Caine M. Vesicouterine fistula: A rare complication of cesarean section. J Urol 1988;139:123–5. 7. Buckspan MB, Simha S, Klotz PG. Vesicouterine fistula: A rare complication of cesarean section. Obstet Gynecol 1983;62(suppl): 64S– 66S. 8. Kottasz S, Gergely I. Successful pregnancy after surgical repair of vesico-uterine fistula. Int Urol Nephrol 1986;18:289 –98.
Address reprint requests to:
Ingrid Nygaard, MD Department of Obstetrics and Gynecology University of Iowa College of Medicine 200 Hawkins Drive Iowa City, IA 52242 E-mail: [email protected]
Received January 11, 1999. Received in revised form March 12, 1999. Accepted March 18, 1999. Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Kennedy et al
Vesicouterine Fistula
809