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Clinical classification of vesicouterine fistula
International Journal of Gynecology & Obstetrics 70 Ž2000. 353᎐357
Article
Clinical classification of vesicouterine fistula Maciej Jozwik, Marcin Jozwik ´´ ´´ U Department of Gynecology, Białystok Medical Uni¨ ersity, Białystok, Poland Received 15 November 1999; received in revised form 4 March 2000; accepted 10 March 2000
Abstract Objecti¨ es and Methods: The aim of this paper is to propose a classification of vesicouterine fistula based on the routes of menstrual flow. Results: Three types of the fistula are distinguished: type I ᎏ with menouria; type II ᎏ with dual flow via both the bladder and vagina; and type III ᎏ with normal vaginal menses. Conclusions: There is relevance of such division to both diagnosis and treatment. The simplicity and clinical utility of this classification warrant its widespread use. 䊚 2000 International Federation of Gynecology and Obstetrics. Keywords: Classification; Menouria; Vesicouterine fistula
1. Introduction Vesicouterine fistulas affect mainly young parous women which greatly extends the social impact of this disorder. Although the actual statistical incidence of this type of fistulas is unknown w1x, existing evidence points to their increased occurrence during the past decades. The number of papers on vesicouterine fistulas grows w1,2x. The numbers of described cases per report are rising w3᎐6x. In some patient populations, their incidence among the urogenital fistulas ranks as high as a third place w4,6,7x. The elevated rate of
cesarean section, currently the principal cause of vesicouterine fistulas w5,6,8x, continues. To date, much discussion in the literature on vesicouterine fistulas has concentrated on the possible explanation of continence and incontinence mechanisms in the course of the disease w8,9x. Its presentation is variable w8᎐10x and has not been clearly systematized. In order to provide clarity in its divergent symptomatology, below a clinical classification of vesicouterine fistula is presented and discussed.
2. Method U
Corresponding author. Tel.: q48-85-7468682; fax: q4885-7468682. E-mail address: [email protected] ŽMarcin Jozwik ´´ ..
Clinical features of the fistula were thoroughly evaluated on the grounds of own experience
0020-7292r00r$20.00 䊚 2000 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 2 4 7 - 2
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
354
w2,6,11x and extensive literature search described in detail elsewhere w2x. The pattern of menstruation was found to be of discriminative value. Specifically, the pattern of menstruation simultaneously reflects the degree of patency of the fistulous tract between the bladder and the uterus, and the degree of patency of the cervical canal. Consequently, the proposed division was based on two possible routes of menstrual flow at the presence of the fistula.
3. Results Three types of vesicouterine fistula could be distinguished ŽFig. 1.: 䢇
䢇
䢇
Type I Žof menouria. is characterized by the following symptoms: amenorrhea Žhere the term is understood as lack of vaginal menstruation., menouria Žcyclical appearance of blood-stained urine during the expected time for menstruation., and complete continence of urine. This triad has been known as Youssef’s syndrome w12x. Type II Žof dual flow. is associated with the coexistence of menouria, vaginal menses, and constant or periodic incontinence of urine. Type III Žof vaginal menses. is characterized by the lack of menouria, normal vaginal menstruation, and constant or periodic incontinence of urine.
4. Discussion Medical classifications represent arbitrary means of communication between health providers in order to describe the diversity of biological phenomena, like types and severity of the disease, subgroups of patients, or treatment modalities. The principle of a good classification is that it should be relatively simple, clinically significant and illustrative. Our classification of vesicouterine fistula fulfills these criteria. It clearly systematizes the fistula’s presentation and we see
the primary role of the classification in helping to define the ailment at the moment of diagnosis. For types I and II, it permits us to ascribe a given patient a particular fistula type on the grounds of prominent symptoms even in the primary care setting. The diagnosis of type III demands laboratory workup and the advent of imaging techniques. The incidence of a particular type of the vesicouterine fistula needs future evaluation since there are not many papers presenting sufficient clinical details. In our experience with 25 fistulas w2,6x, there was one case of type II, the remainder being type I lesions. All six patients from the study of Kumar et al. w3x were of type I. In a five-case study, Furbetta et al. w5x, three cases were of type II while two cases were type III. Therefore, a current conclusion is that the most frequent presentation is type I, and type III being the rarest. Type I fistulas are unusual among urogenital fistulas because of urinary continence. Cyclical appearance of blood-stained urine during the expected menstrual period is the result of the evacuation of menses through the fistulous tract to the bladder where they are diluted in urine and expelled via the urethra during micturition. Some patients are able to notice tissue elements in the discharged urine, these being the fragments of the desquamated endometrium. It should be noted that the term ‘cyclical hematuria’, frequently used instead of the term ‘menouria’, is not accurate, because it only implies the presence of erythrocytes in urine. For the phenomenon of transvesical discharge of puerperal lochia, Parulekar w13x proposed a precise designation: lochiauria. In type I, the symptoms can be well tolerated by the patient since no leakage of urine is present. For reasons unclear to date, at the level of the internal cervical os a stop in passage occurs, and cases of treatment refusal are known w8,13x. Also hygienic aspects of menstruation via the bladder have been considered to be of convenience w14x. Since the presence of urine in the genital tract decreases reproductive capacities w11,15x, type I vesicouterine fistula patients may seek medical assistance because of their wish to have children, and not because of urinary symptoms.
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
355
Fig. 1. Clinical classification of vesicouterine fistula. Type I is consistent with Youssef’s syndrome, i.e. the menstrual blood is discharged transvesically as menouria Ža.. Type II is characterized by the dual flow of menstrual blood, i.e. menouria and vaginal route Žb.. In type III normal discharge of menstrual blood via the vagina occurs Žc.. Black arrows indicate the routes of menstrual blood passage, gray arrows indicate the routes of urine passage.
In contrast, urinary incontinence in the types II and III is extraurethral incontinence; leakage occurs via the fistulous tract through the cervix to the vagina. Also, periodic incontinence of urine in some of type II and type III patients needs com-
menting. This periodicity suggests that a small fistula can be patent during a particular phase of the menstrual cycle. Detailed descriptions of such cases have been published w5,16x. A recent review of world data w2x demonstrated high effectiveness
356
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
of hormonal manipulation by means of amenorrhea induction in the treatment of the fistula. The best candidates for such therapy are yet to be determined. At least small fistulas with only periodic urinary incontinence seem worth trying hormonal manipulation before resorting to surgery. Noteworthy, types of vesicouterine fistulas with menouria, i.e. types I and II, seem to be particularly susceptible to develop sequelae of vesical endometriosis w16,17x and recurrent cystitis w4x as a result of the presence in the bladder of a desquamated ectopic biological material with tremendous implantational capacities. Our classification is helpful in selecting possible patients for treatment of these sequelae. Although the vast majority of the fistula patients are women of reproductive age, two groups of patients beyond that age have also been described. The first group is the women with congenital lesions. All the three cases described had, among other abnormalities, atretic vaginae w18᎐20x. The second group is the postmenopausal women. Unusual singular reports described examples of the fistula due to necrotizing uterine myoma with the involvement of the bladder w21x, intrauterine contraceptive devices left for years in the uterine cavity and penetrating the bladder w22,23x, or ‘burning sensation in the vagina’ w24x. We think that such peculiar cases deserve consideration according to their individual merits. It is important to note that menouria is not a characteristic feature of any type of vesicouterine fistula, but a characteristic feature of the route of menstrual discharge. This distinction has been well illustrated with a case of concomitant vaginal atresia and vesicovaginal fistula w25x. In conclusion, the proposed classification based on the routes of menstrual flow clearly differentiates three subsets of vesicouterine fistula patients. There is relevance of such division to both diagnosis and treatment. The simplicity and clinical utility of this classification warrant its widespread use.
w2x
w3x
w4x
w5x
w6x
w7x
w8x w9x
w10x
w11x
w12x
w13x w14x
w15x
w16x
w17x
w18x
References w1x Jozwik M, Jozwik M, Lotocki W. Actual incidence and ´ ´
w19x
cause of vesico-uterine fistula. Br J Urol 1998;81: 341᎐342. Jozwik ´´ M, Jozwik ´´ M. Spontaneous closure of vesicouterine fistula. Account for effective hormonal treatment. Urol Int 1999;62:183᎐187. Kumar A, Vaidyanathan S, Sharma SK, Sharma AK, Goswami AK. Management of vesico-uterine fistulae: a report of six cases. Int J Gynecol Obstet 1988;26: 453᎐457. El Moussaoui A, Aboutaieb R, Bennani S, Elmrini M, Meziane F, Benjelloun S. Vesico-uterine fistulae. Analysis of 19 cases. J Urol ŽParis. 1994;100:143᎐146. Furbetta A, Fagioli A, Cristini C, Michetti PM, Trucchi A, Signore S et al. Vesicouterine fistulae as complications of repeated cesarean section. Int Urogynecol J 1994;5:240᎐246. Jozwik M, Jozwik M, Łotocki W. Vesicouterine fistula ´´ ´´ ᎏ an analysis of 24 cases from Poland. Int J Gynecol Obstet 1997;57:169᎐172. Onuora VC, Al-Mohalhal S, Youssef AM, Patil M. Iatrogenic urogenital fistulae. Br J Urol 1993;71: 176᎐178. Tancer ML. Vesicouterine fistula ᎏ a review. Obstet Gynecol Surv 1986;41:743᎐753. Dubuisson JB, Barbot J, Santarelli J. Vesico-uterine fistulae after caesarean operation. J Gynecol Obstet Biol Reprod ŽParis. 1979;8:229᎐233. Al-Rifaei M, El-Salmy S, Al-Rifaei A, Salama A. Vesicouterine fistula ᎏ variable clinical presentation. Scand J Urol Nephrol 1996;30:287᎐289. Łotocki W, Jozwik M, Jozwik M. Prognosis of fertility ´´ ´´ after surgical closure of vesicouterine fistula. Eur J Obstet Gynecol Reprod Biol 1996;64:87᎐90. Youssef AF. ‘Menouria’ following lower segment cesarean section. A syndrome. Am J Obstet Gynecol 1957;73:759᎐767. Parulekar SV. Lochiauria: a new entity Ža case report.. J Postgrad Med 1989;35:228᎐229. Rauramo L, Ruponen S. Post-caesarean menouria ŽYoussef’s syndrome.. Acta Obstet Gynecol Scand 1966; 45:248᎐253. Krajnovic B. Asymptomatic ´ P, Smiljanic´ N, Gasparac ˇ postoperative cervico-vesical ventile fistula as possible sterility cause. Arch Gynecol 1979;228:548᎐549. Zie ˛ba Z, Kaczmarek J. Endometriosis of the urinary bladder and uterovesical fistula as a result of cesarean section. Ginekol Pol 1989;60:297᎐299. Borowski K. Uterus᎐bladder fistula following cesarean section ŽYoussef’s syndrome. disguised as urinary bladder endometriosis. Zentralbl Gynakol 1973;95:1684᎐ 1686. Nelson SK, Nelson S. Congenital utero-vesical fistula: a case report. East Afr Med J 1977;54:507᎐509. Reece EA, Wible J, Gilhooly P, Tretter W, Crum C. Congenital uterovesical fistula. Diagn Gynecol Obstet 1982;4:207᎐210.
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357 w20x Williams MPL, Busaidy S, Rickwood AMK. Congenital uterovesical fistula in a patient with the VATER syndrome. Br J Urol 1988;61:361᎐362. w21x Nagyfy SF, Hock E, Courtnage WH. Vesicouterine fistula associated with a calcified leiomyoma. Am J Obstet Gynecol 1955;69:861᎐864. w22x Schwartzwald D, Mooppan UMM, Tancer ML, GomezLeon G, Kim H. Vesicouterine fistula with menouria. A complication from an intrauterine contraceptive device. J Urol 1986;136:1066᎐1067.
357
w23x Buckley P, McInerney PD, Stephenson TP. Actinomycotic vesico-uterine fistula from a wishbone pessary contraceptive device. Br J Urol 1991;68:206᎐207. w24x Gann Jr. D. Healing of vesico-uterine fistula after radium. Urol Cutan Rev 1922;26:343᎐344. w25x Verhoeven ATM. Primary menouria due to congenital vesicovaginal fistula. Obstet Gynecol 1973;41:515᎐520.
Article
Clinical classification of vesicouterine fistula Maciej Jozwik, Marcin Jozwik ´´ ´´ U Department of Gynecology, Białystok Medical Uni¨ ersity, Białystok, Poland Received 15 November 1999; received in revised form 4 March 2000; accepted 10 March 2000
Abstract Objecti¨ es and Methods: The aim of this paper is to propose a classification of vesicouterine fistula based on the routes of menstrual flow. Results: Three types of the fistula are distinguished: type I ᎏ with menouria; type II ᎏ with dual flow via both the bladder and vagina; and type III ᎏ with normal vaginal menses. Conclusions: There is relevance of such division to both diagnosis and treatment. The simplicity and clinical utility of this classification warrant its widespread use. 䊚 2000 International Federation of Gynecology and Obstetrics. Keywords: Classification; Menouria; Vesicouterine fistula
1. Introduction Vesicouterine fistulas affect mainly young parous women which greatly extends the social impact of this disorder. Although the actual statistical incidence of this type of fistulas is unknown w1x, existing evidence points to their increased occurrence during the past decades. The number of papers on vesicouterine fistulas grows w1,2x. The numbers of described cases per report are rising w3᎐6x. In some patient populations, their incidence among the urogenital fistulas ranks as high as a third place w4,6,7x. The elevated rate of
cesarean section, currently the principal cause of vesicouterine fistulas w5,6,8x, continues. To date, much discussion in the literature on vesicouterine fistulas has concentrated on the possible explanation of continence and incontinence mechanisms in the course of the disease w8,9x. Its presentation is variable w8᎐10x and has not been clearly systematized. In order to provide clarity in its divergent symptomatology, below a clinical classification of vesicouterine fistula is presented and discussed.
2. Method U
Corresponding author. Tel.: q48-85-7468682; fax: q4885-7468682. E-mail address: [email protected] ŽMarcin Jozwik ´´ ..
Clinical features of the fistula were thoroughly evaluated on the grounds of own experience
0020-7292r00r$20.00 䊚 2000 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 2 4 7 - 2
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
354
w2,6,11x and extensive literature search described in detail elsewhere w2x. The pattern of menstruation was found to be of discriminative value. Specifically, the pattern of menstruation simultaneously reflects the degree of patency of the fistulous tract between the bladder and the uterus, and the degree of patency of the cervical canal. Consequently, the proposed division was based on two possible routes of menstrual flow at the presence of the fistula.
3. Results Three types of vesicouterine fistula could be distinguished ŽFig. 1.: 䢇
䢇
䢇
Type I Žof menouria. is characterized by the following symptoms: amenorrhea Žhere the term is understood as lack of vaginal menstruation., menouria Žcyclical appearance of blood-stained urine during the expected time for menstruation., and complete continence of urine. This triad has been known as Youssef’s syndrome w12x. Type II Žof dual flow. is associated with the coexistence of menouria, vaginal menses, and constant or periodic incontinence of urine. Type III Žof vaginal menses. is characterized by the lack of menouria, normal vaginal menstruation, and constant or periodic incontinence of urine.
4. Discussion Medical classifications represent arbitrary means of communication between health providers in order to describe the diversity of biological phenomena, like types and severity of the disease, subgroups of patients, or treatment modalities. The principle of a good classification is that it should be relatively simple, clinically significant and illustrative. Our classification of vesicouterine fistula fulfills these criteria. It clearly systematizes the fistula’s presentation and we see
the primary role of the classification in helping to define the ailment at the moment of diagnosis. For types I and II, it permits us to ascribe a given patient a particular fistula type on the grounds of prominent symptoms even in the primary care setting. The diagnosis of type III demands laboratory workup and the advent of imaging techniques. The incidence of a particular type of the vesicouterine fistula needs future evaluation since there are not many papers presenting sufficient clinical details. In our experience with 25 fistulas w2,6x, there was one case of type II, the remainder being type I lesions. All six patients from the study of Kumar et al. w3x were of type I. In a five-case study, Furbetta et al. w5x, three cases were of type II while two cases were type III. Therefore, a current conclusion is that the most frequent presentation is type I, and type III being the rarest. Type I fistulas are unusual among urogenital fistulas because of urinary continence. Cyclical appearance of blood-stained urine during the expected menstrual period is the result of the evacuation of menses through the fistulous tract to the bladder where they are diluted in urine and expelled via the urethra during micturition. Some patients are able to notice tissue elements in the discharged urine, these being the fragments of the desquamated endometrium. It should be noted that the term ‘cyclical hematuria’, frequently used instead of the term ‘menouria’, is not accurate, because it only implies the presence of erythrocytes in urine. For the phenomenon of transvesical discharge of puerperal lochia, Parulekar w13x proposed a precise designation: lochiauria. In type I, the symptoms can be well tolerated by the patient since no leakage of urine is present. For reasons unclear to date, at the level of the internal cervical os a stop in passage occurs, and cases of treatment refusal are known w8,13x. Also hygienic aspects of menstruation via the bladder have been considered to be of convenience w14x. Since the presence of urine in the genital tract decreases reproductive capacities w11,15x, type I vesicouterine fistula patients may seek medical assistance because of their wish to have children, and not because of urinary symptoms.
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
355
Fig. 1. Clinical classification of vesicouterine fistula. Type I is consistent with Youssef’s syndrome, i.e. the menstrual blood is discharged transvesically as menouria Ža.. Type II is characterized by the dual flow of menstrual blood, i.e. menouria and vaginal route Žb.. In type III normal discharge of menstrual blood via the vagina occurs Žc.. Black arrows indicate the routes of menstrual blood passage, gray arrows indicate the routes of urine passage.
In contrast, urinary incontinence in the types II and III is extraurethral incontinence; leakage occurs via the fistulous tract through the cervix to the vagina. Also, periodic incontinence of urine in some of type II and type III patients needs com-
menting. This periodicity suggests that a small fistula can be patent during a particular phase of the menstrual cycle. Detailed descriptions of such cases have been published w5,16x. A recent review of world data w2x demonstrated high effectiveness
356
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357
of hormonal manipulation by means of amenorrhea induction in the treatment of the fistula. The best candidates for such therapy are yet to be determined. At least small fistulas with only periodic urinary incontinence seem worth trying hormonal manipulation before resorting to surgery. Noteworthy, types of vesicouterine fistulas with menouria, i.e. types I and II, seem to be particularly susceptible to develop sequelae of vesical endometriosis w16,17x and recurrent cystitis w4x as a result of the presence in the bladder of a desquamated ectopic biological material with tremendous implantational capacities. Our classification is helpful in selecting possible patients for treatment of these sequelae. Although the vast majority of the fistula patients are women of reproductive age, two groups of patients beyond that age have also been described. The first group is the women with congenital lesions. All the three cases described had, among other abnormalities, atretic vaginae w18᎐20x. The second group is the postmenopausal women. Unusual singular reports described examples of the fistula due to necrotizing uterine myoma with the involvement of the bladder w21x, intrauterine contraceptive devices left for years in the uterine cavity and penetrating the bladder w22,23x, or ‘burning sensation in the vagina’ w24x. We think that such peculiar cases deserve consideration according to their individual merits. It is important to note that menouria is not a characteristic feature of any type of vesicouterine fistula, but a characteristic feature of the route of menstrual discharge. This distinction has been well illustrated with a case of concomitant vaginal atresia and vesicovaginal fistula w25x. In conclusion, the proposed classification based on the routes of menstrual flow clearly differentiates three subsets of vesicouterine fistula patients. There is relevance of such division to both diagnosis and treatment. The simplicity and clinical utility of this classification warrant its widespread use.
w2x
w3x
w4x
w5x
w6x
w7x
w8x w9x
w10x
w11x
w12x
w13x w14x
w15x
w16x
w17x
w18x
References w1x Jozwik M, Jozwik M, Lotocki W. Actual incidence and ´ ´
w19x
cause of vesico-uterine fistula. Br J Urol 1998;81: 341᎐342. Jozwik ´´ M, Jozwik ´´ M. Spontaneous closure of vesicouterine fistula. Account for effective hormonal treatment. Urol Int 1999;62:183᎐187. Kumar A, Vaidyanathan S, Sharma SK, Sharma AK, Goswami AK. Management of vesico-uterine fistulae: a report of six cases. Int J Gynecol Obstet 1988;26: 453᎐457. El Moussaoui A, Aboutaieb R, Bennani S, Elmrini M, Meziane F, Benjelloun S. Vesico-uterine fistulae. Analysis of 19 cases. J Urol ŽParis. 1994;100:143᎐146. Furbetta A, Fagioli A, Cristini C, Michetti PM, Trucchi A, Signore S et al. Vesicouterine fistulae as complications of repeated cesarean section. Int Urogynecol J 1994;5:240᎐246. Jozwik M, Jozwik M, Łotocki W. Vesicouterine fistula ´´ ´´ ᎏ an analysis of 24 cases from Poland. Int J Gynecol Obstet 1997;57:169᎐172. Onuora VC, Al-Mohalhal S, Youssef AM, Patil M. Iatrogenic urogenital fistulae. Br J Urol 1993;71: 176᎐178. Tancer ML. Vesicouterine fistula ᎏ a review. Obstet Gynecol Surv 1986;41:743᎐753. Dubuisson JB, Barbot J, Santarelli J. Vesico-uterine fistulae after caesarean operation. J Gynecol Obstet Biol Reprod ŽParis. 1979;8:229᎐233. Al-Rifaei M, El-Salmy S, Al-Rifaei A, Salama A. Vesicouterine fistula ᎏ variable clinical presentation. Scand J Urol Nephrol 1996;30:287᎐289. Łotocki W, Jozwik M, Jozwik M. Prognosis of fertility ´´ ´´ after surgical closure of vesicouterine fistula. Eur J Obstet Gynecol Reprod Biol 1996;64:87᎐90. Youssef AF. ‘Menouria’ following lower segment cesarean section. A syndrome. Am J Obstet Gynecol 1957;73:759᎐767. Parulekar SV. Lochiauria: a new entity Ža case report.. J Postgrad Med 1989;35:228᎐229. Rauramo L, Ruponen S. Post-caesarean menouria ŽYoussef’s syndrome.. Acta Obstet Gynecol Scand 1966; 45:248᎐253. Krajnovic B. Asymptomatic ´ P, Smiljanic´ N, Gasparac ˇ postoperative cervico-vesical ventile fistula as possible sterility cause. Arch Gynecol 1979;228:548᎐549. Zie ˛ba Z, Kaczmarek J. Endometriosis of the urinary bladder and uterovesical fistula as a result of cesarean section. Ginekol Pol 1989;60:297᎐299. Borowski K. Uterus᎐bladder fistula following cesarean section ŽYoussef’s syndrome. disguised as urinary bladder endometriosis. Zentralbl Gynakol 1973;95:1684᎐ 1686. Nelson SK, Nelson S. Congenital utero-vesical fistula: a case report. East Afr Med J 1977;54:507᎐509. Reece EA, Wible J, Gilhooly P, Tretter W, Crum C. Congenital uterovesical fistula. Diagn Gynecol Obstet 1982;4:207᎐210.
M. Jozwik, M. Jozwik ´´ ´´ r International Journal of Gynecology & Obstetrics 70 (2000) 353᎐357 w20x Williams MPL, Busaidy S, Rickwood AMK. Congenital uterovesical fistula in a patient with the VATER syndrome. Br J Urol 1988;61:361᎐362. w21x Nagyfy SF, Hock E, Courtnage WH. Vesicouterine fistula associated with a calcified leiomyoma. Am J Obstet Gynecol 1955;69:861᎐864. w22x Schwartzwald D, Mooppan UMM, Tancer ML, GomezLeon G, Kim H. Vesicouterine fistula with menouria. A complication from an intrauterine contraceptive device. J Urol 1986;136:1066᎐1067.
357
w23x Buckley P, McInerney PD, Stephenson TP. Actinomycotic vesico-uterine fistula from a wishbone pessary contraceptive device. Br J Urol 1991;68:206᎐207. w24x Gann Jr. D. Healing of vesico-uterine fistula after radium. Urol Cutan Rev 1922;26:343᎐344. w25x Verhoeven ATM. Primary menouria due to congenital vesicovaginal fistula. Obstet Gynecol 1973;41:515᎐520.