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Uterosubvesical fistula as a cause of infertility
IJG-07908; No of Pages 2 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Uterosubvesical fistula as a cause of infertility Paweł Rzymski a,⁎, Maciej Wilczak b, Tomasz Opala a a b
Department of Maternal and Child Health, Poznan University of Medical Sciences, Gynecologic and Obstetric University Hospital, Poznan, Poland Department of Education in Medicine, Poznan University of Medical Sciences Gynecologic and Obstetric University Hospital, Poznan, Poland
a r t i c l e
i n f o
Article history: Received 16 December 2013 Received in revised form 17 February 2014 Accepted 12 March 2014 Keywords: Hysterosalpingography Infertility Uterine dehiscence Uterine fistula
A 32-year-old patient had experienced secondary infertility for 11 years and previous diagnostics had been unsuccessful (ultrasound, laparoscopy, and hormone therapy). Ultrasound examination revealed a discontinuous anterior wall of the uterine isthmus from a previous cesarean delivery. The 15 × 15 × 12 mm dehiscence was of complete thickness. Semen analysis yielded mild astheno-oligospermia, and other causes of infertility were excluded. The patient underwent hysterosalpingography using Schultze instrumentation (Fig. 1). The hysterosalpingogram showed the cervical canal, an oval irregular space measuring approximately 3 × 3 cm in diameter in the isthmus, a normal uterine cavity, and the fallopian tubes. The space was identified as an uterosubvesical fistula that was mildly compressible. The contrast medium did not penetrate to the urinary bladder. The increased risk for ectopic pregnancy, placenta percreta, and uterine rupture during pregnancy was discussed with the patient. The patient accepted limited myometrium resection via minilaparotomy and resuture. The urinary bladder peritoneal margin was incised and the bladder was pulled down. Blue dye was applied transcervically to identify the fistula. Resection of the fistula was performed with a 3-mm margin followed by resuture. Hysterosalpingography was repeated 6 months later and no contrast accumulation was observed. One insemination attempt was performed with the husband’s sperm, which was successful. The course of
the pregnancy was normal. The thickness of the postoperative scar changed from 5.9 mm at 15 weeks of pregnancy to 2.0 mm at 38 weeks. A healthy neonate was delivered by elective cesarean delivery and no scar dehiscence was observed during the puerperium. So-called “delayed postpartum uterine rupture” limited to the subvesical space is very rare [1]. Nineteen cases of ectopic pregnancy within a cesarean delivery scar have been described. This serious condition disrupts the uterine wall and can result in a high risk of placenta accreta [2]. Leaving the uterine wall unrepaired could result in uterine rupture during pregnancy. Early uterine dehiscence is usually treated conservatively and no recommendations for this condition were found in the literature. The pregnancy rate after uterine repair by laparoscopy is 20% − 38% [3]. In the present case, the subvesical space was clearly identified during hysterosalpingography, whereas ultrasound had failed to identify this abnormality. The long period of infertility may have occurred owing to the inflammatory environment in the defective uterine wall and subvesical space [4]. After uterine dehiscence repair some authors recommend careful follow-up of the lower uterine segment and consider elective cesarean delivery. The lower segment should be evaluated carefully during ultrasound to avoid underdiagnosis of this condition. Conflict of interest The authors have no conflicts of interest. References [1] Rivin ME, Carrol CS, Morrison JC. Infectious necrosis with dehiscence of the uterine repair complicating cesarean delivery. A review. Obstet Gynecol Surv 2004;59(12):833–7. [2] Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv 2002;57(8):537–43. [3] Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol 2013;20(3):386–91. [4] Royo P, Maner MG, Olartecoechea B, Alcazar JL. Two-dimentional power Dopplerthree-dimentional ultrasound imaging of a cesarean section dehiscence with uteroperitoneal fistula: a case report. J Med Case Reports 2009;3(1):42.
⁎ Corresponding author at: Department of Maternal and Child Health, Poznan University of Medical Sciences, Gynecologic and Obstetric University Hospital, Polna St 33, 60–535 Poznan, Poland. Tel.: +48 605393096; fax: +48 618419618. E-mail address: [email protected] (P. Rzymski).
http://dx.doi.org/10.1016/j.ijgo.2014.02.007 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Rzymski Pł, et al, Uterosubvesical fistula as a cause of infertility, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/ j.ijgo.2014.02.007
2
P. Rzymski et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Fig. 1. Pretreatment ultrasound examination of uterosubvesical fistula (bottom). Hysterosalpingogram before (left) and after (right) surgical treatment.
Please cite this article as: Rzymski Pł, et al, Uterosubvesical fistula as a cause of infertility, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/ j.ijgo.2014.02.007
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Uterosubvesical fistula as a cause of infertility Paweł Rzymski a,⁎, Maciej Wilczak b, Tomasz Opala a a b
Department of Maternal and Child Health, Poznan University of Medical Sciences, Gynecologic and Obstetric University Hospital, Poznan, Poland Department of Education in Medicine, Poznan University of Medical Sciences Gynecologic and Obstetric University Hospital, Poznan, Poland
a r t i c l e
i n f o
Article history: Received 16 December 2013 Received in revised form 17 February 2014 Accepted 12 March 2014 Keywords: Hysterosalpingography Infertility Uterine dehiscence Uterine fistula
A 32-year-old patient had experienced secondary infertility for 11 years and previous diagnostics had been unsuccessful (ultrasound, laparoscopy, and hormone therapy). Ultrasound examination revealed a discontinuous anterior wall of the uterine isthmus from a previous cesarean delivery. The 15 × 15 × 12 mm dehiscence was of complete thickness. Semen analysis yielded mild astheno-oligospermia, and other causes of infertility were excluded. The patient underwent hysterosalpingography using Schultze instrumentation (Fig. 1). The hysterosalpingogram showed the cervical canal, an oval irregular space measuring approximately 3 × 3 cm in diameter in the isthmus, a normal uterine cavity, and the fallopian tubes. The space was identified as an uterosubvesical fistula that was mildly compressible. The contrast medium did not penetrate to the urinary bladder. The increased risk for ectopic pregnancy, placenta percreta, and uterine rupture during pregnancy was discussed with the patient. The patient accepted limited myometrium resection via minilaparotomy and resuture. The urinary bladder peritoneal margin was incised and the bladder was pulled down. Blue dye was applied transcervically to identify the fistula. Resection of the fistula was performed with a 3-mm margin followed by resuture. Hysterosalpingography was repeated 6 months later and no contrast accumulation was observed. One insemination attempt was performed with the husband’s sperm, which was successful. The course of
the pregnancy was normal. The thickness of the postoperative scar changed from 5.9 mm at 15 weeks of pregnancy to 2.0 mm at 38 weeks. A healthy neonate was delivered by elective cesarean delivery and no scar dehiscence was observed during the puerperium. So-called “delayed postpartum uterine rupture” limited to the subvesical space is very rare [1]. Nineteen cases of ectopic pregnancy within a cesarean delivery scar have been described. This serious condition disrupts the uterine wall and can result in a high risk of placenta accreta [2]. Leaving the uterine wall unrepaired could result in uterine rupture during pregnancy. Early uterine dehiscence is usually treated conservatively and no recommendations for this condition were found in the literature. The pregnancy rate after uterine repair by laparoscopy is 20% − 38% [3]. In the present case, the subvesical space was clearly identified during hysterosalpingography, whereas ultrasound had failed to identify this abnormality. The long period of infertility may have occurred owing to the inflammatory environment in the defective uterine wall and subvesical space [4]. After uterine dehiscence repair some authors recommend careful follow-up of the lower uterine segment and consider elective cesarean delivery. The lower segment should be evaluated carefully during ultrasound to avoid underdiagnosis of this condition. Conflict of interest The authors have no conflicts of interest. References [1] Rivin ME, Carrol CS, Morrison JC. Infectious necrosis with dehiscence of the uterine repair complicating cesarean delivery. A review. Obstet Gynecol Surv 2004;59(12):833–7. [2] Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv 2002;57(8):537–43. [3] Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol 2013;20(3):386–91. [4] Royo P, Maner MG, Olartecoechea B, Alcazar JL. Two-dimentional power Dopplerthree-dimentional ultrasound imaging of a cesarean section dehiscence with uteroperitoneal fistula: a case report. J Med Case Reports 2009;3(1):42.
⁎ Corresponding author at: Department of Maternal and Child Health, Poznan University of Medical Sciences, Gynecologic and Obstetric University Hospital, Polna St 33, 60–535 Poznan, Poland. Tel.: +48 605393096; fax: +48 618419618. E-mail address: [email protected] (P. Rzymski).
http://dx.doi.org/10.1016/j.ijgo.2014.02.007 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Rzymski Pł, et al, Uterosubvesical fistula as a cause of infertility, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/ j.ijgo.2014.02.007
2
P. Rzymski et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Fig. 1. Pretreatment ultrasound examination of uterosubvesical fistula (bottom). Hysterosalpingogram before (left) and after (right) surgical treatment.
Please cite this article as: Rzymski Pł, et al, Uterosubvesical fistula as a cause of infertility, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/ j.ijgo.2014.02.007