- Email: [email protected]
Vesico-Ovarian Fistula in Suppurative Ovarian Inflammation and Salpingitis
0022-534 7 /90/1432-0352$02.00/0 Vol. 143, February
THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
VESICO-OVARIAN FISTULA IN SUPPURATIVE OVARIAN INFLAMMATION AND SALPINGITIS P. CARL From the Department of Urology, Deggendorf A1ain Hospital, Deggendorf, Federal Republic of Germany
ABSTRACT
The development of fistulas between the bladder and right ovary in a 27-year-old woman is reported. This exceedingly rare form of an internal vesical fistula occurred as a consequence of dextrolateral adnexitis with suppurative ovarian inflammation after placement of an intrauterine pessary. Therapy consisted of removal of the right adnexa, excision of the fistulous duct and suturing of the bladder. (J. Ural., 143: 352-353, 1990) Vesical fistulas occur as a consequence of surgical or obstetric interventions and radiation, as well as tumors or inflammatory lesions. Because of the anatomical state of the bladder fistulization may extend to a large number of adjacent organs. Vesicovaginal fistulas are the most frequent form of bladder fistula. Vesicouterine fistulas are rare. Depending on the location and resulting clinical symptoms, vesicocervical fistulas with consequent incontinence are distinguished from actual vesicouterine fistulas with menouria (that is cyclic hematuria as well as amenorrhea but no incontinence). 1 • 2 On the other hand, fistulas between the bladder and other organs of the female urogenital tract are exceedingly rare. As an example, a vesicosalpingovaginal fistula was reported in a patient 4 years after fascia! reconstruction. 3 Vesico-ovarian fistulas are even rarer; no recent reports have appeared in a review of the literature. 4 A case of a vesico-ovarian fistula to the right ovary is reported, and the diagnostic and therapeutic procedure is described.
hyperplastic and follicular chronic urocystitis without indications of specificity or malignancy. Transperitoneal exposure with simultaneous extraperitoneal dissection of the right dorsal bladder wall showed an inflammatory fistulous duct to the right ovary, which was the size of a pigeon egg, was taut and elastic, adhered to the parametrium and was surrounded by circumscribed pelvioperitonitis. Furthermore, an opening the size of a pinhead was found on the lateral side of the ovary. This opening was independent of the fistulous duct and secreted greenish-white pus. Also, the surface of the ovary displayed several blackish dots the size of pinheads (fig. 2).
CASE REPORT
A 27-year-old woman, who had had uncomplicated spontaneous deliveries 6 and 8 years previously, had worn an intrauterine pessary for contraception for the last 1½ years. Four weeks before hospitalization dysuric symptoms occurred, and a urinary tract infection was diagnosed and treated by the family physician. Afterwards, persistent microscopic hematuria led to urological consultation. · Urethrocystoscopy revealed a circumscribed region of alteration in the bladder wall in the form of a bunch of grapes, which was suspicious for a right dorsolateral tumor. Constant erythrocyturia and leukocyturia were found in the catheterized urine. However, the urine samples were sterile. Several tuberculous investigations of the morning urine yielded negative results. Cytologically, the urine revealed no malignant cells. An excretory urogram showed no pathological alterations. Urethrocystoscopy showed a 20 mm. in diameter area on the right posterior wall of the bladder that was suspicious for tumor. The tumor partly comprised papillary structures, edematous mucosal alterations in the periphery and a centrally raised erythematous center. A paste-like, yellow secretion emptied from a small opening in this prominent center. With a 3 Ch. ureteral catheter a duct could be probed for 3 cm. from the fistulous opening (fig. 1). Filling with contrast medium under image transducer x-ray control showed a relatively smoothly delimited cavity the size of a walnut at the end of the fistulous duct. X-ray diagnostics of the urinary tract revealed no pathological changes. During the gynecological investigation an appreciable vaginal discharge with an in situ intrauterine pessary was found. The uterus and both adnexae were palpably normal. Biopsy of the fistulous region showed Accepted for publication September 15, 1989. 352
FIG. 1. Probing of fistulous canal from bladder with 3F ureteral catheter and filling of cavity with contrast medium (suppurative ovarian inflammation) at end of fistulous duct.
VESICO-OVARIAN FISTULA IN SUPPURATIVE OVARIAN INFLAMMATION AND SALPINGITIS
353
tions. Gynecological followup and further endoscopic studies were normal. DISCUSSION
FIG. 2. Curved arrow shows displacement of ovary ( 0) from original position (dotted line) into vicinity of bladder (B). F, fimbriae. Fi, fistulous duct. LL, ligamentum latum. LR, ligamentum rotundum. T, fallopian tube. U, uterus.
The right ovary and fallopian tube, which were normal on palpation, were ablated. The fistulous duct to the bladder was excised and the bladder was closed in 2 layers. The intrauterine pessary was removed during the same session. Bacteriological smear investigations from the ovary, fistulous duct and intrauterine pessary yielded Staphylococcus epidermidis. There were no indications of specificity. The histopathological investigation showed a fistulous suppurative inflammation of the right ovary as well as an ovarian abscess on the right side 2.5 cm. in diameter. Furthermore, granulocytic salpingitis and perisalpingitis were found. A focus of endometriosis could not be detected in this region, although a circumscribed focus of endometriosis could be demonstrated histopathologically in another focus of inflammation in Douglas' space. Convalescence was uneventful and there were no complica-
Endoscopic detection of a central opening with secretion already indicated the presence of a fistula in our patient. Similar findings also are observed in vesicointestinal fistulas and are typical for internal vesical fistulas. The rarity of fistulization between the female bladder and the adnexae despite the relative high frequency of severe inflammatory alterations in the region of the adnexae is attributable to the anatomical barriers that prevent direct contact between the bladder and ovary, especially the ligaments of the uterus. Our case shows that in vesical fistulas this unusual route of an inflammatory process also is to be considered, especially in the presence of an already discernible inflammatory genital lesion with pronounced vaginal discharge. In our patient the adnexitis probably was caused by the intrauterine pessary. Such a complication may occur more often with more frequent use of this means of contraception. To plan the operation imaging of the fistulous duct as well as its communicating organ must be done. Multiple bacteriological investigations enable specific perioperative and intraoperative protection. Tuberculosis diagnostic evaluation should not be neglected. In the absence of an endoscopically detectable fistula, besides inflammatory and tumorous alterations, foci of endometriosis in the bladder also are to be ruled out in the differential diagnosis, especially in cases of periodic hematuria, dysuria and bladder pain. REFERENCES 1. Youssef, A. F.: "Menouria" following lower segment cesarean sec-
tion: a syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 2. Wandschneider, G.: "Menouria", ein Symptom bei Vesikozervikalfisteln. Geburtsh. Frauenheilkd., 36: 517, 1976. 3. Turner, B. I., Ekbladh, L. and Edson, M.: Vesicosalpingovaginal fistula. Urology, 8: 49, 1976. 4. Kunz, J.: Urological Complications in Gynecological Surgery and Radiotherapy. Basel: S. Karger, 1984.
THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
VESICO-OVARIAN FISTULA IN SUPPURATIVE OVARIAN INFLAMMATION AND SALPINGITIS P. CARL From the Department of Urology, Deggendorf A1ain Hospital, Deggendorf, Federal Republic of Germany
ABSTRACT
The development of fistulas between the bladder and right ovary in a 27-year-old woman is reported. This exceedingly rare form of an internal vesical fistula occurred as a consequence of dextrolateral adnexitis with suppurative ovarian inflammation after placement of an intrauterine pessary. Therapy consisted of removal of the right adnexa, excision of the fistulous duct and suturing of the bladder. (J. Ural., 143: 352-353, 1990) Vesical fistulas occur as a consequence of surgical or obstetric interventions and radiation, as well as tumors or inflammatory lesions. Because of the anatomical state of the bladder fistulization may extend to a large number of adjacent organs. Vesicovaginal fistulas are the most frequent form of bladder fistula. Vesicouterine fistulas are rare. Depending on the location and resulting clinical symptoms, vesicocervical fistulas with consequent incontinence are distinguished from actual vesicouterine fistulas with menouria (that is cyclic hematuria as well as amenorrhea but no incontinence). 1 • 2 On the other hand, fistulas between the bladder and other organs of the female urogenital tract are exceedingly rare. As an example, a vesicosalpingovaginal fistula was reported in a patient 4 years after fascia! reconstruction. 3 Vesico-ovarian fistulas are even rarer; no recent reports have appeared in a review of the literature. 4 A case of a vesico-ovarian fistula to the right ovary is reported, and the diagnostic and therapeutic procedure is described.
hyperplastic and follicular chronic urocystitis without indications of specificity or malignancy. Transperitoneal exposure with simultaneous extraperitoneal dissection of the right dorsal bladder wall showed an inflammatory fistulous duct to the right ovary, which was the size of a pigeon egg, was taut and elastic, adhered to the parametrium and was surrounded by circumscribed pelvioperitonitis. Furthermore, an opening the size of a pinhead was found on the lateral side of the ovary. This opening was independent of the fistulous duct and secreted greenish-white pus. Also, the surface of the ovary displayed several blackish dots the size of pinheads (fig. 2).
CASE REPORT
A 27-year-old woman, who had had uncomplicated spontaneous deliveries 6 and 8 years previously, had worn an intrauterine pessary for contraception for the last 1½ years. Four weeks before hospitalization dysuric symptoms occurred, and a urinary tract infection was diagnosed and treated by the family physician. Afterwards, persistent microscopic hematuria led to urological consultation. · Urethrocystoscopy revealed a circumscribed region of alteration in the bladder wall in the form of a bunch of grapes, which was suspicious for a right dorsolateral tumor. Constant erythrocyturia and leukocyturia were found in the catheterized urine. However, the urine samples were sterile. Several tuberculous investigations of the morning urine yielded negative results. Cytologically, the urine revealed no malignant cells. An excretory urogram showed no pathological alterations. Urethrocystoscopy showed a 20 mm. in diameter area on the right posterior wall of the bladder that was suspicious for tumor. The tumor partly comprised papillary structures, edematous mucosal alterations in the periphery and a centrally raised erythematous center. A paste-like, yellow secretion emptied from a small opening in this prominent center. With a 3 Ch. ureteral catheter a duct could be probed for 3 cm. from the fistulous opening (fig. 1). Filling with contrast medium under image transducer x-ray control showed a relatively smoothly delimited cavity the size of a walnut at the end of the fistulous duct. X-ray diagnostics of the urinary tract revealed no pathological changes. During the gynecological investigation an appreciable vaginal discharge with an in situ intrauterine pessary was found. The uterus and both adnexae were palpably normal. Biopsy of the fistulous region showed Accepted for publication September 15, 1989. 352
FIG. 1. Probing of fistulous canal from bladder with 3F ureteral catheter and filling of cavity with contrast medium (suppurative ovarian inflammation) at end of fistulous duct.
VESICO-OVARIAN FISTULA IN SUPPURATIVE OVARIAN INFLAMMATION AND SALPINGITIS
353
tions. Gynecological followup and further endoscopic studies were normal. DISCUSSION
FIG. 2. Curved arrow shows displacement of ovary ( 0) from original position (dotted line) into vicinity of bladder (B). F, fimbriae. Fi, fistulous duct. LL, ligamentum latum. LR, ligamentum rotundum. T, fallopian tube. U, uterus.
The right ovary and fallopian tube, which were normal on palpation, were ablated. The fistulous duct to the bladder was excised and the bladder was closed in 2 layers. The intrauterine pessary was removed during the same session. Bacteriological smear investigations from the ovary, fistulous duct and intrauterine pessary yielded Staphylococcus epidermidis. There were no indications of specificity. The histopathological investigation showed a fistulous suppurative inflammation of the right ovary as well as an ovarian abscess on the right side 2.5 cm. in diameter. Furthermore, granulocytic salpingitis and perisalpingitis were found. A focus of endometriosis could not be detected in this region, although a circumscribed focus of endometriosis could be demonstrated histopathologically in another focus of inflammation in Douglas' space. Convalescence was uneventful and there were no complica-
Endoscopic detection of a central opening with secretion already indicated the presence of a fistula in our patient. Similar findings also are observed in vesicointestinal fistulas and are typical for internal vesical fistulas. The rarity of fistulization between the female bladder and the adnexae despite the relative high frequency of severe inflammatory alterations in the region of the adnexae is attributable to the anatomical barriers that prevent direct contact between the bladder and ovary, especially the ligaments of the uterus. Our case shows that in vesical fistulas this unusual route of an inflammatory process also is to be considered, especially in the presence of an already discernible inflammatory genital lesion with pronounced vaginal discharge. In our patient the adnexitis probably was caused by the intrauterine pessary. Such a complication may occur more often with more frequent use of this means of contraception. To plan the operation imaging of the fistulous duct as well as its communicating organ must be done. Multiple bacteriological investigations enable specific perioperative and intraoperative protection. Tuberculosis diagnostic evaluation should not be neglected. In the absence of an endoscopically detectable fistula, besides inflammatory and tumorous alterations, foci of endometriosis in the bladder also are to be ruled out in the differential diagnosis, especially in cases of periodic hematuria, dysuria and bladder pain. REFERENCES 1. Youssef, A. F.: "Menouria" following lower segment cesarean sec-
tion: a syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 2. Wandschneider, G.: "Menouria", ein Symptom bei Vesikozervikalfisteln. Geburtsh. Frauenheilkd., 36: 517, 1976. 3. Turner, B. I., Ekbladh, L. and Edson, M.: Vesicosalpingovaginal fistula. Urology, 8: 49, 1976. 4. Kunz, J.: Urological Complications in Gynecological Surgery and Radiotherapy. Basel: S. Karger, 1984.