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Vesicouterine Fistula with Menouria: A Complication from an Intrauterine Contraceptive Device
0022-534 7/86/1365-1066$02.00/0 THE JOURNAL OF UROLOGY
Vol. 136, November Printed in U.S.A.
Copyright© 1986 by The Williams & Wilkins Co.
VESICOUTERINE FISTULA WITH MENOURIA: A COMPLICATION FROM AN INTRAUTERINE CONTRACEPTIVE DEVICE DAVID SCHWARTZWALD, UNNI M. M. MOOPPAN, M. LEON TANCER, GUILLERMO GOMEZ-LEON AND HONG KIM From the Departments of Urology, Obstetrics and Gynecology, and Pathology, The Brookdale Hospital Medical Center, Brooklyn, New York
ABSTRACT
We report a case of a vesicouterine fistula with menouria (vesical menstruation) secondary to an intrauterine contraceptive device. Of the 23 cases of menouria reported previously 21 occurred after cesarean section, 1 was secondary to a traumatic forceps delivery and 1 was owing to infection. In our case the fistula did not close after removal of the perforated intrauterine contraceptive device and 2 months of catheter drainage. Closure was achieved by excision of the fistula and hysterectomy. Vesicouterine fistula is an uncommon form of urogenital fistula, which often presents with amenorrhea and cyclic hematuria (menouria). Urinary incontinence occurs only infrequently. To date, only 23 cases of menouria have been reported in the literature, 21 of which were a result of cesarean section. We report a case of a vesicouterine fistula with menouria complicating the placement of an intrauterine contraceptive device.
nected with the lower end of the endometrial cavity, endocervical canal and exocervix, while the upper orifice connected to the upper part of the endometrial cavity. The 2 openings were separated by an area of fibrosis and chronic inflammation containing a remnant of endometrial and endocervical epithelium.
CASE REPORT
E. P., P4024, a 39-year-old woman, was referred to the urology clinic for evaluation of recurrent urinary tract infection and dysuria. She had a 12-year history of oligomenorrhea and had suffered gross painless cyclic hematuria for the last 3 years but no urinary incontinence. A Mazlin spring intrauterine device had been inserted 14 years previously and a subsequent pregnancy 1 year later resulted in a miscarriage. A dilation and curettage procedure was performed, and the patient was told that the intrauterine device was removed. A tubal ligation was done 2 years later to prevent future pregnancy. Present urinalysis showed pus cells and microhematuria. An excretory urogram (IVP) revealed a metal spring in the pelvis and in part of the bladder (fig. 1). Cystoscopy demonstrated metallic wire loops protruding from the posterior wall of the bladder at 2 sites with healthy urothelium between the metal wires. With the patient under general anesthesia a uterine hook was used to remove the metal foreign body (Mazlin spring) from the uterus. Cystoscopy showed 2 small holes at the base of the bladder just above the trigone in the midline where the metal wires had been seen previously. A followup film of the kidneys, ureters and bladder showed no foreign body. A cystogram failed to show any extravasation of urine but a hysterogram revealed a uterovesical fistula (fig. 2). A Foley catheter with a leg bag was worn for 2 months but upon removal gross, cyclic hematuria persisted with amenorrhea. There was no leakage of urine from the vagina. At abdominal hysterectomy the bladder was adherent to the cervix and lower uterine segment by the fistulous tracts. These tracts were transected for removal of the uterus. Two small tracts in the posterior wall of the bladder then were excised and the bladder was closed in 2 layers. An indwelling bladder catheter was left for continuous drainage. The pathological specimen revealed 2 orifices adjacent to each other in a vertical line at the level of the lower uterine segment. The lower orifice conAccepted for publication April 11, 1986.
FIG. 1. Oblique view of IVP shows foreign body, part of it being apparently in bladder. 1066
1067
VESICOUTERINE FKSTiJLA WITH MENOURIA
hematuria, and most often there are symptoms from involvement of other affected areas. Our case readily demonstrates all of the features peculiar to the syndrome of menouria. After injury to the lower segment of the uterus during the insertion of an intrauterine device, the patient experienced many years of oligomenorrhea and cyclic hematuria. There was complete absence of urinary incontinence in the face of a vesicouterine fistula and a patent cervix, both of which were demonstrated by a hysterogram. The foreign body in the bladder contributed to recurrent urinary tract infections. A review of the literature shows that the most common cause of a vesicouterine fistula with menouria is cesarean section. Until 1977 only 14 cases had been reported in the literature and all were secondary to cesarean section. 4 Since then, 6 more cases of menouria resulting from cesarean section, 5- 10 1 owing to a traumatic forceps delivery 11 and 1 resulting from infection 12 have been reported. We believe that our case of a vesicouterine fistula with menouria occurred as a complication of a perforating intrauterine contraceptive device. REFERENCES
FIG. 2. Hysterogram. A to C, progressive filling of bladder. D, oblique film demonstrates fistulous communication between endometrial cavity and bladder.
Convalescence was uneventful and the patient was discharged from the hospital voiding clear urine with no leakage. DISCUSSION
Menouria or vesical menstruation, a syndrome named by Youssef in 1957, is known to occur rarely as a complication of cesarean section with transverse incision in the lower segment. 1 In 194 7 Laffont and Ezes first described this syndrome,2 and in 1956 Falk and Tancer described its treatment. 3 Inadequate downward mobilization of the bladder allows for potential injury by an aberrant suture or excessive devascularization resulting in a vesicouterine fistula. When a fistula is formed above the uterine isthmus patients may have a unidirectional communication resulting in amenorrhea or cyclic hematuria (menouria) but no urinary incontinence. Endometriosis obviously is part of the differential diagnosis. With endometriosis the patient would have normal vaginal menses in addition to
1. Youssef, A. F.: "Menouria" following lower segment cesarean sec-
tion. A syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 2. Laffont, A. and Ezes, H.: Fistule utero-vesicale a sens unique~ regles vesicales. Gynec. et Obst., 46: 248, 1947. 3. Falk, H. C. and Tancer, M. L.: Management of vesical fistulas after cesarean section. Amer. J. Obst. Gynec., 71: 97, 1956. 4. De Carvalho, H. A.: Vesico-uterine fistula. Brit. J. Urol., 49: 172, 1977. 5. Kafetsoulis, A. A.: A case of vesico-uterine fistula. Brit. J. Urol., 46: 587, 1974. 6. Henriksen, H. M.: Vesicouterine fistuia following cesarean section. J. Urol., 125: 884, 1981. 7. Baker, D. A.: Vesicouterine fistula caused by Fusobacterium necrophorum. J. Infect. Dis., 145: 282, 1982. 8. Schroeder, T. and Kristensen, J. K.: A case ofvesicouterine fistula after cesarean section with delivery through the bladder. J. Urol., 129: 371, 1983. 9. Buckspan, M. B., Simha, S. and Klotz, P. G.: Vesicouterine fistula: a rare complication of cesarean section. Obst. Gynec., suppl. 3, 62: 64s, 1983. 10. Pawar, H. N.: Management of vesicouterine fistula following cesarean section. Urology, 25: 66, 1985. 11. Ne!, J. T., Louw, N. S. and Winterbach, H.P.: Youssef's syndrome: a case report. J. Urol., 133: 95, 1985. 12. Mohan, V., Gupta, S. K. and Arora, M.: Cysto-uterine fistula. Brit. ~ Urcl., 55: 245, 1983.
Vol. 136, November Printed in U.S.A.
Copyright© 1986 by The Williams & Wilkins Co.
VESICOUTERINE FISTULA WITH MENOURIA: A COMPLICATION FROM AN INTRAUTERINE CONTRACEPTIVE DEVICE DAVID SCHWARTZWALD, UNNI M. M. MOOPPAN, M. LEON TANCER, GUILLERMO GOMEZ-LEON AND HONG KIM From the Departments of Urology, Obstetrics and Gynecology, and Pathology, The Brookdale Hospital Medical Center, Brooklyn, New York
ABSTRACT
We report a case of a vesicouterine fistula with menouria (vesical menstruation) secondary to an intrauterine contraceptive device. Of the 23 cases of menouria reported previously 21 occurred after cesarean section, 1 was secondary to a traumatic forceps delivery and 1 was owing to infection. In our case the fistula did not close after removal of the perforated intrauterine contraceptive device and 2 months of catheter drainage. Closure was achieved by excision of the fistula and hysterectomy. Vesicouterine fistula is an uncommon form of urogenital fistula, which often presents with amenorrhea and cyclic hematuria (menouria). Urinary incontinence occurs only infrequently. To date, only 23 cases of menouria have been reported in the literature, 21 of which were a result of cesarean section. We report a case of a vesicouterine fistula with menouria complicating the placement of an intrauterine contraceptive device.
nected with the lower end of the endometrial cavity, endocervical canal and exocervix, while the upper orifice connected to the upper part of the endometrial cavity. The 2 openings were separated by an area of fibrosis and chronic inflammation containing a remnant of endometrial and endocervical epithelium.
CASE REPORT
E. P., P4024, a 39-year-old woman, was referred to the urology clinic for evaluation of recurrent urinary tract infection and dysuria. She had a 12-year history of oligomenorrhea and had suffered gross painless cyclic hematuria for the last 3 years but no urinary incontinence. A Mazlin spring intrauterine device had been inserted 14 years previously and a subsequent pregnancy 1 year later resulted in a miscarriage. A dilation and curettage procedure was performed, and the patient was told that the intrauterine device was removed. A tubal ligation was done 2 years later to prevent future pregnancy. Present urinalysis showed pus cells and microhematuria. An excretory urogram (IVP) revealed a metal spring in the pelvis and in part of the bladder (fig. 1). Cystoscopy demonstrated metallic wire loops protruding from the posterior wall of the bladder at 2 sites with healthy urothelium between the metal wires. With the patient under general anesthesia a uterine hook was used to remove the metal foreign body (Mazlin spring) from the uterus. Cystoscopy showed 2 small holes at the base of the bladder just above the trigone in the midline where the metal wires had been seen previously. A followup film of the kidneys, ureters and bladder showed no foreign body. A cystogram failed to show any extravasation of urine but a hysterogram revealed a uterovesical fistula (fig. 2). A Foley catheter with a leg bag was worn for 2 months but upon removal gross, cyclic hematuria persisted with amenorrhea. There was no leakage of urine from the vagina. At abdominal hysterectomy the bladder was adherent to the cervix and lower uterine segment by the fistulous tracts. These tracts were transected for removal of the uterus. Two small tracts in the posterior wall of the bladder then were excised and the bladder was closed in 2 layers. An indwelling bladder catheter was left for continuous drainage. The pathological specimen revealed 2 orifices adjacent to each other in a vertical line at the level of the lower uterine segment. The lower orifice conAccepted for publication April 11, 1986.
FIG. 1. Oblique view of IVP shows foreign body, part of it being apparently in bladder. 1066
1067
VESICOUTERINE FKSTiJLA WITH MENOURIA
hematuria, and most often there are symptoms from involvement of other affected areas. Our case readily demonstrates all of the features peculiar to the syndrome of menouria. After injury to the lower segment of the uterus during the insertion of an intrauterine device, the patient experienced many years of oligomenorrhea and cyclic hematuria. There was complete absence of urinary incontinence in the face of a vesicouterine fistula and a patent cervix, both of which were demonstrated by a hysterogram. The foreign body in the bladder contributed to recurrent urinary tract infections. A review of the literature shows that the most common cause of a vesicouterine fistula with menouria is cesarean section. Until 1977 only 14 cases had been reported in the literature and all were secondary to cesarean section. 4 Since then, 6 more cases of menouria resulting from cesarean section, 5- 10 1 owing to a traumatic forceps delivery 11 and 1 resulting from infection 12 have been reported. We believe that our case of a vesicouterine fistula with menouria occurred as a complication of a perforating intrauterine contraceptive device. REFERENCES
FIG. 2. Hysterogram. A to C, progressive filling of bladder. D, oblique film demonstrates fistulous communication between endometrial cavity and bladder.
Convalescence was uneventful and the patient was discharged from the hospital voiding clear urine with no leakage. DISCUSSION
Menouria or vesical menstruation, a syndrome named by Youssef in 1957, is known to occur rarely as a complication of cesarean section with transverse incision in the lower segment. 1 In 194 7 Laffont and Ezes first described this syndrome,2 and in 1956 Falk and Tancer described its treatment. 3 Inadequate downward mobilization of the bladder allows for potential injury by an aberrant suture or excessive devascularization resulting in a vesicouterine fistula. When a fistula is formed above the uterine isthmus patients may have a unidirectional communication resulting in amenorrhea or cyclic hematuria (menouria) but no urinary incontinence. Endometriosis obviously is part of the differential diagnosis. With endometriosis the patient would have normal vaginal menses in addition to
1. Youssef, A. F.: "Menouria" following lower segment cesarean sec-
tion. A syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 2. Laffont, A. and Ezes, H.: Fistule utero-vesicale a sens unique~ regles vesicales. Gynec. et Obst., 46: 248, 1947. 3. Falk, H. C. and Tancer, M. L.: Management of vesical fistulas after cesarean section. Amer. J. Obst. Gynec., 71: 97, 1956. 4. De Carvalho, H. A.: Vesico-uterine fistula. Brit. J. Urol., 49: 172, 1977. 5. Kafetsoulis, A. A.: A case of vesico-uterine fistula. Brit. J. Urol., 46: 587, 1974. 6. Henriksen, H. M.: Vesicouterine fistuia following cesarean section. J. Urol., 125: 884, 1981. 7. Baker, D. A.: Vesicouterine fistula caused by Fusobacterium necrophorum. J. Infect. Dis., 145: 282, 1982. 8. Schroeder, T. and Kristensen, J. K.: A case ofvesicouterine fistula after cesarean section with delivery through the bladder. J. Urol., 129: 371, 1983. 9. Buckspan, M. B., Simha, S. and Klotz, P. G.: Vesicouterine fistula: a rare complication of cesarean section. Obst. Gynec., suppl. 3, 62: 64s, 1983. 10. Pawar, H. N.: Management of vesicouterine fistula following cesarean section. Urology, 25: 66, 1985. 11. Ne!, J. T., Louw, N. S. and Winterbach, H.P.: Youssef's syndrome: a case report. J. Urol., 133: 95, 1985. 12. Mohan, V., Gupta, S. K. and Arora, M.: Cysto-uterine fistula. Brit. ~ Urcl., 55: 245, 1983.