Fistulas
A fistula is an abnormal communication between anatomical structures, including organs, vessels, body cavities, or skin. In high-income settings, pelvic surgery is the leading cause of female vesicovaginal fistula; radiation and obstetric injury are other causes.[1] Fistula management may involve drainage, reconstruction, or diversion according to cause and tissue condition. This section organizes fistulas by the patient population in which they occur, because the anatomic relationships, surgical approaches, and interposition options differ substantially between men and women.
For the operative origins of these injuries, see Procedures Causing GU Injury and Intraoperative Consultation.
Fistulas in Females
- Vesicovaginal FistulaThe most common acquired GU fistula in the developed world — iatrogenic after gynecologic surgery; obstetric in low-resource settings.
- Vesicouterine FistulaBladder-to-uterus communication — classically Youssef syndrome after cesarean delivery; menouria, amenorrhea, and preserved urinary continence.
- Ureterovaginal FistulaUreter–vagina communication after pelvic surgery; presents like VVF but requires a distinct diagnostic workup and upper-tract management.
- Rectovaginal FistulaRectum-to-vagina communication — obstetric, inflammatory bowel disease, radiation, or surgical injury; often encountered alongside urinary fistulas in complex multi-compartment cases.
- Obstetric FistulaObstetric fistulas follow prolonged obstructed labor or delivery injury, concentrated where emergency obstetric care is limited; repair timing depends on tissue recovery.[1]
Fistulas in Males
- Rectovesical FistulaBladder-to-rectum communication — post-prostatectomy (rare), radiation, pelvic malignancy, or traumatic.
- Rectourethral FistulaAlmost exclusively in men — post-prostate-cancer treatment (radical prostatectomy, radiation, cryotherapy, HIFU); demands coordinated urologic and colorectal reconstruction.
- Urethropubic FistulaUrinary tract-to-pubic-symphysis fistula, usually after prostate radiotherapy (93% of 248 reported cases); often with osteomyelitis, needing bone debridement with reconstruction or diversion.[2][3]
- Urethrocutaneous FistulaThe most common cutaneous GU fistula — complication of hypospadias repair, urethroplasty dehiscence, perineal trauma, or Fournier's gangrene.
- Urethroperineal FistulaUrethra-to-perineum communication — Fournier's sequela, complex urethroplasty failure, or perineal trauma.
Fistulas (All Patients)
- Pyeloenteric FistulaA fistula between the kidney's collecting system and the bowel, usually after infection, stones or trauma.
- Nephropleural FistulaCommunication between the collecting system and pleural space — most often after PCNL in a supracostal puncture or following thoracoabdominal trauma.
- Ureterocolonic FistulaUreter–colon communication from diverticular disease, Crohn's, radiation, malignancy, or iatrogenic colorectal injury.
- Colovesical & Small Bowel FistulasEnterovesical fistulas from diverticulitis (most common), Crohn's disease, colorectal malignancy, radiation, and surgical injury — pneumaturia and fecaluria are characteristic clues requiring confirmation.
- Vesicocutaneous FistulaBladder-to-skin communication — post-operative, radiation-associated, chronic catheterization, or malignant erosion.
- Urinary Fistula After Kidney TransplantUreteroneocystostomy leak, ureteral necrosis from distal-ureter ischemia, and graft-to-bladder disruption — the principal early urologic complication of renal transplantation.
- Vascular-Urinary FistulaArterioureteral fistulas can cause life-threatening hemorrhage; the page also covers renal arteriovenous fistulas, including post-biopsy lesions.
Complex Fistula Principles
The following principles guide repair of complex pelvic urinary and rectovaginal fistulas. Anatomy, tissue condition, and prior treatment determine pelvic fistula complexity; features that affect repair include:
- Multiplicity. Two or more fistulous tracts
- Prior failed repair(s). At least one previous attempt
- Hostile tissue. Radiation, ischemia, infection, or inflammatory bowel disease
- Large defect. Significant tissue loss precluding primary closure
- Multi-organ involvement. Urinary, enteric, and vaginal or cutaneous
- Associated malignancy or recurrent cancer
Staging
Complex fistulas may need staged care. Timing depends on anatomy, tissue quality, infection and the need for diversion; a universal waiting interval is not supported.[1]
- Damage control. Urinary and/or fecal diversion; drainage of abscess or urinoma; nutritional optimization
- Tissue preparation. Address edema, inflammation, necrosis and infection before definitive repair; individualize timing rather than requiring 3–6 months for every fistula[1]
- Definitive reconstruction. Single-stage if possible; may require multiple procedures
Tissue Interposition — The Complexity Step
Vascularized tissue interposition is not routine for every simple primary fistula, but it is commonly added when the field is complex: radiation, recurrent failure, tissue loss, infection, inflammatory disease, mesh, or overlapping urinary-enteric compartments. For vesicovaginal fistula, EAU describes flap use most often with recurrence, radiation, ischemic or obstetric injury, large defects, or tenuous closure; high-level evidence of improved outcomes is lacking:[1]
| Tissue | Best Use |
|---|---|
| Martius flap (labial fat pad) | Vaginal / perineal fistulas; women; reliable, straightforward |
| Gracilis muscle flap | Perineal / rectourethral; irradiated pelvis; excellent bulk |
| Omental pedicle | Abdominal approach; radiation; fills dead space |
| Peritoneal flap | Laparoscopic / robotic VVF repair; limited bulk |
| Fasciocutaneous flap | Large cutaneous defects; perineal reconstruction |
Multi-Compartment Fistulas
- Simultaneous involvement of bladder, vagina, and rectum (cloacal-type) requires coordinated urologic, gynecologic, and colorectal reconstruction.
- Often requires fecal and urinary diversion, staged repair, and gracilis or omental flap.
- Urinary diversion (continent or incontinent) may be the most reliable long-term solution when the bladder is unsalvageable.
Radiation Fistulas
- Irradiated tissue quality limits repair options; in women, a new urinary fistula after primary pelvic radiotherapy may indicate tumor recurrence.[1]
- Modified techniques are usually needed: the wide field of abnormal tissue often calls for permanent urinary and/or fecal diversion, or preliminary diversion with selective later undiversion after reconstruction.[1]
- For radiation-associated female urinary fistulas, EAU weakly recommends an interposition graft when repair is undertaken; high-level evidence that flaps improve outcomes is lacking.[1]
- Results are consistently poorer than for surgical fistulas repaired with the same techniques; counseling about realistic expectations is necessary.[1]
- Permanent urinary and/or fecal diversion should be presented as a valid and dignified option. For female urinary fistulas, EAU weakly recommends avoiding irradiated bowel segments when constructing diversion.[1]
Key Operative Principles
- Address urinary obstruction before or with fistula repair to protect the reconstruction.
- Vascularized tissue interposition is used selectively in vesicovaginal fistula repair, especially after radiation, recurrence, or ischemia, or with a large defect or tenuous closure.[1]
- Diversion is not failure. For radiation or multiply recurrent fistulas, it may be the best quality-of-life decision.
- Multidisciplinary planning (urology, colorectal, plastics, gynecology) is needed for multi-compartment cases.
- Document each prior repair attempt, technique, and tissue used; this drives the next-step strategy.
References
1. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: urinary fistula. 2026. Section 4.8; the disease-specific pages address other fistula populations.
2. Patel N, Mehawed G, Dunglison N, et al. "Uro-Symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework." Urology. 2023;178:1–8. doi:10.1016/j.urology.2023.05.002
3. Kahokehr AA, Boysen WR, Schild MH, et al. "Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors." Urology. 2021;148:297–301. doi:10.1016/j.urology.2020.07.038