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Vesicouterine Fistula

A vesicouterine fistula (VUF) is an abnormal communication between the bladder and uterine body.[37] It accounts for roughly 1–4% of reported GU fistulas, and up to 88% of reported VUFs are related to cesarean delivery; increasing cesarean rates raise concern about future VUF burden.[1][2][3][19] An intact cervix can act as a one-way valve, so VUF may present with menouria and preserved continence rather than vaginal urine leakage; counseling should address closure, symptoms, uterine preservation and fertility goals when relevant.[2]

For the operation associated with most reported VUFs, see Cesarean Section.[2] For the broader fistula framework, see the Fistulas landing page. For operative selection across all repair routes, see the Female Fistula Repair database.

Epidemiology​

  • VUF accounts for 1–4% of all urogenital fistulas in reported series.[2][5][19]
  • Historically rare before 1947 when low-segment cesarean replaced the classical incision; recognition has risen with cesarean rates.[2]
  • Reproductive-age population: mean age was 19 years among 12 patients with minimum follow-up in one Indian series, 27 in a Serbian series and 31 in another Indian series.[6][7][8]

Etiology and Pathogenesis​

CauseNotes
Cesarean sectionUp to 88% of reported VUFs are related to cesarean section. In a review restricted to post-cesarean surgical repairs, 78.6% of patients had >1 prior cesarean[1][2][3]
Uterine rupture / VBACLess common; reported after vaginal birth after cesarean and after vaginal delivery (4 of 17 in one series)[5][6][9][10]
Placenta accreta spectrumManual removal of morbidly adherent placenta during cesarean[11]
IUD erosionRare; migration of a retained or forgotten device through the uterine wall into the bladder, sometimes with a vesical calculus and without classic Youssef symptoms[29]
Pelvic trauma, uterine curettage, radiationRare[2][4]

Mechanism after cesarean:[3]

  • Inadequate reflection of bladder peritoneum from the lower uterine segment
  • Unrecognized cystotomy at hysterotomy or closure
  • Bladder wall caught in the uterine closure suture
  • Approximately 10% of patients in a review of surgically repaired post-cesarean VUF had recognized intraoperative bladder injury or uterine rupture[3]
  • The supratrigonal bladder was involved in 92.5% of cases in the post-cesarean surgical-repair review[3]

Classification​

Youssef syndrome (1957)​

Classic triad when the fistula sits above the internal cervical os and the cervix functions as a competent valve:[7][14][15]

  1. Menouria: cyclic hematuria with menstruation
  2. Amenorrhea: no vaginal menstrual flow
  3. Preserved urinary continence: no leakage per vagina

Józwik classification (2000)​

This descriptive classification uses the route of menstrual flow:[16]

TypeMenstrual routeTypical presentation
IBladder onlyClassic Youssef syndrome — menouria, amenorrhea, continent
IIBladder + vaginaMenouria with vaginal menses; vaginal urinary leakage may coexist[20]
IIIVagina onlyNormal vaginal menses without menouria; vaginal urinary leakage may occur[20]

Clinical Presentation​

The intact cervix changes the symptom profile fundamentally compared with VVF.[6][7][17]

  • Menouria is the most characteristic feature; present in 7 of 17 patients in one series[6]
  • Urinary leakage per vagina: reported in 11 of 17 patients (65%) in one retrospective surgical series[6]
  • Amenorrhea: when all menstrual flow diverts through the bladder
  • Recurrent UTI
  • Secondary infertility: diversion of menstrual flow and altered uterine environment
  • First-trimester pregnancy loss: described in post-cesarean VUF reports.[38]

Timing:

  • Early (days to weeks post-cesarean): vaginal urine leakage
  • Delayed (months to years, occasionally decades): menouria and amenorrhea; one patient presented 22 years after the index cesarean and underwent repair 26 years after it[19]

Pregnancy with a VUF: a 2025 systematic review of case reports identified 22 intrauterine pregnancies with a VUF, all after prior cesarean: 14 fetal deaths, one surgically terminated pregnancy, and seven live births (five preterm, four before 32 weeks). Fetus in the bladder through the tract is a separate, very rare presentation.[18][30]

Diagnostic Evaluation​

The EAU guideline recommends a complete history and focused physical examination with direct visual inspection for suspected urinary fistula .[28] Because flow may be unidirectional, bladder-side contrast can be nondiagnostic; uterine-side contrast has been described to demonstrate the tract.[20][21]

ModalityRoleNotes
Hysterosalpingography (HSG)Tancer's 92-case review favored hysterography for diagnosis[2]; exclude pregnancy before HSG[34]Contrast injected through the uterus opacifies the bladder[2]
CystographyOften false-negativeWhen positive, classic "flower on top of the bladder" appearance[21]
CystoscopyMaps fistula location, relationship to ureteral orifices, presence of endometrial / granulation tissue at the site[9][10]
HysteroscopyVisualizes the fistula from the uterine side; methylene-blue confirmation[1][10]
MRI pelvisTissue planes, fibrosis, fistula tract for surgical planning[20]
Contrast-enhanced ultrasound (CEUS)Case reports describe intravesical or intrauterine contrast; an intrauterine route may demonstrate unidirectional flow[4][20]
CT urogram with late excretory phaseEvaluates concurrent ureteral injury and can help map a difficult fistula[28]

Management​

Selected small, recent VUFs may close with bladder drainage with or without menstrual suppression. The EAU 2026 guideline notes case reports of closure with induced amenorrhea (estrogen, estrogen-progestin or LHRH analogues) for small fistulae (<7 mm) after cesarean; evidence is limited to case reports and small series, not comparative trials.[22][23][28]

Conservative — bladder drainage​

  • For VUF recognized just after delivery, a 4–8-week Foley drainage trial has been proposed.[38]
  • Closure has been reported in small, early-recognized fistulas without significant fibrosis; one report suggests simple fistulas under 0.5 cm and surgery if unresolved after about 2 months[24][13][12]
  • Suprapubic drainage is an alternative
  • Reassess persistent fistulas after a planned drainage trial; surgical timing depends on tissue condition and patient goals[24]

Conservative — induced amenorrhea​

Endometrial-like tissue with estrogen and progesterone receptors has been demonstrated in a small histologic study, providing a rationale for menstrual suppression.[22][23]

  • GnRH agonists (e.g., leuprolide) have been used in case reports; selection, duration and management of hypoestrogenic adverse effects require gynecologic input[22]
  • Continuous combined oral contraceptives: In two case reports, both VUFs closed after six months of treatment; another six-patient series described hormonal suppression.[13][35] After cesarean delivery, assess postpartum timing, breastfeeding, and VTE risk; combined hormonal contraception is U.S. MEC category 4 during the first 21 days postpartum.[36]
  • Consider only selected small fistulas with favorable tissue and symptoms
  • Drainage and induced amenorrhea have each been reported in small series, sometimes in the same report[13]

Surgical repair — timing and approach​

Timing: Delayed repair through laparotomy accounted for 88.8% of patients in the post-cesarean surgical-repair review.[3] The review describes delayed repair but provides no mandatory three-month threshold. Individualize timing after edema, inflammation, necrosis and infection have resolved.[3][28]

Approach selection:

ApproachBest fitNotes
Transabdominal (open)Established option for high or complex fistulasDelayed laparotomy was used in 88.8% of patients in the post-cesarean review; midline or Pfannenstiel access and sagittal cystotomy describe a transvesical O'Conor variant[3][6][8]
Robotic-assistedOption at centers with appropriate expertiseMirrors open technique; magnified visualization for the dense vesicouterine adhesion plane; a mixed VUF/vesicocervical series of three patients reported discharge on postoperative day 2; uterine-sparing repair has been described[9][19][25]
LaparoscopicSame indications as roboticDemonstrated in case reports / small series; in the systematic review, minimally invasive repair had shorter stay and less blood loss[10][3]
TransvaginalSelected vaginally accessible fistulas, including a reported high VUF, in surgeons experienced with vaginal repair3 of 17 patients in one series successfully repaired vaginally; prone-jackknife position useful[6][11][26]

Operative principles (every approach)​

  1. Adhesiolysis of the vesicouterine plane; adhesions at the cesarean scar are routinely dense
  2. Excision of the fistula tract with debridement of fibrotic edges
  3. Separation of bladder from uterus to allow non-overlapping suture lines
  4. Double-layer bladder closure and single-layer uterine closure is the most-reported pattern in the systematic review; check bladder integrity intraoperatively after closure[3][19]
  5. Tissue interposition may separate suture lines when tissue quality or repair complexity warrants it; omentum or peritoneum are options. One small series had recurrence in 1/5 repairs without and 0/9 with a flap.[3][8] 6.[9] Ureteral stents selectively for identification where anatomy is uncertain[9]
  6. Postrepair drainage: Maintain continuous bladder drainage until healing is confirmed; EAU expert opinion suggests 10–14 days after simple/post-surgical fistula repair and 14–21 days after complex/post-radiation repair. If cystography is used before catheter removal, a voiding phase may reveal a persistent tract.[28]

Hysterectomy vs uterine conservation​

  • Discuss uterine conservation and fertility goals. Conservation was performed in 10/17 patients in one series, with all three patients desiring pregnancy conceiving spontaneously after repair; these are small selected denominators.[6][19][25]
  • Hysterectomy may be appropriate for extensive uterine destruction, concurrent uterine pathology or an informed patient preference; completed childbearing alone does not require hysterectomy.[2]

Outcomes​

A review of 67 studies and 284 patients, mostly case reports or small observational series, reported very high surgical closure. The review’s 100% first-attempt success has limited predictive and comparative value because of selection, publication bias and inconsistent outcome reporting.[3] Recurrence has been reported, including one in the 14-patient series.[8]

Fertility after repair​

For patients who desire pregnancy, discuss the limited fertility evidence:[3][6][8][27]

  • 8 of 14 patients in one series became pregnant after repair and delivered by elective cesarean.[8]
  • 3 of 3 patients desiring pregnancy conceived spontaneously in another.[6]
  • In a Polish series of 16 women, 5 pregnancies occurred after repair (31%), 4 reaching term (25%).[27]
  • 23 patients with a reported live birth after repair in the systematic-review cohort.[3]
  • Subsequent pregnancy warrants specialist obstetric planning; published series commonly used planned cesarean delivery. The uterine scar, repair details and obstetric circumstances guide timing and delivery counseling.[6][8]
  • Secondary infertility may be the presenting complaint.[17]

Prevention​

Prevention is operative-technique driven at the index cesarean:[3]

  • Identify the bladder and vesicouterine plane before hysterotomy, especially when adhesions obscure anatomy; mobilize the bladder as needed for safe exposure.[3] Randomized trials have not established routine bladder-flap creation as protective against bladder injury; VUF prevention was not studied.[31]
  • Avoid deep suture bites at hysterotomy closure that may incorporate the bladder wall
  • Confirm the bladder dome is clear before placement of every closure suture
  • Recognize and immediately repair any cystotomy on the table
  • Counsel about bladder-injury risk associated with repeat cesarean, adhesions, second-stage labor and emergency surgery.[3][32]

VUF vs VVF — quick comparison​

FeatureVUFVVF
Frequency1–4% of reported GU fistulas; 2.6% in one tertiary referral cohort[19][33]79.7% in the same tertiary referral cohort[33]
Primary etiologyCesarean sectionHysterectomy (HIC); obstructed labor (LMIC)
Hallmark symptomMenouria; often continentContinuous urine leakage per vagina
Conservative managementSelected small, recent fistulas; hormonal evidence mainly case reportsSelected small, recent fistulas may close with drainage
Fertility implicationsDiscuss uterine preservation and pregnancy goalsRelevant, particularly after obstetric injury; assess associated reproductive tract damage
Closure outcomesHigh in selected reports; uncertain generalizability[3]Depend on size, tissue quality, etiology and prior repairs

See Also​

Videos​

Genitourinary Fistulas: Interdisciplinary Care
UBC Urology Rounds (2025)
Laparoscopic Vesicouterine Fistula Repair
Nascimento LAC, et al. Urology Video Journal 2024 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

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2. Tancer ML. "Vesicouterine fistula — a review." Obstet Gynecol Surv. 1986;41(12):743–753. doi:10.1097/00006254-198612000-00001

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