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Vesicouterine Fistula

A vesicouterine fistula (VUF) is an epithelialized communication between the bladder and the uterine cavity. It is uncommon — roughly 1–4% of all GU fistulas — but its incidence is rising globally in parallel with cesarean delivery rates, and cesarean section accounts for 83–93% of cases.[1][2][3] VUF is unique in two ways the reconstructive surgeon must respect: the intact cervix often acts as a one-way valve, so the classic presentation is menouria with preserved urinary continence rather than vaginal urine leakage; and because patients are almost always of reproductive age, counseling should address closure, symptoms, uterine preservation and the patient’s fertility goals.

For the operation that produces nearly every VUF, see Cesarean Section. 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]
  • Historically rare before 1947 when low-segment cesarean replaced the classical incision; recognition has risen with cesarean rates.[2]
  • Mean age at presentation 27–31 years — reproductive-age population.[6][7][8]

Etiology and Pathogenesis​

CauseNotes
Cesarean section83–93% of all VUF; risk rises with each repeat cesarean — 78.6% of patients had >1 prior cesarean in the largest systematic review[1][2][3]
Uterine rupture / VBACLess common; presents acutely[5][6]
Placenta accreta spectrumManual removal of morbidly adherent placenta during cesarean[7]
IUD erosionRare; perforation through uterine wall into bladder[8]
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
  • ~10% of patients had recognized intraoperative bladder injury or uterine rupture
  • The supratrigonal bladder is involved in 92.5% of cases

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 plus partial vaginal menses; mixed urinary leakage
IIIVagina onlyNo menouria; urinary leakage per vagina dominates

The classification describes symptoms; it is not a validated rule for selecting hormonal treatment versus surgery.[16]

Clinical Presentation​

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

  • Menouria — present in 41–58% of patients; the most characteristic feature
  • Urinary leakage per vagina — present in ~65% of series; more common when the fistula sits at or below the internal os
  • Amenorrhea — when all menstrual flow diverts through the bladder
  • Recurrent UTI
  • Secondary infertility — diversion of menstrual flow and altered uterine environment
  • First-trimester miscarriage — reported[18]

Timing:

  • Early (days–weeks post-cesarean) — vaginal urine leakage
  • Delayed (months–years, occasionally decades) — menouria and amenorrhea; one case report 26 years after the inciting cesarean[19]

Rare presentation: at least four reported cases describe fetal implantation in the bladder through the fistula tract.[18]

Diagnostic Evaluation​

The diagnostic challenge is the one-way valve physiology — intrauterine pressure during menses or HSG exceeds intravesical pressure, so contrast must often be instilled from the uterine side to demonstrate the tract.[20][21]

ModalityRoleNotes
Hysterosalpingography (HSG)First-line in many seriesContrast 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]
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, but this is not a required or established first-line test[4][20]
CT urogramRules out concurrent ureteral injury

Management​

Selected small, recent VUFs may close with bladder drainage with or without menstrual suppression. Evidence for hormonal treatment is limited to case reports and small series, not comparative trials.[22][23]

Conservative — bladder drainage​

  • Indwelling Foley for 4–8 weeks
  • Closure has been reported in small, early-recognized fistulas without significant fibrosis[24][13][5]
  • 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; this does not establish predictable closure.[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 contraceptive as an alternative[13]
  • Consider only selected small fistulas with favorable tissue and symptoms; the Józwik type alone does not establish suitability
  • Combined approach (drainage + amenorrhea) is reported[13]

Surgical repair — timing and approach​

Timing: Delayed repair through laparotomy accounted for 88.8% of patients in the systematic review. This describes published practice; it does not establish a mandatory three-month wait. Individualize timing after edema, inflammation, necrosis and infection have resolved.[3][28]

Approach selection:

ApproachBest fitNotes
Transabdominal (open O'Conor)Established option for high or complex fistulasMost commonly performed (~89% of series); midline / Pfannenstiel; sagittal cystotomy down to the tract[3][6][8]
Robotic-assistedOption at centers with appropriate expertiseMirrors open technique; magnified visualization for the dense vesicouterine adhesion plane; LOS ~ 2 days; uterine-sparing[9][19][25]
LaparoscopicSame indications as roboticDemonstrated in case reports / small series[10][12]
TransvaginalSelected low fistulas 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 + single-layer uterine closure is the most-reported pattern in the systematic review[3]
  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; this cannot establish a universal benefit[3][8]
  6. Ureteral stents selectively for identification where anatomy is uncertain; they do not guarantee protection from injury[9]
  7. Prolonged catheter drainage with cystogram before removal in selected cases

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. Its reported 100% first-attempt success should not be treated as a patient-level guarantee or evidence that one approach is superior: selection, publication bias and inconsistent outcome reporting limit inference.[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]
  • Older reports describe pregnancies in 25–31% of followed patients; these are not validated probabilities of conception among patients actively attempting pregnancy.[27]
  • 23 documented live births 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; pregnancy after repair is possible, but recovery of fertility is not assured.[17]

Prevention​

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

  • Adequate sharp reflection of the bladder peritoneum from the lower uterine segment, especially in repeat cesarean
  • 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 — delayed recognition is the principal driver of fistula formation
  • Counsel about cumulative risk in patients with multiple prior cesareans

VUF vs VVF — quick comparison​

FeatureVUFVVF
Frequency1–4% of GU fistulasMost common acquired GU fistula in women
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)

References​

1. Caraman R, Toma A, Balescu I, et al. "Vesico-uterine fistula following C-section — a case report and literature review." In Vivo. 2022;36(1):528–532. doi:10.21873/invivo.12734

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

3. Bonavina G, Busnelli A, Acerboni S, et al. "Surgical repair of post-cesarean vesicouterine fistula: a systematic review and a plea for prevention." Int J Gynaecol Obstet. 2024;165(3):894–915. doi:10.1002/ijgo.15256

4. Sun F, Cui L, Zhang L, et al. "Intravesical contrast-enhanced ultrasound (CEUS) for the diagnosis of vesicouterine fistula (VUF): a case report." Medicine (Baltimore). 2018;97(17):e0478. doi:10.1097/MD.0000000000010478

5. Buckspan MB, Simha S, Klotz PG. "Vesicouterine fistula: a rare complication of cesarean section." Obstet Gynecol. 1983;62(3 Suppl):64s–66s.

6. Rajamaheswari N, Chhikara AB. "Vesicouterine fistulae: our experience of 17 cases and literature review." Int Urogynecol J. 2013;24(2):275–279. doi:10.1007/s00192-012-1798-8

7. Rao MP, Dwivedi US, Datta B, et al. "Post caesarean vesicouterine fistulae — Youssef syndrome: our experience and review of published work." ANZ J Surg. 2006;76(4):243–245. doi:10.1111/j.1445-2197.2006.03591.x

8. Hadzi-Djokic JB, Pejcic TP, Colovic VC. "Vesico-uterine fistula: report of 14 cases." BJU Int. 2007;100(6):1361–1363. doi:10.1111/j.1464-410X.2007.07067.x

9. Perveen K, Gupta R, Al-Badr A, Hemal AK. "Robot-assisted laparoscopic repair of rare post-cesarean section vesicocervical and vesicouterine fistula: a case series of a novel technique." Urology. 2012;80(2):477–482. doi:10.1016/j.urology.2012.04.027

10. Melon J, Chao F, Chan W, Rosamilia A. "Video of the laparoscopic repair of a vesico-uterine fistula." Int Urogynecol J. 2018;29(4):599–600. doi:10.1007/s00192-018-3566-x

11. Milani R, Cola A, Frigerio M, Manodoro S. "Repair of a vesicouterine fistula following cesarean section." Int Urogynecol J. 2018;29(2):309–311. doi:10.1007/s00192-017-3506-1

12. Ravi B, Schiavello H, Abayev D, Kazimir M. "Conservative management of vesicouterine fistula: a report of 2 cases." J Reprod Med. 2003;48(12):989–991.

13. Kumar A, Vaidyanathan S, Sharma SK, Sharma AK, Goswami AK. "Management of vesico-uterine fistulae: a report of six cases." Int J Gynaecol Obstet. 1988;26(3):453–457. doi:10.1016/0020-7292(88)90344-x

14. Al-Shaikh G, Marwa B. "A cervix penetrating the posterior bladder wall: case report." Int Urogynecol J. 2013;24(4):697–699. doi:10.1007/s00192-012-1849-1

15. Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H. "Unusual case of post-cesarean vesicouterine fistula (Youssef's syndrome)." Int J Urol. 2003;10(4):236–238. doi:10.1046/j.0919-8172.2003.00599.x

16. Józwik M, Józwik M. "Clinical classification of vesicouterine fistula." Int J Gynaecol Obstet. 2000;70(3):353–357. doi:10.1016/s0020-7292(00)00247-2

17. Lenkovsky Z, Pode D, Shapiro A, Caine M. "Vesicouterine fistula: a rare complication of cesarean section." J Urol. 1988;139(1):123–125. doi:10.1016/s0022-5347(17)42315-9

18. Armstrong H, Thistle P. "Vesicouterine fistula and fetus in bladder: a case report." J Obstet Gynaecol Can. 2020;42(5):634–636. doi:10.1016/j.jogc.2019.06.010

19. Romito F, Achtari C. "Robot-assisted uterus-sparing repair of a vesicouterine fistula 26 years after cesarean section: a case report and review of surgical techniques." Int Urogynecol J. 2025. doi:10.1007/s00192-025-06304-w

20. Gan L, Xie L, Li H. "Intrauterine contrast-enhanced ultrasound (CEUS) can be an effective approach for the diagnosis of vesicouterine fistula (VUF), especially for patients with fistulas flowing unidirectionally from the uterine cavity." Heliyon. 2023;9(2):e13268. doi:10.1016/j.heliyon.2023.e13268

21. Goel A, Goel S, Singh BP, Sankhwar SN. "Cystographic images of Youssef syndrome: flower on top of the bladder." Urology. 2012;79(5):e69–e70. doi:10.1016/j.urology.2012.01.032

22. Yokoyama M, Arisawa C, Ando M. "Successful management of vesicouterine fistula by luteinizing hormone-releasing hormone analog." Int J Urol. 2006;13(4):457–459. doi:10.1111/j.1442-2042.2006.01325.x

23. Jozwik M, Jozwik M, Sulkowska M, Musiatowicz B, Sulkowski S. "The presence of sex hormone receptors in the vesicouterine fistula." Gynecol Endocrinol. 2004;18(1):37–40. doi:10.1080/09513590310001651768

24. He Z, Cui L, Wang J, Gong F, Jia G. "Conservative treatment of patients with bladder genital tract fistula: three case reports." Medicine (Baltimore). 2020;99(31):e21430. doi:10.1097/MD.0000000000021430

25. Baker MV, Kisby CK, Occhino JA. "Vesicouterine fistula: a robotic approach." Int Urogynecol J. 2022;33(6):1685–1687. doi:10.1007/s00192-021-04940-6

26. Cao M, Zhang J, Chen Y, Liang Y. "Transvaginal repair of vesicouterine fistulae: our experience of three cases." Int Urogynecol J. 2022;33(3):737–740. doi:10.1007/s00192-021-04973-x

27. Lotocki W, Jóźwik M, Jóźwik M. "Prognosis of fertility after surgical closure of vesicouterine fistula." Eur J Obstet Gynecol Reprod Biol. 1996;64(1):87–90. doi:10.1016/0301-2115(95)02251-1

28. European Association of Urology. Non-neurogenic Female LUTS Guidelines: Disease Management — Urinary Fistula. 2026. Guideline.