Vesicovaginal Fistula
A vesicovaginal fistula (VVF) is an epithelialized communication between the bladder and vagina that produces continuous, painless urinary leakage per vaginum. In high-income countries it is overwhelmingly iatrogenic — most commonly after benign gynecologic surgery — while in low-resource settings it is dominated by prolonged obstructed labor and remains a global public-health problem.[1][2][3] VVF is the prototype reconstructive fistula: the principles refined here (excision of the tract, tension-free multilayer closure with non-overlapping suture lines, vascularized tissue interposition, prolonged drainage) generalize across the entire fistula chapter.
For the operative settings that produce VVF, see Cesarean Section and Intraoperative Consultation. Cross-compartment and complex-fistula principles are kept on the Fistulas section landing.
Epidemiology and Etiology
VVF is the most common acquired GU fistula in women.[1][4]
| Etiology | Setting | Notes |
|---|---|---|
| Benign gynecologic surgery | Hysterectomy is the dominant cause in high-income countries | Estimated incidence ~0.1–0.2% after benign hysterectomy; laparoscopic / robotic routes carry higher VVF risk than open or vaginal hysterectomy[2][5] |
| Cesarean delivery | Uterine incision into the bladder, bladder-flap injury, placenta accreta spectrum | Often vesicouterine rather than vesicovaginal; see Vesicouterine Fistula |
| Obstetric — prolonged obstructed labor | Dominant cause in sub-Saharan Africa and South Asia | Pressure necrosis of the anterior vaginal wall and bladder against the symphysis; addressed in detail in Obstetric Fistula |
| Pelvic radiation | Cervical, endometrial, vaginal, rectal cancer treatment | Late presentation (months to years); poor tissue quality; high recurrence; mandatory tissue interposition[6] |
| Pelvic malignancy | Direct invasion or post-treatment necrosis | Workup must rule out recurrence before reconstruction |
| Mesh erosion | Synthetic midurethral sling or transvaginal mesh erosion through bladder | Mesh excision concurrent with repair |
| Trauma | Penetrating, foreign body, sexual violence | Rare in high-income settings |
Pathophysiology
Three injury mechanisms drive VVF formation, and they predict tissue quality at the time of repair:[1][2]
- Direct surgical injury — unrecognized cystotomy at the time of hysterectomy or cesarean, or a suture placed through bladder wall during cuff closure. Tissue is otherwise healthy; fistula declares itself 1–3 weeks postoperatively as the suture line breaks down.
- Ischemic — devascularization of the bladder base from electrothermal injury, hemostatic suture, or compressive packing. Presents at 2–6 weeks; surrounding tissue may be inflamed but generally heals well after excision.
- Pressure necrosis — sustained compression of the vesicovaginal septum between the fetal head and the symphysis pubis (obstetric) or by retained foreign body. Tissue loss is broader than the visible defect; calcification, fibrosis, and field damage extend well beyond the fistula edge.
Radiation VVF is a fourth category — endarteritis obliterans produces progressive ischemia, the tissue bed is hostile and worsens with time, and recurrence is the rule without vascularized tissue interposition.[6]
Classification
Simple vs complex (operative phenotype)
The single most important categorization at the bedside:[7][8]
| Feature | Simple | Complex |
|---|---|---|
| Number | Single | Multiple |
| Size | < 2.5 cm | ≥ 2.5 cm |
| Location | Supratrigonal, away from ureteral orifices | Trigonal / juxta-ureteral, involving bladder neck |
| Etiology | Iatrogenic (post-hysterectomy), non-irradiated | Obstetric, post-radiation, malignancy-related, mesh |
| Prior repair | None | One or more failed |
| Tissue | Healthy | Scarred, ischemic, irradiated |
Goh classification (most widely used global system)
Goh's system grades fistulas on three axes — distance from external urethral meatus, fistula size, and degree of fibrosis / vaginal length — and predicts continence outcome after closure.[9]
| Axis | Grades |
|---|---|
| Distance from meatus | I > 3.5 cm; II 2.5–3.5 cm; III 1.5–2.5 cm; IV < 1.5 cm |
| Fistula size (largest diameter) | a < 1.5 cm; b 1.5–3 cm; c > 3 cm |
| Special considerations | i normal vagina, no fibrosis; ii moderate fibrosis or shortened vagina; iii severe fibrosis, circumferential, or prior failed repair |
Waaldijk classification (obstetric-fistula-focused)
Distinguishes Type I (no urethral involvement), Type II (urethral involvement, with subtypes for sphincter and circumferential defects), and Type III (ureteral or other special variants). Used primarily in obstetric-fistula practice and surgical-outcome reporting in low-resource settings.[10]
Clinical Presentation
- Continuous, painless urinary leakage per vaginum beginning 1–3 weeks postoperatively (iatrogenic) or after a difficult delivery (obstetric)
- Leakage may be positional — worse supine, sometimes provoked by bladder filling
- Reduced or absent voiding per urethra when the fistula is large
- Recurrent UTI, vaginal candidiasis, vulvar excoriation
- Psychosocial morbidity — particularly in obstetric fistula, where social isolation and depression are part of the syndrome[3]
A surgeon called to evaluate "post-hysterectomy incontinence" must rule out VVF before attributing leakage to detrusor overactivity, sphincter injury, or ureterovaginal fistula.
Diagnostic Evaluation
The workup answers four questions: Is it VVF? Where is it relative to the ureters? Is the upper tract involved? Is there cancer recurrence?
Office maneuvers
- Speculum exam — pooled urine in the vault, visible fistula tract on the anterior vaginal wall (often after reduction of inflammation)
- Dye test (single-tampon or three-swab) — instill methylene blue or dilute indigo carmine into the bladder via Foley; a stained proximal tampon confirms VVF, a stained mid tampon suggests ureterovaginal fistula, and a stained distal tampon suggests urethrovaginal leak. The classic double-dye / three-swab test combines oral phenazopyridine (stains urine orange — ureteric source) with intravesical methylene blue (blue — bladder source) to discriminate VVF from ureterovaginal fistula in a single test.[11]
- Vaginoscopy with a cystoscope — useful when the fistula is small or covered by granulation tissue
Endoscopy and imaging
- Cystoscopy is mandatory — defines the fistula location relative to both ureteral orifices, identifies multiple tracts, and rules out mesh, foreign body, or intravesical malignancy[2]
- CT urogram — assesses for synchronous ureterovaginal fistula or upper-tract obstruction; 10–12% of VVFs have a concurrent ureteral injury[1]
- Pelvic MRI — preferred for radiation VVF, recurrent fistula, and suspected malignancy recurrence; characterizes tissue quality and defect anatomy
- Retrograde or antegrade pyelogram — when CT urogram is equivocal for ureteral involvement
Adjuncts
- Urine culture before any repair attempt
- EUA when in-office examination is non-diagnostic — particularly for the small, late-presenting fistula
- Biopsy of the fistula edge if there is any concern for malignancy or recurrence in the radiated patient
Management
Conservative — bladder drainage alone
A small (< 5 mm), early-recognized, non-irradiated VVF may close with continuous catheter drainage for 4–8 weeks. Reported spontaneous closure rates in selected case series range from 10–20%, with anticholinergics added to suppress detrusor contractions.[12] Conservative management is reasonable as a first step in the right patient — but most fistulas require operative closure, and prolonged unsuccessful drainage delays definitive repair without changing outcomes.
Timing of repair
The classic teaching of 3–6 month delay to allow inflammation to resolve has been challenged by contemporary series.[2][8][13]
| Timing | Indication |
|---|---|
| Immediate (intraoperative recognition) | Iatrogenic injury identified at the index operation — repair on the table after urologic consult |
| Early (within 4–6 weeks) | Small, simple, non-irradiated, post-hysterectomy fistula in healthy tissue — equivalent or superior outcomes to delayed repair in modern series[13] |
| Delayed (≥ 3 months) | Persistent inflammation, large or multiple fistulas, prior failed repair, complex anatomy |
| Long delay (6–12 months) | Radiation VVF — tissue must be allowed to declare itself; consider hyperbaric oxygen between identification and repair |
Surgical principles (apply to every approach)
- Cystoscopic mapping — confirm fistula location and rule out ureteral involvement; place ureteral stents if either orifice is within 1 cm of the tract
- Wide circumferential mobilization of the fistula edges
- Excision of the fistulous tract and surrounding scar when feasible — minimal mucosal trim if a Latzko-style closure is planned
- Tension-free, multi-layer, non-overlapping closure — bladder mucosa, detrusor / fibromuscular layer, vaginal wall, each in a different orientation
- Vascularized tissue interposition in any complex case — and almost always in radiation, recurrent, or large fistulas
- Prolonged urethral catheter drainage — typically 14 days for simple repairs, 21 days or longer for complex/radiated; cystogram before catheter removal in selected cases
- Bladder rest — anticholinergics to suppress detrusor activity and avoid suture-line stress
Surgical Approach
The choice of approach depends on fistula location, vaginal access, surgeon expertise, and the need for concurrent ureteral reimplant or augmentation.[8][14][15]
| Approach | Best fit | Caveats |
|---|---|---|
| Transvaginal — classic flap repair (Sims-style) | Most simple supratrigonal VVFs with good vaginal access | Excises tract, advances vaginal flap; gold standard for the right patient |
| Transvaginal — Latzko partial colpocleisis | Small, post-hysterectomy, vault-apex fistula in a patient with a deep vagina | Inverts the fistula without tract excision; vaginal foreshortening of ~1–2 cm; success rates ~93–98% in series[15] |
| Transabdominal — open or laparoscopic O'Conor | Large, juxta-ureteral, complex, or recurrent VVF; concurrent need for ureteral reimplant or augmentation | Sagittal cystotomy carried down to the fistula; tract excised; bladder closed in two layers with omental interposition between bladder and vagina[16] |
| Robotic O'Conor | Same as open O'Conor, with shorter LOS and equivalent success | Modern multi-institutional series report success rates ~93–100% with median LOS 2–3 days[14][17] |
Transvaginal repair — operative pearls
- Position — high lithotomy or prone jackknife (the latter for the difficult-to-expose vault fistula in a foreshortened vagina)
- Schuchardt incision to widen vaginal access when needed
- Hold the fistula edge with stay sutures — convert a hole into a slit by tagging at 12 and 6 o'clock to deliver the edges
- Avoid aggressive tract excision in the small fistula — Latzko-style mucosal denudation and inverting closure preserves bladder and vaginal length
- Martius flap is the workhorse interposition — labial fat-pad flap mobilized on its inferior pedicle, tunneled subcutaneously to the fistula bed (see Martius flap)
- Test with retrograde fill of dilute methylene blue before closing the vaginal layer
Transabdominal (O'Conor) repair — operative pearls
- Bladder bivalving — sagittal cystotomy from the dome down to (but not through) the fistula
- Tract excision with debridement to healthy tissue at all margins
- Wide bladder–vagina dissection to allow non-overlapping closure
- Omental pedicle interposition between the closed bladder and vagina is the standard interposition for the abdominal approach; alternatives are peritoneal flap (laparoscopic / robotic) or rectus muscle flap
- Robotic series favor the transvesical approach with Firlit-style mobilization and a peritoneal interposition flap when omentum is unavailable[14][17]
Tissue interposition
Vascularized tissue between the closed bladder and vagina is the single intervention most consistently associated with successful complex repair.[6][8]
| Tissue | Best use | Notes |
|---|---|---|
| Martius flap | Transvaginal repair; vaginal/perineal fistulas | Reliable, low-morbidity, available in any vaginal repair |
| Omental pedicle | Transabdominal / robotic O'Conor; radiation cases | Excellent bulk; depends on omental reach |
| Peritoneal flap | Robotic / laparoscopic; when omentum unavailable | Limited bulk; reliable for non-radiated repair |
| Gracilis muscle flap | Recurrent, large, or radiated VVF; failed prior interposition | Requires medial-thigh harvest; substantial bulk |
The Martius flap deserves a specific caveat in obstetric-fistula practice: Browning's randomized data in a high-volume obstetric-fistula cohort showed no improvement in closure or continence rates with Martius interposition for routine obstetric VVF — reinforcing that interposition is a tool for specific indications (radiation, recurrence, large defect, hostile bed), not a default for every repair.[18]
Outcomes
Modern series report first-attempt closure rates of 80–95% for simple VVF, with success dropping with each subsequent repair and with adverse fistula characteristics.[2][7][8][19]
| Setting | Typical first-attempt closure | Notes |
|---|---|---|
| Simple iatrogenic VVF, transvaginal or O'Conor | 90–95% | The benchmark for primary repair[8][14] |
| Robotic O'Conor (modern multi-institutional) | 93–100% | Median LOS 2–3 days; equivalent to open in experienced hands[14][17] |
| Latzko (selected vault VVF) | 93–98% | Vaginal foreshortening of 1–2 cm; preserves bladder[15] |
| Obstetric VVF (high-volume centers) | 80–95% closure; continence lower (~70–85%) | Stress incontinence after closure is the durable challenge[3][19] |
| Radiation VVF | 40–70% primary; permanent diversion is a legitimate alternative | Tissue quality dominates outcome[6] |
Stress urinary incontinence persists in ~10–20% of women after successful anatomic closure of obstetric VVF — particularly when the fistula involved the proximal urethra or sphincter complex; concurrent or staged anti-incontinence surgery may be required.[19]
Special Situations
Radiation VVF
Tissue quality is the rate-limiting factor.[6]
- Wait 6–12 months from completion of radiation before attempting repair
- Hyperbaric oxygen (20–40 sessions) may improve tissue oxygenation in selected cases
- Mandatory vascularized tissue interposition — omentum or gracilis preferred
- Counsel realistically about recurrence and about permanent urinary diversion as a dignified, durable alternative when reconstruction is not feasible
Mesh-erosion VVF
- Concurrent mesh excision with VVF repair
- Avoid leaving residual synthetic material at the suture line
- Tissue interposition recommended even for "simple"-appearing mesh-related VVFs
Recurrent VVF
- Always repair through a fresh tissue plane — do not redo the same approach without reconsideration
- Vascularized interposition is mandatory
- Diversion (continent or incontinent) is a valid endpoint after multiple failures; framing this as a quality-of-life decision rather than as failure is part of the conversation
Large or trigonal VVF involving the ureteral orifice
- Stent both ureters preoperatively if either is within 1 cm of the tract
- Consider concurrent ureteral reimplant at the time of repair when the fistula involves the ureteral orifice
- Plan an abdominal / robotic approach; transvaginal exposure is rarely adequate
References
1. Hilton P. "Urogenital fistula in the UK: a personal case series managed over 25 years." BJU Int. 2012;110(1):102–110. doi:10.1111/j.1464-410X.2011.10630.x
2. Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K. "Management of vesicovaginal fistulas in women following benign gynaecologic surgery: a systematic review and meta-analysis." PLoS One. 2017;12(2):e0171554. doi:10.1371/journal.pone.0171554
3. Wall LL. "Obstetric vesicovaginal fistula as an international public-health problem." Lancet. 2006;368(9542):1201–1209. doi:10.1016/S0140-6736(06)69476-2
4. Stamatakos M, Sargedi C, Stasinou T, Kontzoglou K. "Vesicovaginal fistula: diagnosis and management." Indian J Surg. 2014;76(2):131–136. doi:10.1007/s12262-012-0787-y
5. Hilton P, Cromwell DA. "The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service: a retrospective cohort study." BJOG. 2012;119(12):1447–1454. doi:10.1111/j.1471-0528.2012.03474.x
6. Pushkar DY, Dyakov VV, Kasyan GR. "Management of radiation-induced vesicovaginal fistula." Eur Urol. 2009;55(1):131–137. doi:10.1016/j.eururo.2008.04.044
7. Eilber KS, Kavaler E, Rodríguez LV, Rosenblum N, Raz S. "Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition." J Urol. 2003;169(3):1033–1036. doi:10.1097/01.ju.0000049723.57485.e7
8. Angioli R, Penalver M, Muzii L, et al. "Guidelines of how to manage vesicovaginal fistula." Crit Rev Oncol Hematol. 2003;48(3):295–304. doi:10.1016/s1040-8428(03)00123-9
9. Goh JTW. "A new classification for female genital tract fistula." Aust N Z J Obstet Gynaecol. 2004;44(6):502–504. doi:10.1111/j.1479-828X.2004.00315.x
10. Waaldijk K. "Surgical classification of obstetric fistulas." Int J Gynaecol Obstet. 1995;49(2):161–163. doi:10.1016/0020-7292(95)02350-l
11. Raghavaiah NV. "Double-dye test to diagnose various types of vaginal fistulas." J Urol. 1974;112(6):811–812. doi:10.1016/s0022-5347(17)59866-8
12. Bazi T. "Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: review of the evidence." Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):329–333. doi:10.1007/s00192-006-0194-7
13. Waaldijk K. "The immediate surgical management of fresh obstetric fistulas with catheter and/or early closure." Int J Gynaecol Obstet. 1994;45(1):11–16. doi:10.1016/0020-7292(94)90759-5
14. Bragayrac LA, Azhar RA, Fernandez G, et al. "Robotic repair of vesicovaginal fistulae with the transperitoneal-transvaginal approach: a case series." Int Braz J Urol. 2014;40(6):810–815. doi:10.1590/S1677-5538.IBJU.2014.06.13
15. Ansquer Y, Mellier G, Santulli P, et al. "Latzko operation for vault vesicovaginal fistula." Acta Obstet Gynecol Scand. 2006;85(10):1248–1251. doi:10.1080/00016340600804617
16. O'Conor VJ Jr, Sokol JK, Bulkley GJ, Nanninga JB. "Suprapubic closure of vesicovaginal fistula." J Urol. 1973;109(1):51–54. doi:10.1016/s0022-5347(17)60344-3
17. Miklos JR, Moore RD, Chinthakanan O. "Laparoscopic and robotic-assisted vesicovaginal fistula repair: a systematic review of the literature." J Minim Invasive Gynecol. 2015;22(5):727–736. doi:10.1016/j.jmig.2015.03.001
18. Browning A. "Lack of value of the Martius fibrofatty graft in obstetric fistula repair." Int J Gynaecol Obstet. 2006;93(1):33–37. doi:10.1016/j.ijgo.2006.01.003
19. Frajzyngier V, Ruminjo J, Barone MA. "Factors influencing urinary fistula repair outcomes in developing countries: a systematic review." Am J Obstet Gynecol. 2012;207(4):248–258. doi:10.1016/j.ajog.2012.02.006