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Urethrovaginal Fistula Repair

Urethrovaginal fistula (UVF) is a rare communication between the urethra and vagina — iatrogenic in developed countries (sling, urethral diverticulectomy, anterior colporrhaphy, hysterectomy) and obstetric in low-resource settings. The transvaginal layered repair is the standard of care, with primary closure rates of 90–100%, but post-repair stress urinary incontinence (SUI) is the dominant long-term issue, occurring in up to 52% of patients.[2][4][5] The defining technical challenge is the periurethral tissue deficit — the minimal space between urethral and vaginal walls often does not allow placing additional tissue between them, making meticulous layered closure and the selective use of vascularized interposition central to durable repair.[2]

For broader fistula context see the Female Fistula treatment atlas. Anti-incontinence options at Female Slings & Suspensions.

Etiology and Epidemiology​

UVF accounts for 1.9–15% of all genitourinary fistulae.[3][6]

SettingDominant causes
Developed countries (iatrogenic)Sling procedures, urethral diverticulectomy (1–5% of cases), anterior colporrhaphy, hysterectomy, radiation, prolonged indwelling catheter, mesh erosion ± urethral diverticulum[1][3][7][8][9][10]
Low-resource countriesObstructed labor (ischemic compression of urethra against pubic symphysis), traumatic forceps delivery[6][11]

Singh 2026 (n = 638 GUF, 25-yr Indian series): UVF was 1.88% (12/638); hysterectomy was the leading overall GUF cause.[3]

Classification​

By urethral location​

  • Distal UVF — below the sphincteric mechanism; technically simpler, continence usually preserved
  • Mid-urethral UVF — at the sphincteric mechanism; higher post-repair SUI risk
  • Proximal / bladder-neck UVF — most challenging; highest incontinence risk; may coexist with VVF[2][12]

By complexity​

  • Simple — small, single tract, adequate surrounding tissue
  • Complex — large, associated stricture, significant tissue loss, prior failed repair, radiation, or concomitant VVF[2][12]

Diagnostic Workup​

ModalityRole
Speculum + dye testDirect visualization on the anterior vaginal wall; intravesical methylene blue confirms urinary fistula
Double-dye testOral phenazopyridine (orange) + intravesical methylene blue — distinguishes VVF, UVF, and ureterovaginal fistula
CystourethroscopyEssential — maps fistula location, proximity to bladder neck and ureteral orifices, rules out concomitant VVF[2][13]
VCUGDemonstrates tract during voiding
MRISoft-tissue detail for complex cases; concomitant urethral diverticulum[8]
IVP / CT urogramRules out ureteral injury or ureterovaginal fistula
EUA with metal soundSometimes the only way to define small / complex fistulae[2]

Symptoms: continuous urinary leakage per vagina, often positional / activity-aggravated (distinguishes from gravity-dependent VVF). Recurrent UTI, dyspareunia, vulvar dermatitis, vaginal discharge.

Timing of Repair​

EtiologyOptimal timing
Iatrogenic, non-irradiated8–12 weeks after fistula formation or failed repair[5]
Obstetric2–3 months post-delivery[6]
Radiation-induced6–12 months; tissue interposition essential
Post-diverticulectomyCatheter trial 2–4 wk first; delayed repair if persistent

Conservative trial first — continuous urethral drainage 2–6 wk; spontaneous closure in up to 15% of non-radiation GU fistulae.[11][14][15] Best candidates: small fistulae, acute / early presentation, no active infection.

Surgical Approaches​

ApproachRole
TransvaginalStandard of care for most UVF — shorter OR time, less blood loss, less pain, shorter LOS[2][4][5][16]
TransabdominalReserved for complex / proximal / bladder-neck UVF inaccessible vaginally, or recurrent UVF after failed vaginal repair[17]
TransurethralRare; very small fistulae amenable to fulguration / injection[18]

Surgical Techniques​

1. Transvaginal Primary Layered Repair (no interposition)​

The simplest and most commonly used technique for uncomplicated, non-irradiated UVF with adequate surrounding tissue.[3][4][18]

Steps:

  1. Position dorsal lithotomy; Foley catheter; intubate fistula tract with small Foley for traction.[7]
  2. Vaginal incision circumferential or longitudinal around the fistula with 5–10 mm margin; dissect epithelium off periurethral tissue; wide mobilization of vaginal flaps.[7][16]
  3. Excise the tract completely — all fibrotic / epithelialized tissue; freshen edges to healthy vascularized tissue.
  4. Layer 1 — Urethral closure with interrupted 4-0 or 5-0 Vicryl/PDS, longitudinal direction (avoids narrowing), watertight (confirm with saline / dye through catheter).[7]
  5. Layer 2 — Periurethral fibromuscular tissue approximated over the urethral closure with interrupted absorbable sutures, offset from Layer 1.
  6. Layer 3 — Vaginal epithelium closed with interrupted or running absorbable suture, offset from underlying layers.
  7. Catheter — 14–16 Fr Foley for continuous drainage; ± suprapubic catheter for proximal UVF.

Outcomes: Milani 2021 — completed in 60 min with successful closure and no SUI at follow-up.[18] Mörgeli & Tunn 2021 (47 cases, modified Sims-Simon variant): 100% success, no interposition, median OR 40 min.[4]

Best for: small, simple, non-irradiated UVF with adequate periurethral tissue.

2. Modified Sims-Simon (partial colpocleisis)​

Vaginal epithelium denuded around the fistula without excising the tract; multiple imbricating layers bury the tract.[4][6]

Outcomes: Mörgeli & Tunn 2021 — 100% success in all 47 cases (incl. 11 UVF); median OR 40 min; 14% complication rate.[4]

Advantages: simpler, shorter OR time, no interposition needed, preserves vaginal length.

Best for: non-irradiated iatrogenic UVF with adequate tissue quality.

3. Latzko + Martius​

Latzko partial colpocleisis combined with a Martius bulbocavernosus fat-pad flap — combines the simplicity of Latzko closure with vascularized tissue support.[19][20]

Outcomes: Zilberlicht 2016 — complete fistula closure with no leakage at 2 mo.[19]

Best for: UVF with tissue deficit, recurrent fistulae, or where additional vascularized tissue is needed to reinforce.

4. Martius flap interposition (standalone)​

Most commonly used tissue interposition for UVF; combinable with any closure method.[19][21][22]

Technique:

  1. Vertical incision over the labium majus ipsilateral to the fistula.
  2. Dissect the fibroadipose pad from overlying skin and underlying bulbocavernosus.
  3. Mobilize on anterior pedicle (external pudendal — for anterior rotation) or posterior pedicle (internal pudendal — for posterior rotation).[23]
  4. Subcutaneous tunnel from labial incision to vaginal field.
  5. Pass the flap and suture over the urethral closure, interposed between urethral and vaginal suture lines.
  6. Close the labial incision primarily.

Outcomes:

  • Rangnekar 2000 — 91.7% Martius vs 25% anatomic repair for UVF; 0% dyspareunia with Martius vs 33% anatomic.[21]
  • Malde 2017 (n = 159) — good cosmesis (79% good/excellent), low complication rate.[22]
  • Kapriniotis 2024 review — interposition is probably unnecessary for most simple fistulae in healthy tissue; valuable for tissue loss, urethral involvement, poorly vascularized tissue, or prior failed repair (80–97% success in challenging situations).[24]

Indications: recurrent UVF, periurethral tissue deficit, radiation, large / complex fistulae, concomitant urethral diverticulectomy.

See Martius flap for the full flap atlas.

5. Fascial-patch + pubovaginal sling​

Addresses the dual challenge of recurrent UVF + coexisting SUI when periurethral tissue is devastated.[25]

Steps:

  1. Inverted-U vaginal flap; identify and separate any prior Martius flap from the urethra.
  2. Single-layer closure of attenuated periurethral tissue (when multilayer is not feasible).
  3. Through low transverse abdominal incision, harvest 15 × 2 cm rectus fascia strip.
  4. 2 × 2 cm fascial patch transfixed to periurethral tissue over the closure site.
  5. Reposition prior Martius (if present) over the patch.
  6. Pubovaginal sling with the remaining fascia — simultaneously addresses SUI.

Outcomes: Golomb 2006 — successful healing and full continence in patient with recurrent UVF after failed TVT removal and failed Martius.[25]

Best for: recurrent UVF with devastated periurethral tissues + coexisting SUI.

6. Rectus abdominis muscle flap​

Salvage technique for refractory UVF after failed Martius.[26]

Steps:

  1. Standard transvaginal layered closure first.
  2. Lower abdominal incision; mobilize rectus abdominis on the inferior epigastric pedicle.
  3. Tunnel through retropubic space to the pelvis.
  4. Interpose between fistula closure and vaginal suture line — robust vascularized cover for urethra, bladder neck, bladder base.

Outcomes: Bruce 2000 (n = 6, mean 1.3 prior failed repairs all with at least one failed Martius): 100% closure, 83% continence at mean 23 mo.[26] Atan 2007 — successful in a 6-yr-old with refractory UVF.[27]

Best for: refractory UVF after failed Martius; complex fistulae needing maximal vascularized tissue.

7. Urethroplasty for UVF + stricture / urethral loss​

Xu 2013 (n = 44 UVF + stricture) — five technique selection by fistula location, stricture length, and vaginal anatomy: 93.2% anatomical / 90.9% functional success at mean 42.3 mo.[12]

TechniquenNotes
Labial pedicle flap urethroplasty24Pedicled labia minora/majora flap (~3 × 3.5 × 3 cm) tubularized over 18–22 Fr stent — most reliable for complex strictures; bilateral flaps for longer strictures
Anterior vaginal flap urethroplasty11Pedicled vaginal-wall flap rolled into a tube or used as onlay; Blaivas 9/10 satisfactory neourethra in total/partial urethral loss[28]
Vulvar flap urethroplasty3Island vulvar-skin flap; ± simultaneous colpoplasty
End-to-end anastomosis4Short strictures; ± Martius
Bladder flap urethroplasty2Extensive urethral loss requiring bladder-derived neourethra

See Labia Majora Fasciocutaneous for the labial flap atlas.

8. Transpubic approach for pelvic-fracture UVF​

For UVF with obliterative urethral stricture from pelvic fracture, a partial pubectomy or pubic-symphysis split exposes the obliterated segment for pedicled tubularized labial-flap urethroplasty. Xu 2009 (n = 8): all voiding normally at mean 48.25 mo; 1 required dilation for postop stricture.[29]

Technique Selection Algorithm​

Clinical scenarioRecommended techniqueTissue interposition
Simple, small, non-irradiated UVF, adequate tissueTransvaginal primary layered repair or modified Sims-SimonNot required[2][4]
Moderate tissue deficit or first recurrenceLayered repair + MartiusMartius[19][21]
Recurrent UVF, devastated periurethral tissue + SUIFascial patch + pubovaginal slingRectus fascia patch ± Martius[25]
Refractory UVF after failed MartiusRectus abdominis muscle flapRectus abdominis muscle[26]
UVF + short strictureEnd-to-end anastomosis± Martius[12]
UVF + long / complex strictureLabial pedicle flap urethroplastyLabial flap as neourethra[12]
UVF + extensive urethral lossVaginal-flap or bladder-flap neourethra± Martius[28]
Pelvic-fracture UVF with obliterative strictureTranspubic labial-flap urethroplastyLabial flap as neourethra[29]

Outcomes Summary​

Seriesn (UVF)ApproachPrimary successOverall successKey findings
Pushkar 200671Transvaginal90.1%98.6% (after 2nd repair)SUI in 52%; managed with slings; no recurrence at 99.6 mo[2]
Lee 1988 (Mayo)—Transvaginal92%100% (after 2nd repair)All 4 failures corrected on 2nd attempt[5]
Mörgeli & Tunn 202111Transvaginal (mod. Sims-Simon)100%—No interposition; median OR 40 min[4]
Ockrim 20099Transvaginal (8) / TA (1)89% (8/9)92%Size > 3 cm and lack of interposition predicted failure[30]
Rangnekar 200012Transvaginal (Martius 8 / anatomic 4)87.5% Martius vs 25% anatomic—0% dyspareunia with Martius[21]
Bazeed 199513Transvaginal (11 simple, 2 neourethra)77%—Neourethra needed in 2 with extensive urethral loss[6]
Singh 202612Mixed94–97% (all GUF)—UVF = 1.88% of all GUF; hysterectomy leading cause[3]

Post-Repair Stress Urinary Incontinence — the Dominant Long-Term Issue​

Post-repair SUI occurs in up to 52% of patients because the fistula and its repair often involve the urethral sphincteric mechanism, periurethral tissue loss compromises the intrinsic sphincter, and the repair itself may alter urethral mobility and coaptation.[2]

Management​

Per AUA/SUFU 2023 and ACOG Practice Bulletin, autologous fascial pubovaginal sling is preferred over synthetic mesh slings in previously operated tissue to avoid urethral erosion.[31][32]

Pushkar 2006 (n = 71):[2]

  • 37 (52.1%) developed post-repair SUI
  • Both synthetic and autologous slings used
  • 22 (59.5%) cured / 12 (32.4%) improved / 3 (8.1%) remained incontinent
  • 5.6% bladder outlet obstruction after sling — managed with dilation or urethrotomy

Lee & Zimmern 2016 — 95% overall repair success at mean 52 mo; synthetic-sling-related UVF group had significantly worse functional outcomes than non-sling group.[33]

Timing​

Defer anti-incontinence surgery 3–6 months after fistula healing is confirmed.[34] Reeves & Chapple — autologous sling at 6 mo post-diverticulectomy in patients with bothersome de novo SUI.[35]

Special Situations​

UVF + urethral stricture​

Common in obstetric injury — Xu 2013 algorithm (above) drives technique selection. Overall 93.2% anatomical / 90.9% functional success at 42.3 mo.[12]

UVF after urethral diverticulectomy​

UVF complicates 1–5% of urethral diverticulectomies.[8][9] Risk factors: complex / proximal diverticula. Prophylactic Martius at the index diverticulectomy may reduce the risk.[8][10] If UVF develops: catheter trial 2–4 wk; if persistent, transvaginal repair with Martius.

UVF after mesh sling erosion​

Mesh erosion into the urethra can produce a UVF, sometimes with concomitant urethral diverticulum.[10] Management: complete mesh excision + tract excision + layered closure with Martius; staged autologous pubovaginal sling for persistent SUI.[31][32]

Postoperative Care​

  • Continuous urethral drainage 7–14 days — Barone 2015 multicenter RCT: 7-day catheter is non-inferior to 14-day for simple GU fistula repair[36]
  • ± Suprapubic catheter — particularly for proximal UVF
  • Anticholinergics to prevent bladder spasms that stress the repair
  • Antibiotics — perioperative prophylaxis; extended if infection
  • No vaginal intercourse ≥ 6–8 weeks
  • No heavy lifting / straining ≥ 6–8 weeks
  • PVR monitoring after catheter removal
  • Dye test before catheter removal to confirm closure
  • Follow-up clinical exam and cystourethroscopy at 6–8 wk, then 3, 6, 12 mo

Predictors of Success and Failure​

FactorEffect
Fistula size > 3 cmSignificantly predicts failure (P = 0.02)[30]
Tissue interposition availableStrongly predicts success (P = 0.002 when omentum unavailable for abdominal repair)[30]
Primary vs recurrent repairFirst attempt most likely to succeed — centralizing care to experienced surgeons is critical[2][34]
Radiation etiologyPoorer tissue quality, lower success[3]
Tissue deficitDefining UVF challenge; limited space may preclude interposition[2]

Summary Algorithm​

  1. Diagnosis — cystourethroscopy + double-dye test; rule out concomitant VVF / ureterovaginal fistula
  2. Conservative trial — urethral catheter 2–6 wk (spontaneous closure in ~15%)
  3. If persistent — wait 8–12 wk from formation for tissue maturation
  4. Primary transvaginal layered repair ± Martius (for recurrent, complex, radiation, or tissue-deficient fistulae)
  5. Postoperative drainage 7–14 d
  6. Assess SUI — defer anti-incontinence surgery 3–6 mo; autologous fascial sling preferred over synthetic
  7. If repair fails — repeat transvaginal + Martius; if Martius failed, consider rectus abdominis muscle flap or transabdominal approach

References​

1. Hillary CJ, Osman NI, Hilton P, Chapple CR. "The aetiology, treatment, and outcome of urogenital fistulae managed in well- and low-resourced countries: a systematic review." Eur Urol. 2016;70(3):478–492. doi:10.1016/j.eururo.2016.02.015

2. Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. "Management of urethrovaginal fistulas." Eur Urol. 2006;50(5):1000–1005. doi:10.1016/j.eururo.2006.08.002

3. Singh V, Bhandari K, Mandal S, et al. "Evolving surgical strategies for management of genitourinary fistula repair over 25 years: insights from a paradigm shift." Int J Gynaecol Obstet. 2026;173(1):283–295. doi:10.1002/ijgo.70598

4. Mörgeli C, Tunn R. "Vaginal repair of nonradiogenic urogenital fistulas." Int Urogynecol J. 2021;32(9):2449–2454. doi:10.1007/s00192-020-04496-x

5. Lee RA, Symmonds RE, Williams TJ. "Current status of genitourinary fistula." Obstet Gynecol. 1988;72(3 Pt 1):313–319.

6. Bazeed M, Nabeeh A, el-Kenawy M, Ashamallah A. "Urovaginal fistulae: 20 years' experience." Eur Urol. 1995;27(1):34–38. doi:10.1159/000475120

7. Clifton MM, Goldman HB. "Urethrovaginal fistula closure." Int Urogynecol J. 2017;28(1):157–158. doi:10.1007/s00192-016-3111-8

8. Greenwell TJ, Spilotros M. "Urethral diverticula in women." Nat Rev Urol. 2015;12(12):671–680. doi:10.1038/nrurol.2015.230

9. Lee RA. "Diverticulum of the female urethra: postoperative complications and results." Obstet Gynecol. 1983;61(1):52–58.

10. Smith A, Burton L, Mama S. "Surgical approach to urethral diverticulum and urethrovaginal fistula with mesh erosion." Int Urogynecol J. 2024;35(6):1327–1329. doi:10.1007/s00192-024-05787-3

11. Wei N, Pfeuti C, Linder BJ. "Contemporary genitourinary fistula management: treatment, trends, and innovations." Curr Opin Obstet Gynecol. 2025. doi:10.1097/GCO.0000000000001065

12. Xu YM, Sa YL, Fu Q, et al. "A rationale for procedure selection to repair female urethral stricture associated with urethrovaginal fistulas." J Urol. 2013;189(1):176–181. doi:10.1016/j.juro.2012.09.005

13. Rogers RG, Jeppson PC. "Current diagnosis and management of pelvic fistulae in women." Obstet Gynecol. 2016;128(3):635–650. doi:10.1097/AOG.0000000000001519

14. 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

15. Henriksson C, Kihl B, Pettersson S. "Urethrovaginal and vesicovaginal fistula. A review of 29 patients." Acta Obstet Gynecol Scand. 1982;61(2):143–148. doi:10.3109/00016348209156545

16. Okada Y, Matsushita T, Hasegawa T, et al. "Surgical interventions for treating vesicovaginal fistula in women." Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

17. Henriksson C, Kihl B, Pettersson S. (See ref 15.)

18. Milani R, D'Alessandro G, Barba M, et al. "Transvaginal primary layered repair of postsurgical urethrovaginal fistula." Int Urogynecol J. 2021;32(7):1941–1943. doi:10.1007/s00192-021-04819-6

19. Zilberlicht A, Lavy Y, Auslender R, Abramov Y. "Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap." Int Urogynecol J. 2016;27(12):1925–1927. doi:10.1007/s00192-016-3085-6

20. Kieserman-Shmokler C, Sammarco AG, English EM, Swenson CW, DeLancey JO. "The Latzko: a high-value, versatile vesicovaginal fistula repair." Am J Obstet Gynecol. 2019;221(2):160.e1–160.e4. doi:10.1016/j.ajog.2019.05.021

21. Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. "Role of the Martius procedure in the management of urinary-vaginal fistulas." J Am Coll Surg. 2000;191(3):259–263. doi:10.1016/s1072-7515(00)00351-3

22. Malde S, Spilotros M, Wilson A, et al. "The uses and outcomes of the Martius fat pad in female urology." World J Urol. 2017;35(3):473–478. doi:10.1007/s00345-016-1887-2

23. Elkins TE, DeLancey JO, McGuire EJ. "The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair." Obstet Gynecol. 1990;75(4):727–733.

24. Kapriniotis K, Loufopoulos I, Gresty HCM, Greenwell TJ, Ockrim JL. "The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence." BJU Int. 2024;134(3):365–374. doi:10.1111/bju.16350

25. Golomb J, Leibovitch I, Mor Y, Nadu A, Ramon J. "Fascial patch technique for repair of complicated urethrovaginal fistula." Urology. 2006;68(5):1115–1118. doi:10.1016/j.urology.2006.06.001

26. Bruce RG, El-Galley RE, Galloway NT. "Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas." J Urol. 2000;163(4):1212–1215.

27. Atan A, Tuncel A, Aslan Y. "Treatment of refractory urethrovaginal fistula using rectus abdominis muscle flap in a six-year-old girl." Urology. 2007;69(2):384.e11–13. doi:10.1016/j.urology.2006.11.023

28. Blaivas JG. "Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra." J Urol. 1989;141(3):542–545. doi:10.1016/s0022-5347(17)40887-1

29. Xu YM, Sa YL, Fu Q, et al. "Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture." Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046

30. Ockrim JL, Greenwell TJ, Foley CL, Wood DN, Shah PJ. "A tertiary experience of vesico-vaginal and urethro-vaginal fistula repair: factors predicting success." BJU Int. 2009;103(8):1122–1126. doi:10.1111/j.1464-410X.2008.08237.x

31. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023)." J Urol. 2023;209(6):1091–1098. doi:10.1097/JU.0000000000003435

32. ACOG Committee on Practice Bulletins. "Urinary incontinence in women. ACOG practice bulletin no. 155." Obstet Gynecol. 2015;126(5):e66–e81. doi:10.1097/AOG.0000000000001148

33. Lee D, Zimmern PE. "Long-term functional outcomes following non-radiated urethrovaginal fistula repair." World J Urol. 2016;34(2):291–296. doi:10.1007/s00345-015-1601-9

34. Klemm J, Stelzl DR, Schulz RJ, et al. "Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review." BJU Int. 2024;134(3):407–415. doi:10.1111/bju.16395

35. Reeves FA, Inman RD, Chapple CR. "Management of symptomatic urethral diverticula in women: a single-centre experience." Eur Urol. 2014;66(1):164–172. doi:10.1016/j.eururo.2014.02.041

36. Barone MA, Widmer M, Arrowsmith S, et al. "Breakdown of simple female genital fistula repair after 7 day versus 14 day postoperative bladder catheterisation: a randomised, controlled, open-label, non-inferiority trial." Lancet. 2015;386(9988):56–62. doi:10.1016/S0140-6736(14)62337-0