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Urinary fistula

Background

Overview

Definition
Urinary fistulas are abnormal connections between the urinary tract and another organ or body surface.
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Pathophysiology
The pathophysiology of urinary fistulas typically involves tissue damage and necrosis, subsequently leading fistula formation. This damage can arise from a variety of causes, including trauma, surgery, or infection. Obstetric fistulas often occur due to prolonged obstructed labor, leading to tissue ischemia and necrosis and the formation of a fistula between the urinary and genital tracts.
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Epidemiology
The incidence of bladder injury associated with gynecologic surgery is estimated at 3.2-4.8%. The prevalence of vesicovaginal fistula is estimated at 1 in 1,000 after hysterectomy and 1 in 1,000 deliveries.
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Disease course
The clinical course of urinary fistulas can vary widely depending on the location and size of the fistula. Common symptoms include urine leakage, urinary incontinence, recurrent UTIs, discomfort, and skin irritation or breakdown in the area where the urine is leaking. In vesicouterine fistulas, patients may present with hematuria, vaginal leakage of urine, and urethral passage of lochia.
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Prognosis and risk of recurrence
The prognosis of urinary fistulas is largely dependent on the cause, location, and size of the fistula. Simple obstetric fistulas with the following characteristics generally have a good prognosis: single fistula < 4 cm, vesicovaginal fistula, closing mechanism not involved, no circumferential defect, minimal tissue loss, ureters not involved, first attempt to repair. Complex obstetric fistulas with the following characteristics have an uncertain prognosis: fistula > 4 cm, multiple fistula, rectovaginal mixed fistula, cervical fistula, closing mechanism involved, scarring, circumferential defect, extensive tissue loss, intravaginal ureters, failed previous repair, radiation fistula.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of urinary fistula are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/EAUN 2024)....
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Diagnostic investigations

Clinical assessment: as per EAU/EAUN 2024 guidelines, Elicit a complete medical history and perform a focused physical examination, including direct visual inspection, for the evaluation of patients with suspected urinary fistula.
A
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  • Diagnostic imaging

Diagnostic procedures

Cystoscopy: as per EAU/EAUN 2024 guidelines, Perform cystoscopy and retrograde bladder filling with a colored fluid to confirm the diagnosis of urinary fistula.
B

Medical management

Nonoperative management: as per EAU/EAUN 2024 guidelines, Offer conservative or endoluminal techniques, if expertise and facilities are available, for the initial management of upper urinary tract fistulas.
B

Perioperative care

Perioperative management
As per EAU/EAUN 2024 guidelines:
Provide appropriate skin care, nutrition, rehabilitation, counseling, and support before and after fistula repair.
B
Ensure that the bladder is continuously drained following fistula repair until healing is confirmed (10-14 days for simple and/or post-surgical fistulas and 14-21 days for complex and/or post-radiation fistulas).
B

Surgical interventions

Surgical repair: as per EAU/EAUN 2024 guidelines, Tailor the timing of fistula repair to the individual patient and surgeon requirements once edema, inflammation, tissue necrosis, or infection have resolved.
B
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Preventative measures

Prevention during gynecological surgery: as per EAU/EAUN 2024 guidelines, Do not use ureteric stents routinely as prophylaxis against injury during routine gynecological surgery.
D