Vesicouterine fistula refers to an abnormal communication between the bladder and uterus. The first case of vesicouterine fistula was reported in 1908. It was however first described in 1957 by Abdel Fattah Youssef, an obstetrician and gynaecologist in Kasr el-Aini hospital,

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. It is characterized by a vesicouterine fistula above the level of the internal os, absence of menstrual bleeding, cyclical presence of blood in urine and absence of

urinary incontinence Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geria ...

with a patent

cervical canal The cervical canal is the spindle-shaped, flattened canal of the cervix, the neck of the uterus. Anatomy The cervical canal communicates with the uterine cavity via the internal orifice of the uterus (or internal os) and with the vagina via the ...

following a lower segment caesarean section. Six of such cases had been reported by other clinicians before the term Menouria was coined by Youssef.

Pathology

Vesicouterine fistula is the least common type of urogenital fistula accounting for 1-4% of urogenital fistulas. It occurs following

lower segment caesarean section A lower (uterine) segment Caesarean section (LSCS) is the most commonly used type of Caesarean section. Most commonly to deliver the baby a transverse incision is made in the lower uterine segment above the attachment of the urinary bladder to ...

and the incidence is increasing due to the increasing incidence of caesarean deliveries. The occurrence of menoruria in the absence of vaginal bleeding or passage of urine from the vagina is attributed to a sphincteric mechanism of the

uterine isthmus The uterine isthmus is the inferior-posterior part of uterus, on its cervical end — here the uterine muscle ( myometrium) is narrower and thinner. It connects the body and cervix. The uterine isthmus can become more compressibile in pregnanc ...

. Jozwik and Jozwik classified vesicouterine fistula into three types based on the route of menstrual flow; I - Menstrual flow from the bladder only without urinary incontinence II - Menstrual flow from both the bladder and vagina with urinary incontinence III - Normal menstrual flow from the vagina only (no menouria) with urinary incontinence Youssef syndrome corresponds to a type I vesicouterine fistula.

Causes

Vesicouterine fistulas occur most commonly after lower segment caesarean sections (about 83-93% of cases). The possible mechanisms by which vesicouterine fistulas occur following caesarean sections include undetected bladder injury during caesarean section, inadvertent placement of a suture through the bladder during the repair of the uterus and abnormal blood vessel connections following multiple caesarean sections. It may also present following use of

obstetric forceps Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse (vacuum extraction) method. Medical uses Forceps births, like all assisted births, should only be undertaken to help pro ...

, manual placenta removal, external cephalic version, morbidly adherent placenta, surgical removal of fibroids, rupture of the uterus, perforation of the uterus and

radiation therapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...

in the treatment of cervical cancer. Vesicouterine fistula can also occur as a

birth defect A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities ca ...

in conjunction with

vaginal atresia Vaginal atresia is a condition in which the vagina is abnormally closed or absent. The main causes can either be complete vaginal hypoplasia, or a vaginal obstruction, often caused by an imperforate hymen or, less commonly, a transverse vaginal se ...

Diagnosis

The diagnosis of a vesicouterine fistula is made by demonstrating an abnormal connection between the cavities of the bladder and uterus. It can be diagnosed using

hysterosalpingography Hysterosalpingography (HSG), also known as uterosalpingography, is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the Fallopian tubes. It is a special x-ray using dye to look at the womb (ute ...

, hysterography, cystography,

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...

(MRI) and computerised tomography. MRI has been found to have 100% accuracy in the diagnosis of vesicouterine fistula. It is also less invasive than other modalities and is considered the

gold standard A gold standard is a monetary system in which the standard economic unit of account is based on a fixed quantity of gold. The gold standard was the basis for the international monetary system from the 1870s to the early 1920s, and from the la ...

for diagnosis.

Treatment

The options of treatment include

watchful waiting Watchful waiting (also watch and wait or WAW) is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed. Related terms include ''expec ...

for spontaneous resolution of the fistula, use of medications that can stop menstrual periods such as oral contraceptive pills,

progesterone Progesterone (P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species. It belongs to a group of steroid hormones called the progestogens and is the m ...

and gonadotropin releasing hormone analogs. Surgery can be carried out through the vagina, bladder or peritoneum and can be done via

laparoscopic Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

or robotic surgery. Watchful waiting is the treatment of choice in case of small fistulas. The bladder is catheterised for a period of 4 to 8 weeks in order to allow spontaneous closure of the vesicouterine fistula.

Fulguration Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using the heat generated from medium frequency alternati ...

of the fistula can also be done via cystoscopy in cases of small fistulas.

Differential diagnosis

Endometriosis Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, f ...

References