A urogenital fistula is an abnormal tract that exists between the

urinary tract The urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, c ...

and

bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...

ureter The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually long and around in diameter. The ureter is lined by urothelial cells, a type of transitional epit ...

s, or

urethra The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra c ...

. A urogenital fistula can occur between any of the

organs In biology, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to act together in a f ...

and structures of the pelvic region. A

fistula A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...

allows

urine Urine is a liquid by-product of metabolism in humans and in many other animals. Urine flows from the kidneys through the ureters to the urinary bladder. Urination results in urine being excreted from the body through the urethra. Cellular ...

to continually exit through and out the urogenital tract. This can result in significant

disability Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physical, ...

, interference with

sexual activity Human sexual activity, human sexual practice or human sexual behaviour is the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts, ranging from activities done alone (e.g., masturbation) ...

, and other

physical health Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organi ...

issues, the effects of which may in turn have a negative impact on mental or

emotional state Emotions are mental states brought on by neurophysiological changes, variously associated with thoughts, feelings, behavioral responses, and a degree of pleasure or displeasure. There is currently no scientific consensus on a definition. ...

, including an increase in

social isolation Social isolation is a state of complete or near-complete lack of contact between an individual and society. It differs from loneliness, which reflects temporary and involuntary lack of contact with other humans in the world. Social isolation ...

. Urogenital fistulas vary in etiology (medical cause). Fistulas are usually caused by injury or surgery, but they can also result from

malignancy Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...

, prolonged and obstructed labor and deliver in

childbirth Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births glob ...

, hysterectomy,

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. Radi ...

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

. Of the fistulas that develop from difficult childbirth, 97 percent occur in

developing countries A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agreem ...

. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the

gastrointestinal system The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...

, and these may also be termed fistulas.

Classification

Abnormal passageways or fistulas can exist between the vagina and bladder, ureters, uterus, and rectum with the resulting passage of urine from the vagina, or intestinal gas and feces into the vagina, in the case of a vaginal–rectal fistula. These vaginal fistulas are named according to the origin of the defect: * vesicovaginal * urethrovaginal * ureterovaginal * vesicocervical * vesicouterine * vesicouretovaginal * uterocervical * vesicocervical * uretercervical * ureteruterine The vagina is susceptible to fistula formation because the gastrointestinal tract and urinary system are relatively close to the vagina. A small number of vaginal fistulas are congenital. The presence of a vaginal fistula has a profound effect on the quality of life since there is little control over the passage of urine and feces through the vagina. Urogenital fistulas are often classified according to their cause:

obstetric fistula Obstetric fistula is a medical condition in which a hole develops in the birth canal as a result of childbirth. This can be between the vagina and rectum, ureter, or bladder. It can result in incontinence of urine or feces. Complications may i ...

, congenital fistula and iatrogenic fistula. Urogenital fistulas can be classified by size and more specific anatomical location such as 'upper vagina' or 'posterior vaginal wall'.

Causes

In developed countries, the causes of fistulas are

iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...

(caused by surgical accidents). Physician error and lack of training contribute to the unsuccessful treatment of obstetric fistulas in developing countries. Injuries to pelvic organs are a cause of fistulas. Most of those not caused by obstructed labor develop from injuries. An example of this would be the improper placement of an instrument during a hysterectomy. Fistulas can form after long-term pessary use, hysterectomies, malignant disease and pelvic irradiation, pelvic surgery, cancer or a pelvic fracture. Fistulas are sometimes found after a cesarean section. Providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery. The more training the physician has had, the less likely a uro-vaginal fistula will occur. Some women develop more than one fistula.

Treatment

Surgery is often needed to correct a fistula leading to the vagina. Conservative treatment with an in-dwelling catheter can be effective for small and recently formed urinary fistulas. It has a success rate of 93%. Collagen plugs are used but have been found not to be successful. The surgical treatment to correct can be approached in different ways. Surgery through the vagina is successful 90% of the time. Surgical correction can be accomplished by abdominal surgery, by laparoscopic and robot-assisted laparoscopic surgery. The various treatments vary in frequency. The transvaginal approach is used 39% of the time, transabdominal/transvesical approach is used 36% of the time, the laparoscopic/robotic approach is used to treat 15% of urogenital fistulas and a combination of transabdominal-transvaginal approach is used 3% of the time.

Epidemiology

Globally, 75 percent of urogenital fistulas are obstructive labor fistulas. The average age of a woman who develops a fistula due to prolonged labor is 28 years old. The average age of a woman who develops a fistula from other causes is 42 years old. Women with a small pelvis are more likely to develop a fistula. Though rare, a fistula can form after the minimally invasive oocyte retrieval part of infertility treatment. Urogenital fistulas (vesicovaginal) caused by surgical complications occur at a frequency of 0.8 per 1000.

Rectovaginal fistulas

Abnormal passage of stool through the vagina is caused by a rectovaginal fistula. Treatment is often surgical with the use of tissue grafts. The presence of bowel disease increases the risk of a rectovaginal fistula. An entero-vaginal fistula can form between the bowel and the vagina. Rectovaginal fistulae result from inflammatory bowel disease, Chrohn's disease trauma, or iatrogenic injury and diversions to other organs. Episiotomies can cause the formation of a rectovaginal fistula.

References