The treatment of urogenital fistulas in women remains a complex issue in reconstructive urogynecology, since it requires a significant amount of knowledge and considerable practical experience of the surgeon, and care for women should be provided by highly qualified urologists with the involvement of gynecologist colleagues.

Urinary fistula is one of the most serious diseases in women, leading not only to damage to organs, long-term and permanent disability, but also causing moral and physical suffering, menstrual, sexual and reproductive dysfunction. The constant leakage of urine from the vagina, the inability to use a urinal make it unbearably difficult for a woman to be in a team and even in a family.

According to the Mauo Clinic (USA), among 303 operations for urogenital fistulas, 82% occurred after gynecological operations, 8% - as a result of obstetric interventions, 6% - after radiation therapy, 4% - due to trauma or cauterization. It should be noted that 88% of postoperative fistulas are the consequences of hysterectomy. In developing countries, in 90-95% of cases, the main cause of the formation of urogenital fistulas (vesicovaginal and ureterovaginal) is obstetric trauma - obstructive (protracted) labor.

Prolonged clamping of the posterior wall of the bladder and urethra by the fetal head causes ischemia and necrosis of the latter. Less commonly, obstetric trauma and genitourinary fistula formation can be caused by surgical interventions (caesarean section or hysterectomy) with damage to the bladder and ureters.

Causes of urinary fistulas in women

Hysterectomy is believed to be the leading cause of genitourinary fistulas, with transabdominal hysterectomy 3 times more likely than transvaginal hysterectomy to be associated with bladder injury. According to modern literature, the frequency of formation of urogenital fistulas (vesicovaginal, ureterovaginal) after obstetric and gynecological operations is 0.05-1.0%, although some authors give significantly higher (up to 4-6%) figures.

The incidence of bladder injury during abdominal hysterectomy is 0.5-1.0%, and vesico-vaginal fistulas form in 0.1-0.2% of cases, which are usually associated with unrecognized trauma during surgery and improper placement seams for damage. Other reasons for the formation of vesico-vaginal fistulas can be: surgical interventions in the pelvic area (on the rectum, vessels), inflammatory and malignant processes or irradiation of the pelvic organs, foreign bodies and sexual trauma to the vagina. Vesico-vaginal fistulas also occur after conization of the cervical canal, anterior colporrhaphy, operations for stress urinary incontinence (anti-stress or anti-incontinent operations), resection of the bladder neck, after surgical treatment of the intestine, less often with pelvic abscesses, bladder stones.

Causes of vesicovaginal fistulas:

1. Traumatic:

a) after surgery dvtifntkmcndf:

    abdominal hysterectomy;
    • vaginal hysterectomy;
    • anti-continental surgery;
    • anterior colporrhaphy for prolapse;
    • vaginal biopsy;
    • transurethral resection (biopsy) of the bladder, incl. and laser;
    • other pelvic surgery (rectal surgery).
b) trauma to the anterior wall of the vagina (including sexual trauma).

2. Radiotherapy.

3. Often tumors of the pelvic organs.

4. Infectious diseases of the pelvic organs.

5. Foreign bodies in the vagina (including pessaries).

6. OB:

    obstructive (protracted, prolonged) labor;
    • forceps application;
    • uterine rupture;
    • caesarean section with bladder injury.
7. Congenital fistulas.

The frequency of iatrogenic damage to the ureters during obstetric and gynecological operations, according to the literature, reaches 0.5-2.5%. The main reason for the formation of vesicouterine fistulas is cesarean section, much less often they occur after uterine rupture due to obstructive childbirth, with transposition of an intrauterine contraceptive (spiral) into the bladder, embolization of the uterine artery, traumatic catheterization of the bladder.

Symptomatology and diagnosis of urogenital fistulas in women

The main symptom of the disease is uncontrolled excretion of urine - its constant incontinence, the nature and characteristics of which depend on the size, shape and location of the fistula. Urinary incontinence is absent in vesico-adnexal and vesico-uterine fistulas with localization in the body of the uterus. With vesicouterine fistulas with localization in the cervix, women note a symptom of persistent urinary incontinence, in the area of ​​​​the body of the uterus - cyclic menouria or hematuria. The amount of urine excreted depends on the size of the fistula: with small defects in urination, there may be partial incontinence in a natural way, with large ones, all urine is excreted through the vagina (complete incontinence). When the fistula is located in the region of the bladder neck, they keep urine only in a horizontal position.

Types of treatment for urogenital fistulas in women

According to most researchers, conservative therapy of vesicovaginal fistulas is indicated for small (up to 3 mm in diameter) sizes and in the early stages of their occurrence. The bladder is drained with a Foley catheter, a tampon with a synthomycin emulsion is inserted into the vagina, and bed rest is prescribed. Duration of treatment - up to 3-6 weeks.

Foreign literary sources describe cases of fistula closure after electrocoagulation and its cauterization in 10-50% of patients. Other authors note self-healing of fistulas only in 2-3% of such patients. According to D.V. Kana, if the fistula does not close within 10-12 days, then conservative therapy should be abandoned.

In ureterovaginal fistulas, it is sometimes possible to pass a stent (usually for 3-4 weeks) or a ureteral catheter through the ureter into the kidney and achieve closure of the fistula. The absence of inflammation of the tissues around the fistula is one of the important factors for successful surgical treatment. Most urologists and gynecologists believe that the optimal time for closing post-traumatic urogenital fistulas is 3-6 months. Normal epithelialization in the fistula area and the possibility of surgical intervention are evidenced by: the absence of bleeding, edema and inflammatory reaction in the area of ​​the defect; preserved color of the epithelium; sufficient tissue mobility.

In rare cases (up to 24-48 hours after the formation of a post-traumatic fistula), surgical intervention is possible to close the fistula in the absence of an inflammatory reaction of tissues, edema, necrosis. Due to the physical and psychological discomfort in a woman with a genitourinary fistula, many cases of early success (1-1.5 months) are reported in the literature.

Thus, the treatment of urogenital fistulas in women remains a complex issue in reconstructive urogynecology, requires the knowledge and practical experience of the surgeon, and care should be provided in specialized institutions by highly qualified urologists with the involvement of gynecologist colleagues.

According to the journal “Medical Aspects of Women's Health”

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