Bladder fistula is the presence of a pathological passage connecting the bladder with adjacent internal organs (vagina, intestines) or skin. Pathology is characterized by urine excretion through a communicating organ, permanent urinary tract infections. The scope of the diagnostic examination should include gynecological examination, ultrasound of the bladder and pelvic organs, cystoscopy, chromocystoscopy, fistulography, urography, cystography, examination of urine and smears. Treatment of fresh fistulas can be conservative; with long-term non-healing fistulas, their excision is indicated.
Meaning
Taking into account the organs involved in the pathological process, vesico-genital, vesico-intestinal and external fistulas of the bladder are isolated. Pathology often has a long course, causes moral and physical suffering to the patient, leads to disability, has a negative impact on the functioning of the genitourinary and intestinal tract. The treatment of fistulas of this localization is carried out by specialists in the field of practical urology with the participation of proctologists and gynecologists.
Causes
Acquired bladder fistulas may be of traumatic, inflammatory, oncological or radiation origin. The most common causes of enterovesical fistulas are bowel cancer, Crohn’s disease, diverticulitis. Vesico-genital fistulas occur mainly in women and are associated with injuries resulting from childbirth or gynecological operations. Among them, the majority (55-65%) are vesicovaginal fistulas.
The occurrence of fistulas between the bladder and genitals in women is usually caused by birth injuries, intraoperative injuries (during medical abortion, diagnostic curettage, hysterectomy, etc.). Among other causes of the development of fistulas are bladder wounds, urological operations (in particular, transurethral removal of bladder neoplasms).
Fistulas of inflammatory genesis can form when a pyosalpinx, parametritis, prostate abscess, etc. breaks into the bladder. purulent formations of the pelvis. In some cases, fistulas occur due to the germination of the bladder wall tumor in bladder cancer, vaginal cancer, prostate cancer, etc. Pathology can develop after irradiation of the pelvic organs several months or even years after the end of treatment.
Classification
According to the time of occurrence, congenital bladder fistulas and acquired ones are distinguished. Congenital fistulas, along with urachus cyst and diverticulum of the bladder, belong to embryonic defects and are formed as a result of complete non-infection of the primary urinary duct. These types of anomalies include vesicolabular, vesicolecular fistulas.
Acquired fistulas represent a much more common and diverse group. In women, depending on the organ with which the abnormal communication of the bladder is formed, fistulas can be vesico-vaginal, vesico-cervical, vesico-uterine, vesico-appendage, parametric-vesicular. Rarely there are complex combined fistulas – urethro-vesicovaginal, ureteral-vesicovaginal and reservoir-vaginal (between the orthotopic bladder formed from the intestine and the vagina). When the intestinal wall is damaged, urolithiasis (intestinal fistulas) are formed.
Quite often, to divert urine in urology, they resort to artificial imposition of a suprapubic fistula – epicystostomy. Indications for the formation of epicystostomy are persistent urinary retention and the inability to catheterize the bladder (for example, with prostatic hyperplasia, prostate cancer, urethral stricture, etc.). In addition, there are external fistulas communicating with the skin and internal fistulas opening into the organ cavity.
Symptoms
The course of the bladder fistula is determined by its type and the organs involved. External fistulas, as a rule, have a straight short course, open on the surface of the skin, where hyperemia, maceration, pustules occur around the hole. Pathological passages with a more complex structure can be long, winding, with numerous pockets, which causes the formation of abscesses and phlegmon in the surrounding tissues. Vesico-vaginal fistulas (vesicovaginal) usually appear 1-2 weeks after childbirth or gynecological intervention.
Vesicovaginal fistulas are characterized by the appearance of permanent watery discharge from the vagina, the intensity of which may be different. With small fistulas, periodic involuntary leakage of urine is observed with preserved natural urination. Often, minor urine discharge from the vagina is mistaken for stress incontinence. Fistulas located at the base of the bladder are usually quite wide, so part or even all of the urine can be released through the vagina. Along with these symptoms, women often have menstrual irregularities, frequent cystitis, colpitis.
Vesicular-appendage, parametric-appendage and combined fistulas occur with the phenomena of pronounced general intoxication and pain caused by destructive processes in the pelvis. If the fistula opens into the intestine, then liquid feces and gases are constantly released from the rectum. The leakage of urine (through the external fistula, vagina, rectum) is accompanied by wetness and irritation of the skin, the presence of a sharp urinary odor, causes psychoemotional disorders in patients and negatively affects all spheres of life.
Diagnostics
A urinary-vaginal fistula can be detected by a urologist or gynecologist. If involuntary leakage of urine is detected, a vaginal examination is required. A large fistula connecting the bladder to the vagina is clearly visible when viewed in mirrors, since the vaginal cavity is filled with free fluid – urine quite quickly. In case of doubts about the nature of the discharge, a biochemical examination of the vaginal transudate is resorted to. If the creatinine level in the fluid secreted from the vagina exceeds the same indicator in the blood serum, then this transudate is urine.
A cystoscopy performed against the background of a tight vaginal tamponade with gauze swabs also allows to identify a bladder fistula. During cystoscopy, localization and size, severity of inflammation and swelling of the mucosa are evaluated. Small and punctate fistulas can be detected using a dye sample. To do this, three tampons are placed in the vagina, and an indigocarmine solution is injected into the bladder via a catheter. When staining the lower tampon for 15 minutes, stress urinary incontinence is most likely; when staining the upper tampons, the presence of a fistula is assumed.
In order to detect concomitant infection of the genitourinary tract, urine and urethral discharge are performed, and a vaginal smear is examined. To monitor kidney function, biochemical blood parameters are determined – creatinine, urea, electrolytes. The most accurate information about the nature of the fistula, its localization and the relationship with neighboring organs is obtained when performing contrast studies – vaginography, excretory urography, cystography, chromocystoscopy, retrograde ureteropyelography. To clarify the branching of the fistula, fistulography is performed.
The detection of urinary-intestinal fistulas requires finger examination and additional examination of the rectum (anoscopy, rectoromanoscopy). With fistulas caused by radiation therapy for cancerous tumors, it is necessary to exclude a recurrence of the oncoprocess by biopsy and histological examination of the edges of the fistula.
Treatment
With punctate (less than 3 mm in diameter) vesicovaginal fistulas, an attempt is made to close them conservatively. To do this, a permanent Foley catheter is installed in the bladder, bladder instillations are performed, ointment swabs are inserted into the vagina, uroseptics and antibiotics are prescribed. Scarring can be achieved in 2-3% of patients. If the fistula does not close on its own within 6-8 weeks, conservative therapy should be abandoned in favor of surgical treatment.
Surgical closure of the fistula – fistuloplasty is performed after drug preparation and the subsiding of purulent-inflammatory processes in the area of the pathological course. Regardless of the type of fistula, scar-altered tissues are excised during fistuloplasty, the bladder wall is mobilized and completely disconnected from neighboring organs and tissues, after refreshing the edges, the defects are sutured. Operations to close the formed fistulas are performed by suprapubic, transvaginal (in women), perineal (in men) or combined access.
After suturing the vesicovaginal fistula, an epicystostomy or a permanent urinary catheter is left for a while. The presence of a vesico-intestinal fistula may require the temporary imposition of a colostomy, resection of a segment of the intestine, transplantation of ureters into the intestine or cystectomy with the creation of an artificial intestinal reservoir for urine.
Prognosis and prevention
Prevention of bladder fistulas in women requires proper organization of obstetric care, especially in pregnant women with a narrow pelvis, large fetus, transverse fetal position, etc.; prevention of intraoperative organ damage during gynecological operations. In all cases, for a more favorable prognosis, it is necessary to timely recognize the injury of the urinary organs, its correct assessment and the choice of an adequate way to eliminate the fistula.