Uterovesical Fistula

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UTEROVESICAL FISTULA UTEROVESICAL FISTULA (Youssef’s syndrome)(Youssef’s syndrome)

Dr.K.Malleswar Rao, MD, DGO

Civil Surgeon SpecialistDept. of Obstetrics &

GynecologyESI Hospital, Sanathnagar,

Hyderabad.

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CASE REPORTCASE REPORT Presenting complaints:1. Bleeding while passing urine since 6years. (Menourea)2. Pain in the lower abdomen since 6months. 3. Irregular bleeding per vagina since 3months. (Uterine

bleeding) Previous history:1. No h/o urinary incontinence. Nothing particular.

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CASE REPORTCASE REPORTObstetric history: Para 2, Live 2, both deliveries by C-sections, one in Delhi and another at Bihar state. The delivery records are unavailable. She underwent tubectomy.Menstrual history: Previous: 4-5days/30days, regular flow. H/o passing blood in urine at the time of menstrual flow (so called Cyclic Menourea) since 6years. Present: Irregular excessive menstrual flow since 3months associated hematuria since 3months.General Exam: Patient is anemic, P.R. 80/min, BP 110/70mmHg, CVS/RS: NAD, P/A: NAD.Gynaec. Exam: Bimanual vaginal examination: Uterus AV, bulky, mobile, FF, non-tender.

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CASE REPORTCASE REPORTINVESTIGATIONS: ROUTINE (BASIC) WORKUP: -1.CUE on 7-4-04:WNL except haematuria.2.IVU on 3-3-04:Both are kidneys normal, no evidence of

obstruction and dilatation of Pelvicalyceal system.3.Urine for C/S on 3-3-04: E. coli grown in culture and sensitive to

1.Furadantine, 2.Amikacin.4. Hb% on 8-3-04: 6gm%. 5. RBS: 103mg%, Blood Urea: 15mg%.6. “B” Rh-positive, HIV & Hbs Ag: non-reactive.7. LFT: S. Bilirubin: 0.72mg%, SGPT: 2 IU/L, Alk. Phos: 4KA.8. X-Ray Chest PA view: Normal.9. X-KUB on 8-3-04: No ROD seen.

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CASE REPORTCASE REPORT

Specific WORK-UP: -

1. U/S scan total abdomen done in a private center on 6-1-04: GB stone 19mm in size, and evidence of “UTEROVESICAL FISTULA” seen, other findings normal.

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2. U/S scan repeated on 8-3-04 in ESI Hospital, Sanathnagar: GB calculus of 13mm size seen, endometrial polyp/ sub-mucous fibroid with cervix hypertrophied and uterine endometrial cavity is in uterine endometrial cavity is in continuity with the bladder,continuity with the bladder, Right Ovary 3/3cm, Left Ovary 3/3cm.

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3. Double dye test (oral pyridium + Intravesical instillation of Methyline blue dye) done on 3-3-04 revealed no evidence of VVF or UVF.

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4. CYSTOSCOPIC Exam. Done in OGH on 25-03-04: Ureter and both Ureteric orifices and Bladder wall are normal; Blood clot present in bladder and it is evacuated.

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5. Endovaginal sonogram + Saline infusion sonohysterogram (SIS) had been done with the assistance of equipment company, (as we have no access to the U/S machine with TV probe).




CLINICAL MANAGEMENT: Preoperatively on pint of blood transfused on 6-04-04 to correct anemia and Hb% improve to 10gm% before surgery.

Urinary Tract Infection had been treated by Inj. Amikacin 15mg/kg /day X 10days. Later, Urine became Sterile on Culture.



On 15-04-2004: Laparotomy done and total abdominal Hysterectomy with Repair of the uterovesical fistula performed.

Per-operative findings:Per-operative findings:

1. Bladder was adherent up to the fundus of the uterus.

2. Uterus was larger than normal size.3. Sub mucous fibroid polyp found at fundus region.4. Large fistulous track was found between base of

the bladder and anterior wall of the body of the uterus, which was approx. 1.5 inches in size, and in fact bladder wall is in continuity with the uterus as appropriately mentioned in U/S scan.



POST-OPERATIVE MANAGEMENT: Patient was kept on continuous bladder drainage for 14days for proper healing of the bladder wall. Skin sutures were removed on 7th POD. Uneventful P.O. course and went home.



FOLLOW-UP:

She was referred to UROLOGIST for Urodynamic exam., as frequency of urine developed post-operatively.

She didn't have any significant urological dysfunction such as Vesicourethral anomalies or dysfunction.



CLINICAL PRESENTATIONTypically, Cyclic Hematuria (Menouria, Vesical menstruation)Lochiauria (Urethral passage of Lochia)In some reported cases, Urinary Incontinence (vaginal leakage of urine) when fistula involves isthmus region (VESICOCERVICAL FISTULA)Herniation of the Amniotic sac through Uterovesical fistulaInfertility, AmenorrheaBladder endometriosis

POSSIBLE CAUSESCommonly, following Caesarian SectionPrevious traumatic (difficult) forceps deliveryMigration of (Perforated) Intrauterine Contraceptive Device



DIAGNOSISCystoscopy, Cystogram, HysterosalpingogramTransabdominal/Transvaginal SonogramExclusion of other Genitourinary fistula like Vesico Vaginal Fistula or Uretero Vaginal Fistula by DOUBLE DYE TEST (i.e., intravesical instillation of Methylene Blue+Oral adm. Of Pyridium)SALINE INFUSION SONOHYSTEROGRAM (SIS) + ENDOVAGINAL SONOGRAM



Sonographic Diagnosis of a Sonographic Diagnosis of a Uterovesical FistulaUterovesical Fistula

•Abdominal and endovaginal sonography showed a large defect in the anterior myometrium in the lower body of the uterus. •The adjacent wall of the urinary bladder also appeared deficient without any area of thickening in the adjacent bladder wall.

•The rest of the endometrium, myometrium, and urinary bladder wall appeared normal. •Both kidneys were normal without obstruction.


UTEROVESICAL FISTULAUTEROVESICAL FISTULASonohysterographySonohysterography:-:-

It was performed at the time of menses. The patient was placed in the lithotomy position, and the cervix was visualized

with the help of a Sims speculum and an anterior vaginal wall retractor. The cervix was grasped with Volsellum forceps. It

was cleaned with povidone-iodine. A Leech-Wilkinson– type

cannula was introduced into the cervical canal after expelling

air from it with saline. The speculum was removed carefully,

and an ATL C9-5 endovaginal probe (Philips Ultrasound, Bothell, WA) was introduced into the vagina. Saline was injected into the cannula, and simultaneously the uterus was scanned in the longitudinal plane. The saline freely entered the urinary bladder in a jet through the deficiency in the myometrium, confirming the uterovesical fistula



MANAGEMENTConservative approach:i) Cystoscopic fulguration, ii) Cyclic combine hormonal therapy with continuous catheterization,iii) Spontaneous resolution by continuous catheterizationSurgical approach:i) Transabdominal transperitoneal repair of fistula with/without Hysterectomy, ii) Fistula repair with Omental interposition or Myouterine flap, iii) Vaginal repair in cases of previous subtotal hysterectomy



INTERNATIONAL CLASSIFICATION OF DISEASES 619 Fistula involving female genital tract

Excludes: vesicorectal and intestinovesical fistula(596.-)619.0 Urinary-genital tract fistula, female Fistula: cervicovesical ureterovaginal urethrovaginal uteroureteric uterovesical vesicovaginal ICD Version 2007 (http://www.who.int/classifications/apps/icd/icd10online/index.htm?navi.htm+n00 )


The typical triad of Youssef's syndrome i.e. cyclic hematuria

and amenorrhea without vaginal

leakage of urine.

Youssef’s syndromeYoussef’s syndrome


UTEROVESICAL FISTULAUTEROVESICAL FISTULAFirst case of menouria was reported in the literature by Machado in 1935. Into about 92 cases were reported since 1908 (on the date of surgery) and it is rare accounting about 4% of all Genitourinary fistulas. Today, 141 articles are reported in Pubmed data.Vesicouterine fistula is a rare complication of gynecologic surgery, which is usually treated by abdominal hysterectomy and bladder repair. We present a case showing the etiology of vesicouterine fistula and contemporary reconstructive techniques. Suggestions for the avoidance of vesicouterine fistulas are also made.


UTEROVESICAL FISTULAUTEROVESICAL FISTULASUMMARYSUMMARY

A 40 yr old rural woman presented with Menouria (Vesical menstruation) tolerating the symptom in silence since 6 yrs, came to the hospital with intolerable “MENORRHAGIA + MENOURIA” (due to the growth of submucous fibroid) since 3 months.We had managed the case by “TOTAL HYSTERECTOMY ALONG WITH REPAIR OF FISTULA”.Though woman developed transient frequency and urgency of urine in postoperative period, she is now totally asymptomatic and relieved of distressing symptoms.


UTEROVESICAL FISTULAUTEROVESICAL FISTULAUnusual case of post-cesarean vesicouterine fistula (Youssef's syndrome).Therefore, it is pertinent to have periodic training courses (Update of C-section workshops) not only for qualified ObGyn specialists but also for Basic Medical Practitioners in rural areas, since Cesarian delivery is the commonest surgical procedure performed throughout the World today.


Review of literature in Review of literature in Pubmed database Pubmed database

(Medline) (Medline)


1) Unusual case of post-cesarean vesicouterine fistula (Youssef's

syndrome).Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H.

Department of Urology, Baskent University, 01250 Adana, Turkey. [email protected]

http://www.ncbi.nlm.nih.gov/pubmed/12657106?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed


2) An unusual case of Youssef's syndrome

(vesicouterine fistula) and its relationship with placenta

percreta.Majeed SM, Subhani SS.

Department of Surgery, KRL General Hospital, Islamabad, Pakistan.

http://www.ncbi.nlm.nih.gov/pubmed/17374305?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed


3) Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature.

Porcaro AB, Zicari M, Zecchini Antoniolli S, Pianon R, Monaco C, Migliorini F, Longo M, Comunale L.

Urologic Operating Unit, Civil Major Hospital, Verona, Italy. [email protected]

Spontaneous healing is reported in 5% of cases. Conservative management by bladder catheterization for

at least 4-8 weeks is indicated when the fistula is discovered just after delivery since there is good chance for spontaneous closure of the fistulous track. Hormonal management should be tried in women presenting with

Youssef's syndrome. Surgery is the mainstay and definitive treatment of vesicouterine fistulas after

cesarean section. http://www.ncbi.nlm.nih.gov/pubmed/12899224?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedreviews&logdbfrom=pubmed


4) Youssef's syndrome: an appraisal of hormonal treatment.

Hemal AK, Wadhwa SN, Kriplani A, Hemal U.Department of Urology, AIIMS, New Delhi.

Two cases of vesicouterine fistula, caused by LSCS, are presented. Both cases had classical symptoms of Youssef's syndrome,

i.e. cyclic hematuria, absence of vaginal bleeding and complete urinary continence.

These patients were treated by the continuous administration of an estrogen-progestogen combination for 6 months.

However, it failed in 1 case requiring transabdominal transperitoneal closure of the fistula

with an interposition of omentum. We feel that hormonal treatment may be tried as first modality

in the treatment of Youssef's syndrome, before resorting to surgery. http://www.ncbi.nlm.nih.gov/pubmed/8140684?ordinalpos=

1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_

Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed


5) Vesico-uterine fistula secondary to cesarean section.

Michielsen DP, Wyndaele JJ, Batchvarov YA.Department of Urology, University of Antwerp, Belgium.

A vesico-uterine fistula with vaginal urinary incontinence secondary to cesarean section is reported.

Diagnosis was made clinically, radiologically and endoscopically. Conservative management failed. Surgical repair was successful.

http://www.ncbi.nlm.nih.gov/pubmed/9864873?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_

ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed


6) 'Menouria'—a presentation of vesicouterine fistula.

Bhutta SZ.Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi.

http://www.ncbi.nlm.nih.gov/pubmed/8993046?ordinalpos=1&itool=EntrezSystem2.PEntrez.

Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_

RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed


7) Management of vesicouterine fistula following cesarean section.

Pawar HN.Department of Pathology, Faculty of Medicine, Kuwait University.

Contrary to belief, urinary incontinence in vesicouterine fistulas following cesarean section

is as common as cyclic hematuria with apparent amenorrhea. Review of the English literature revealed 21 cases and

herein is added a new case.

http://www.ncbi.nlm.nih.gov/pubmed/3966287?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_

ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed


8) Treatment of vesicouterine fistula by fulguration.

Molina LR, Lynne CM, Politano VA.Department of Urology,

University of Miami School of Medicine, Florida.

A 29-year-old woman suffered a vesicouterine fistula following cesarean section.

The fistula was treated successfully after cystoscopic identification and fulguration of the tract.

Although various surgical approaches to this problem have been described,

and a number of cases of spontaneous resolution are reported, to date there have been no reports of treatment of this problem

via cystoscopic fulguration. We advocate this simple technique

as a primary approach to vesicouterine fistulas.http://www.ncbi.nlm.nih.gov/pubmed/2724440?ordinalpos=1&itool=

EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_



9) Vesicocervical fistula—a rare complication secondary

to caesarean section.Mahomoud S, Arunkalaivanan AS, Devarajan R, Kaur H.

Department of Obstetrics and Gynaecology, City Hospital, Dudley Road, Birmingham, B18 7QH, UK.

Conservative management with indwelling catheterisation for 3 weeks failed.

Hence the fistula was repaired surgically by an abdominal approach.

http://www.ncbi.nlm.nih.gov/pubmed/15309282?ordinalpos=1&itool=

EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_



10) A case report on vesico-uterine fistula: a very rare complication of the

lower caesarean section.Abu J, Wong MY, Foo KT, Yu SL.

Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore.

http://www.ncbi.nlm.nih.gov/pubmed/11284616?ordinalpos=1&itool=

EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_

RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed


Vesicouterine fistula – Imaging

http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=17&cat2=103&cat3=721&cat4=1&stype=n



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Uterovesical Fistula

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