aberrant abnormal communication between the bladder and vagina

• Obstructed labor is the most common cause of VVF worldwide with an estimated >100,000 new cases yearly.

In industrialized countries, most vesicovaginal fistulas are due to pelvic surgery (eg, hysterectomy), particularly when complicated by distorted anatomy (eg, endometriosis, pelvic adhesions), which can cause occult intraoperative bladder injury or delayed tissue ischemia

The proximity of the bladder and vagina make them vulnerable to fistulization, and patients develop symptoms with variable time frames:

• immediately following intraoperative bladder injury (eg, cesarean delivery, hysterectomy)
• weeks or months following surgery or childbirth (eg, obstructed labor) due to tissue necrosis and sloughing
• years after pelvic radiotherapy as a delayed presentation of radiation-induced microvascular injury (ie, endarteritis) and progressive tissue ischemia and breakdown

| Risk factors | • Pelvic surgery • Pelvic irradiation • Prolonged labor/childbirth trauma • Genitourinary malignancy | | --- | --- | | Clinical features | • Painless continuous vaginal discharge with an abnormally elevated pH (ie, >4.5) due to urine, which may be malodorous due to surrounding necrotic tissue.  Pelvic examination typically shows vaginal pooling of urine, a visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall. | | Diagnostic studies | • Mainly clinically by physical exam • Bladder dye testing & Cystourethroscopy may identify small fistulas that are difficult to visualize.  | | Treatment | • Surgical repair and bladder decompression (ie, catheterization). |

Bladder dye testing is performed to confirm the diagnosis, particularly in patients who have small fistulas that are not visualized on pelvic examination.  During a bladder dye test, the bladder is filled with dyed fluid and patients are monitored for vaginal leakage of dye via speculum examination or tampon placement.

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