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1. obstetrics gynecology articles
obstetrics gynecology Enterocele Massive Vaginal
Massive vaginal vault prolapse (uterovaginal prolapse) is a devastating condition with discomfort and
genitourinary and defecatory abnormalities as the primary consequences. Vaginal vault prolapse
refers to significant descent of the vaginal apex following a hysterectomy.
Enterocele and massive vaginal eversion. Posthysterectomy vaginal vault prolapse.
Apical prolapse is used to denote prolapse of the vaginal apex with or without the presence of a
uterus. Prolapse of the vaginal apex may or may not be accompanied by an enterocele. Whereas
complete vaginal eversion is obvious, lesser degrees of prolapse and the presence of enterocele are
more difficult to discern and require careful evaluation of anterior, posterior, and apical compartment
defects. The International Urogynecological Association and International Continence Society define
pelvic organ prolapse as the descent of 1 or more of the anterior vaginal wall, posterior vaginal wall,
the uterus (cervix), or the apex of vagina (vaginal vault or cuff scar after hysterectomy).3 Yet, a clear
demarcation between normal descent and abnormal prolapse has not been determined. Not all
patients with prolapse are symptomatic, and the degree of prolapse often does not correlate with the
degree of symptoms reported by the patient. Furthermore, pelvic floor-related symptoms do not
predict the anatomic location of the prolapse, especially in women with mild-to-moderate prolapse.4
The pelvic organ prolapse quantification (POP-Q) has been instituted to address this by defining the
extent of prolapse. Stage 0 denotes no prolapse (the apex can descend as far as 2 cm relative to the
total vaginal length).
Enterocele and massive vaginal eversion. Swift reported on the frequency of different stages of pelvic
organ prolapse based upon the POP-Q staging system.8 In a routine gynecologic clinic population,
most women had stage 1 or stage 2 prolapse (43.3% and 47.7%, respectively), few women had stage
0 or stage 3 prolapse (6.4% and 2.6%, respectively), and no women had stage 4 pelvic organ
prolapse. In a population-based Dutch study, the prevalence of pelvic organ prolapse by POP-Q
staging was as follows: Stage 0 = 25.0%, stage I = 36.5%, stage II = 33%, stage III = 5.0%, and stage
IV = 0.5%.10
Recent epidemiological studies by Dietz et al10 and Slieker-ten Hove et al11 contradict the opinion
that female pelvic organ prolapse worsens with age.

2. Current basic science research suggests a molecular etiology of pelvic organ prolapse. The precise
etiology regarding pelvic organ prolapse remains elusive. DeLancey describes the anatomy of vaginal
vault prolapse in terms of 3 levels of support.17
Enterocele and massive vaginal eversion. Apical prolapse occurs because of tearing or attenuation of
the cardinal-uterosacral ligament complex. Level I support is considered most important in
maintaining adequate overall pelvic support.
Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Apical enterocele
may present with or without vaginal vault prolapse.
Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of
peritoneal contents with vaginal mucosa, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault
prolapse.
Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.
Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that
peritoneal contents have dissected between the vaginal mucosa and rectovaginal fascia through a
proximal defect.
Posterior enterocele is usually accompanied by significant uterovaginal prolapse and prolapse of
other compartments as well.
A cross-sectional study indicates that urge urinary incontinence is associated with anterior wall
prolapse, while stress urinary incontinence is strongly linked to posterior wall prolapse.4 Severe pelvic
prolapse may result in ureteral kinking, with the potential for hydroureter, hydronephrosis, and
subsequent renal damage. Hydronephrosis severity was proportional to prolapse severity with a
higher likelihood of uterovaginal versus posthysterectomy vaginal prolapse.19
Treatment of pelvic organ prolapse is indicated if it is symptomatic or is causing associated morbidity.
The cardinal-uterosacral ligaments are localized thickenings of the endopelvic fascia that invest the
pelvic organs. The same endopelvic fascia that is anterior to the vagina is called pubocervical;

3. posteriorly, it is termed rectovaginal fascia or Denonvillier fascia. The integrity of the vaginal apex
following hysterectomy depends on the fusion of the pubocervical fascia with the rectovaginal fascia.
Bowel incontinence (fecal incontinence) definition
Fecal incontinence can be defined as the unintentional loss of stool (feces) or gas (flatus). It is often
due to a failure of one or more of the components that allow the body to control the evacuation of
feces, when it is socially appropriate.
A normal bowel movement requires a complex interaction and feedback system between the nerves
and muscles of the rectum and anus. The anatomy of this area is complicated. The rectum is a
reservoir for holding stool. Two sphincters or circular muscles separate the rectum from the anus and
control when the anus should allow a bowel movement. The internal anal sphincter (IAS) is under
involuntary control of the body's nervous system, while the external anal sphincter (EAS) can be
actively controlled by the indivdiual. In addition, the puborectalis muscle tugs at the junction of the
rectum and anus, creating a 90 degree angle, which makes it harder for stool to move involuntarily
into the anus.
When the rectum is full and for a normal bowel movement to occur, the IAS relaxes just a little. Cells
in the anus can detect feces or flatus and if the brain says that it is an opportune social time to pass
gas or have a bowel movement, the puborectalis muscle relaxes, straightening the path from the
rectum to the anus. Squatting or sitting helps increase the pressure within the abdomen, and muscles
that surround the rectum squeeze its contents, the EAS relaxes and a bowel movement occurs.
If it is not an appropriate time to open the bowel, the puborectalis muscle contracts, the EAS
contracts, the rectum relaxes and stool is forced back into the upper part of the rectum, causing the
urge to have a bowel movement to be temporarily quieted.
What causes bowel incontinence
Fecal incontinence occurs because of an underlying disease or illness (it is not considered a
"disease"). There are numerous potential causes and many patients have more than one reason to
cause loss of bowel control.
Damage to muscles and nerves may occur directly at the time of vaginal childbirth or after anal or
rectal surgery.

4. Neurologic diseases such as stroke, multiple sclerosis, spinal cord injury, and spina bifida can be
potential causes of fecal incontinence. Complications of diabetes can also cause peripheral nerve
damage leading to incontinence.
Patients with inflammatory bowel disease (Crohn's disease, ulcerative colitis) and irritable bowel
disease may develop fecal incontinence.
Stool seepage is different than fecal incontinence. Minor staining can occur in people who have
hemorrhoids, rectal fistula, rectal prolapse and poor hygiene. Other causes include chronic diarrhea,
parasite infections, and laxative abuse.
Paradoxical diarrhea or overflow incontinence may occur is a a person who has chronic constipation.
In paradoxical diarrhea, stool fills the rectum, hardens and becomes impacted. Liquid stool leaks
around the fecal mass, imitating incontinence.
What are the symptoms of bowel incontinence?
Bowel incontinence refers to the inability to control the passage of small amount of stool, liquid or
solid, or control flatus.
People are sometimes reluctant to discuss their lack of bowel control because of the social stigma
attached to it. Their initial complaint might be anal itching (pruritis ani), a buttock skin infection, or
breakdown of the skin and ulcers.
How is bowel incontinence diagnosed?
Taking a history is very important and the health care professional will spend time learning about
how often loss of bowel control occurs, in what situations and whether it is solid, liquid, or gas. Past
medical and surgical history is important, especially obstetric history or surgery of the anus, including
hemorrhoids. It could be several years before the complication of a surgery or childbirth lead to fecal
incontinence. Dietary habits and medications (including over-the-counter medications and laxative)
will also be considered and evaluated.
Physical examination will likely include a rectal examination to assess sphincter tone. In females, a
pelvic exam will also be performed.

5. While blood tests are not usually needed to make the diagnosis, other tests may be helpful in
deciding the potential cause of fecal incontinence. Anal manometry measures the pressure within the
rectum, both at rest and when the patient squeezes the anal sphincter. Nerve and muscle conduction
studies may be considered. Ultrasound can evaluate the anal sphincters and look for muscle damage.
What is the treatment for bowel incontinence?
The treatment approach for a patient with fecal incontinence is individualized based upon the
underlying cause. The purpose is to regulate bowel movements, decrease their frequency, and
increase stool firmness and consistency. Often this involves dietary changes and the use of
medications that bulk the stool.
Increasing the strength of the muscles of the pelvic floor might be helpful. Kegel exercises and
electrical stimulation may be recommended. Biofeedback is often used to help retrain the anal
sphincters and have the patient appreciate the sensation of rectal fullness that comes just before the
need to defecate.
If the incontinence persists even after maximum medical therapy has been attempted, surgery may be
an alternative. If damaged, attempts can be made to repair the muscles of the pelvic floor including
the external anal sphincter. The internal anal sphincter function may be enhanced by injecting
materials like silicone, carbon beads, or collagen.
As a last resort, where all other options have failed, a colostomy may be performed, where the colon
is diverted through the abdominal wall to empty into a removable bag.
What about bowel incontinence in children?
In children, fecal incontinence (also called encopresis) is often due to chronic constipation and
overflow incontinence or diarrhea. By definition, there should be at least one inappropriate bowel
movement per month for at least three months in a child older than age 4 years. The incontinence
usually happens during the day and not at night.
Most often, the diagnosis is made by history and physical examination by the health care professional
and further testing is not needed.
Treatment is directed at developing a more routine bowel evacuation schedule and may require
changes in diet, behavior modification, and the addition of stool bulking agents.

6. Can bowel incontinence be prevented?
Maintaining sphincter tone may prevent fecal incontinence. This might include preventing
constipation by increasing fiber in the diet and keeping well hydrated and avoiding straining to
promote a bowel movement.
Unfortunately, many times the cause of incontinence is childbirth anal surgery. It may be years until
the symptoms of incontinence arise.
What is the prognosis for bowel incontinence?
The frequency of fecal incontinence increases with age. Once it occurs, the patient may be able to
control the symptoms with diet, medication, and exercise. Many patients may initially benefit from
surgery, but that benefit gradually decreases over the years and incontinence may recur
Bowel incontinence (fecal incontinence) definition
Fecal incontinence can be defined as the unintentional loss of stool (feces) or gas (flatus). It is often
due to a failure of one or more of the components that allow the body to control the evacuation of
feces, when it is socially appropriate.
A normal bowel movement requires a complex interaction and feedback system between the nerves
and muscles of the rectum and anus. The anatomy of this area is complicated. The rectum is a
reservoir for holding stool. Two sphincters or circular muscles separate the rectum from the anus and
control when the anus should allow a bowel movement. The internal anal sphincter (IAS) is under
involuntary control of the body's nervous system, while the external anal sphincter (EAS) can be
actively controlled by the indivdiual. In addition, the puborectalis muscle tugs at the junction of the
rectum and anus, creating a 90 degree angle, which makes it harder for stool to move involuntarily
into the anus.
When the rectum is full and for a normal bowel movement to occur, the IAS relaxes just a little. Cells
in the anus can detect feces or flatus and if the brain says that it is an opportune social time to pass
gas or have a bowel movement, the puborectalis muscle relaxes, straightening the path from the
rectum to the anus. Squatting or sitting helps increase the pressure within the abdomen, and muscles
that surround the rectum squeeze its contents, the EAS relaxes and a bowel movement occurs.

7. If it is not an appropriate time to open the bowel, the puborectalis muscle contracts, the EAS
contracts, the rectum relaxes and stool is forced back into the upper part of the rectum, causing the
urge to have a bowel movement to be temporarily quieted.
Pelvic organ prolapse, a type of pelvic floor disorder, can affect many women. In fact, about one-third
of all women are affected by prolapse or similar conditions over their lifetime.
What Is a Pelvic Floor Disorder?
The "pelvic floor" is a group of muscles that form a kind of hammock across your pelvic opening.
Normally, these muscles and the tissues surrounding them keep the pelvic organs in place. These
organs include your bladder, uterus, vagina, small bowel, and rectum.
Sometimes, these muscles and tissue develop problems. Some women develop pelvic floor disorders
following childbirth. And as women age, pelvic organ prolapse and other pelvic floor disorders
become more common.
When pelvic floor disorders develop, one or more of the pelvic organs may stop working properly.
Conditions associated with pelvic floor disorders include:
 Pelvic organ prolapse
 Urinary incontinence
 Anal incontinence
What Is Pelvic Organ Prolapse?
"Prolapse" refers to a descending or drooping of organs. Pelvic organ prolapse refers to the prolapse
or drooping of any of the pelvic floor organs, including:
 Bladder
 Uterus
 Vagina
 Small bowel
 Rectum
These organs are said to prolapse if they descend into or outside of the vaginal canal or anus. You
may hear them referred to in these ways:
 Cystocele: A prolapse of the bladder into the vagina, the most common condition

8.  Urethrocele: A prolapse of the urethra (the tube that carries urine)
 Uterine prolapse
 Vaginal vault prolapse: prolapse of the vagina
 Enterocele: Small bowel prolapse
 Rectocele: Rectum prolapse
What Causes Pelvic Organ Prolapse?
Anything that puts increased pressure in the abdomen can lead to pelvic organ prolapse. Common
causes include:
 Pregnancy, labor, and childbirth (the most common causes)
 Obesity
 Respiratory problems with a chronic, long-term cough
 Constipation
 Pelvic organ cancers
 Surgical removal of the uterus (hysterectomy)
Genetics may also play a role in pelvic organ prolapse. Connective tissues may be weaker in some
women, perhaps placing them more at risk.
What Are the Symptoms of Pelvic Organ Prolapse?
Some women notice nothing at all, but others report these symptoms with pelvic organ prolapse:
 A feeling of pressure or fullness in the pelvic area
 A backache low in the back
 Painful intercourse
 A feeling that something is falling out of the vagina
 Urinary problems such as leaking of urine or a chronic urge to urinate
 Constipation
 Spotting or bleeding from the vagina
Symptoms depend somewhat on which organ is drooping. If the bladder prolapses, urine leakage
may occur. If it's the rectum, constipation and uncomfortable intercourse often occur. A backache as
well as uncomfortable intercourse often accompanies small intestine prolapse. Uterine prolapse is also
accompanied by backache and uncomfortable intercourse.

9. Pelvic Organ Prolapse
How Is Pelvic Organ Prolapse Diagnosed?
Your doctor may discover pelvic organ prolapse during a routine pelvic exam, such as the one you
get when you go for your Pap smear. Your doctor may order a variety of tests:
 Urinary tract X-ray (intravenous pyelography)
 CT scan of the pelvis
 Ultrasound of the pelvis
 MRI scan of the pelvis
How Is Pelvic Organ Prolapse Treated?
Treatment of pelvic organ prolapse depends on how severe the symptoms are. Treatment can include
a variety of therapies, including:
Urinary Incontinence in Women
 Behavioral treatments, such as doing Kegel exercises designed to strengthen the pelvic floor
muscles
 Mechanical treatments, such as inserting a small plastic device called a pessary into the
vagina to provide support for the drooping organs
 Surgical treatment, either to repair the affected tissue or organ or to remove the organ (such
as removal of the uterus by hysterectomy)
Can Pelvic Organ Prolapse Be Prevented?
Many risk factors for pelvic organ prolapse are out of your control. These include:
 Family history
 Advancing age
 A difficult vaginal delivery
 Having had a hysterectomy
But you can reduce the likelihood you will have problems. Try these steps:

10.  Do Kegel exercises daily to maintain good muscle strength in your pelvic area
 Maintain a healthy weight
 Avoid constipation
 Do not smoke, as smoking can affect tissues, and a chronic cough often seen in smokers
boosts the risk of problems
Repair of Rectocele or Enterocele
A rectocele occurs when the end of the large intestine (rectum) pushes against and moves the back
wall of the vagina. An enterocele (small bowel prolapse) occurs when the small bowel presses against
and moves the upper wall of the vagina. Rectoceles and enteroceles develop if the lower pelvic
muscles become damaged by labor, childbirth, or a previous pelvic surgery or when the muscles are
weakened by aging. A rectocele or an enterocele can be present at birth (congenital), though this is
rare.
A rectocele or an enterocele may become large or more obvious when you strain or bear down (for
example, during a bowel movement). A rectocele and an enterocele may occur together, especially if
you have had surgery to remove the uterus (hysterectomy).
Because rectocele and enterocele are defects of the pelvic supporting tissue and not the bowel wall,
they are treated most successfully with surgery that repairs the vaginal wall. This surgery pulls
together the stretched or torn tissue in the area of prolapse. Surgery will also strengthen the wall of
the vagina to prevent prolapse from recurring. Unless there is another health problem that would
require an abdominal incision, rectoceles and enteroceles are usually repaired through the vagina.
Pelvic Organ Prolapse: Should I Have Surgery?
What To Expect After Surgery
General anesthesia is usually used for repair of a rectocele or enterocele. You may stay in the hospital
from 1 to 2 days. Most women can return to their normal activities in about 6 weeks. Avoid strenuous
activity for the first 6 weeks. And increase your activity level gradually.
Normal bowel function returns within 2 to 4 weeks. It is important to avoid constipation during this
time. Your doctor will give you special bowel care instructions. But it is important to include sources
of fiber and adequate fluids in your diet. Try to drink about 6 to 8 glasses of water a day.
Most women are able to resume sexual intercourse in about 6 weeks.

11. Why It Is Done
Surgical repair of rectoceles and enteroceles is used to manage symptoms such as movement of the
intestine that pushes against the wall of the vagina, low back pain, and painful intercourse. An
enterocele may not cause symptoms until it is so large that it bulges into the midpoint of the vaginal
canal.
Rectocele and enterocele often occur with other pelvic organ prolapse, so tell your doctor about
other symptoms you may be having. If your doctor finds a bladder prolapse (cystocele), urethral
prolapse (urethrocele, or uterine prolapse during your routine pelvic exam, that problem can also be
repaired during surgery.
How Well It Works
Not much is known about how well the surgery works over time. The surgery is more likely to be
successful if the woman can avoid constipation, does not go through pregnancy and delivery, and
does not have any other pelvic organ prolapse.1
Risks
Risks of rectocele and enterocele repair are uncommon but include:
 Urinary retention.
 Bladder injury.
 Bowel or rectal injury.
 Infection.
 Painful intercourse.
 Formation of an abnormal connection or opening between two organs (fistula).
What To Think About
Pelvic organ prolapse is strongly linked to labor and vaginal delivery. So you may want to delay
surgical repair of a rectocele or enterocele until you have finished having children.
Surgical repair may relieve some, but not all, of the problems caused by a rectocele or enterocele.
 If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may
still occur after surgery.

12.  Symptoms of constipation may return following surgery.
 The success rate is lower if you have had previous pelvic surgery or radiation therapy to the
pelvis.
You can control many of the activities that contributed to your rectocele or enterocele or made it
worse. After surgery:
 Avoid smoking.
 Stay at a healthy weight for your height.
 Avoid constipation.
 Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long
periods of standing
 The current generation of women is maintaining a more active lifestyle into an older age,
resulting in an increase in the number of women who seek treatment for prolapse conditions.
An active lifestyle and improved quality of life can usually be preserved; however, this requires
a thorough understanding of pelvic anatomy and pathophysiology and experience in
selecting appropriate surgical procedures.
 The following image depicts a relaxed vaginal outlet after treatment for a prolapse condition.
 Relaxed vaginal outlet. This elderly woman had a large rectocele and pronounced perineal
body relaxation. The anterior repair and incontinence procedure had already been performed.
Problem
 A relaxed vaginal outlet can be defined as a weakening of the tissues of the distal
rectovaginal septum and perineal body. A relaxed outlet is almost always associated with
some degree of weakening of the more proximal rectovaginal fascias, which may result in a
rectocele. Common symptoms include difficulty with defecation and, possibly, difficulty with
sexual function.
Ureteral injury is one of the most serious complications of gynecologic surgery. Less common
than injuries to the bladder or rectum, ureteral injuries are far more serious and troublesome
and are often associated with significant morbidity, the formation of ureterovaginal fistulas,
and the potential loss of kidney function, especially when recognized postoperatively. For
these reasons, injuries to the urinary tract, particularly the ureter, are the most common cause
for legal action against gynecologic surgeons.
Despite the close anatomical association between the female reproductive organs and the
ureter, injury to the ureter is relatively uncommon. Nevertheless, when a ureteral injury does

13. occur, quick recognition of the problem and a working knowledge of its location and
treatment are essential in providing patients with optimal medical care. The purpose of this
article is to elucidate how and why ureteral injuries occur and to review their surgical and
nonsurgical treatments.
The use of a uterine manipulator or similar device in the vagina with cephalad displacement of the
cervix will increase the distance between the ureter and the uterine artery and increase the safety of
cardinal ligament coagulation and division. However, cephalad displacement does not guarantee
prevention of ureteral injury because it may not achieve sufficient displacement if the ureter is
adjacent to the lateral cervical wall.
Ureteral injury at endoscopic hysterectomy can occur at many points during hysterectomy, but this
discussion will be limited to potential injuries during cardinal ligament division and vaginal cuff
closure.
The ureter during cardinal ligament division.
Assessing the parametrial ureter’s proximity to the cervix requires visualizing the intersection of the
ureter and the uterine artery (Figure 1), starting with identification of the ureter upstream, cephalad
to the intersection and then along the lateral pelvic peritoneum.
As a rule, ureters coursing high in the lateral pelvic wall, at a distance from the uterosacral ligament,
are usually lateral to the cervix, whereas those located near the uterosacral ligament usually course
close to the cervix. However, the ureters can be found at any level on the lateral pelvic wall and can
be at any distance from the cervix.
The ureter noted in Figure 1 appeared safe for cardinal ligament division because it was identified
lateral to the cervix proximal to the crossing with the uterine artery (Figure 2). However, once
followed to the uterine artery intersection, the ureter was noted to be adjacent to the cervix and at
risk of injury (Figure 1). Whenever there is any suspicion of proximity, ureteral dissection to the
crossing with the uterine artery is mandatory to prevent injury
How to find the intersection of the ureter with the uterine artery.
The 2 surgical approaches to identifying the intersection of the ureter with the uterine artery are
following the pelvic ureter or following the uterine artery.
1. Following the ureter. The level of the pelvic brim is the area in which it is easiest to identify the
pelvic ureter. In that location, the ureter is superficial. Make a peritoneal incision lateral and parallel

14. to the infundibulopelvic ligament below and above the pelvic brim to allow easy visualization of the
ureter as it crosses over the common iliac artery
Once identified, follow it along the lateral pelvic peritoneum until it intersects with the uterine artery.
2. Following the uterine artery. Make a peritoneal incision lateral and parallel to the infundibulopelvic
ligament as indicated for the ureteral approach. Identify the external iliac artery and follow it
cephalad to the common iliac artery bifurcation. Expose the internal iliac artery by simply displacing
or dividing the loose areolar retroperitoneal connective tissue immediately ventral to the artery at the
12 o’clock position.
The superior vesical artery will become apparent as part of the anterior division of the internal iliac,
and the uterine artery will be immediately medial to the takeoff of the superior vesical artery Follow
the uterine artery until it intersects with the ureter. Sometimes it may be difficult to identify the
internal iliac or superior vesical arteries. In that case, place the lateral umbilical ligament under
tension lateral to the bladder and follow it in retrograde fashion toward the origin of the superior
vesical artery from the internal iliac artery. The uterine artery will be immediately medial to the origin
of the superior vesical artery. Follow it as described for the uterine artery approach.
Lateral displacement of the ureter at risk.
Once the intersection of the ureter and uterine artery are identified (Figure 1) and in the presence of
the so-called cervical ureter, there is no need to completely dissect the parametrial portion of the
ureter, known as “unroofing of the ureter,” to prevent ureteral injury. The simple division of the
uterine artery at its intersection with the ureter is adequate to visualize the direction of the
parametrial ureter and also to laterally displace it, whenever necessary.
Elevate the uterine artery from the ureter and pass an instrument between the artery and the ur eter A
vessel sealing device can then be safely applied to transect the uterine artery Lateral displacement of
the ureter (known as “rolling” the ureter, allows for a safe division of the cardinal ligament
The cardinal ligament can now be safely divided with an electrocoagulation device Use a blunt
instrument to gently displace the ureter. Electrocoagulation is unnecessary unless the entire
parametrial ureter needs to be dissected, which is almost never the case in a simple hysterectomy.
The ureter at vaginal cuff closure.
After the uterus is removed, the relative safety that the uterine manipulator affords in cephalad
displacement of the cervix and vaginal fornices no longer exists. Some ureters may then be close to

15. the vaginal fornix and at risk of entrapment. They may be found lateral to the cervix and appear safe
from injury, but then may take a sharp medial course toward the vaginal fornix, and be included
during closure of the vaginal cuff angles
The ureter in was lateral to the cervix and safe for cardinal ligament division. However, it was noted
to have a sharp turn toward the vaginal fornix in spite of cephalad displacement of the cervix by the
vaginal cup. In that situation, when the displacement is removed, the ureter may be at risk of
entrapment during vaginal cuff closure. In another patient the right ureter was suspected to be close
to the vaginal fornix and it was dissected. It was then noted coursing within 5 mm of the vaginal cuff
and could have been easily incorporated during cuff closure.
Urologic Complications from Pelvic and Vaginal Surgery: How to Diagnose and Manage
Lower urinary tract injury during gynecologic surgery is relatively uncommon. Bladder injuries are the
most frequent urologic injury inadvertently caused by a surgeon. Bladder injuries usually are
recognized and repaired immediately, and potential complications are typically minor. However,
ureteral injuries typically are not recognized immediately and have the potential to be life-threatening
or to result in permanent kidney damage or removal of a kidney. (1)
Anatomy of the Ureters
The ureters are a pair of tubes that carry urine away from the kidneys to the bladder. In the bladder,
the urine is stored and then emptied by urination. The adult ureter is a delicate structure, about the
width of a pencil, and roughly 30 cm in length.
Ureteral Injuries
Ureteral injuries are a potential complication of any open or endoscopic pelvic operation. Gynecologic
surgery accounts for more than 50 percent of all ureteral injuries resulting from an operation, with
the remaining occurring during colorectal, general, vascular and urologic surgery. (2-4) The ureter is
injured in roughly 0.5 to 2 percent of all hysterectomies and routine gynecologic pelvic operations
and in 10 percent (range, 5 to 30 percent) of radical hysterectomies. (4-6) Ureteral complications from
radical hysterectomy have declined over the years because of improved patient selection, limiting of
surgery to mostly low-stage disease, decreased use of preoperative radiation and modifications in
surgical technique that limit extreme skeletonization of the ureter. (6) Of ureteral injuries from
gynecologic surgery, roughly 50 percent are from radical hysterectomy, 40 percent are from
abdominal hysterectomy and less than 5 percent result from vaginal hysterectomy. (1) All gynecologic
ureteral injuries occur to the distal one third of the ureter (or in other words, the segment of ureter
closest to bladder and in the pelvis).

16. The ureter can be injured during any anterior vaginal wall surgery that extends to the bladder neck
(such as vaginal hysterectomy, bladder neck suspension surgery, anterior repair of the vaginal wall,
repair of an enterocele [hernia] and neovagina construction). Repair of high-grade pelvic prolapse
(that is, grade 4 cystocele [hernia of the bladder] or total uterine prolapse) pose a particular risk for
ureteral injury. The majority of ureteral injuries here are during vaginal vault reconstruction or vaginal
cuff closure, where sutures can ligate (be tied to) the ureter or kink the ureter by displacing it.
Prolapse patients can have extremely dilated and thin ureters that can be enclosed in the prolapse
and, thus, be predisposed to potential ureteral injury. (7) Similarly, in pregnancy, the ureters are
dilated, exposure is difficult and the risks are increased. Other gynecological procedures that can
result in ureteral injury are abdominal oophorectomy (removal of an ovary), pelvic mass resection,
removal of a fallopian tube, caesarian section, adnexectomy (removal of one of the uterine tubes and
an ovary), extended pelvic lymphadenectomy (removal of lymph nodes) and laparoscopy (a minimally
invasive method used to examine the interior of the body or to perform surgery). (8-10)
Risk Factors and Prevention of Ureteral Injury
Prevention
The most reliable way for surgeons to avoid ureteral injury is to clearly identify the ureter throughout
the region of the body that will undergo the operation.
For pelvic operations expected to be difficult, or for patients with large pelvic masses, pelvic
inflammatory disease, prior pelvic surgery or prior irradiation, the use of preoperative ureteral
radiographic imaging by intravenous urography (IVU) or computed tomography (CT) has been widely
advocated. However, placement of a stent (a short, narrow tube) in the ureter is not recommended
on a routine basis. In fact, most ureteral injuries occur during technically straightforward
hysterectomies for minimal disease. (2, 10)
In most cases, ureteral identification is not difficult and, thus, preoperative stents are unnecessary.
However, stent placement clearly helps identify a ureteral injury when it does occur. Furthermore, if
surgical removal is difficult, stents can be placed as part of the operation, with the use of a
cystoscope (a type of endoscope, or fiber-optic instrument) or through a small surgical incision of the
bladder. When a pelvic tumor is large or ureteral anatomy is distorted on preoperative imaging,
preoperative stents may increase the ability to examine the ureters by touch, minimize need for
ureteral removal and minimize ureteral kinking by adjacent suturing. (11)
The initial point in preventing ureteral injury is acknowledging and recognizing the risk for injury.
Regardless of the ureteral position on imaging, it is important to recognize the potential hazards and

17. to identify the ureters despite the presence of disease and through their pelvic course. In general,
generous surgical exposure, meticulous surgical technique and visual ureteral identification all ar e
more useful than preoperative body imaging or ureteral stenting.
Risk Factors
Most ureteral injuries (80 to 90 percent) occur in the part of the ureter in the pelvis, the segment of
ureter closest to the bladder. In vaginal hysterectomy, the primary risk point is the clamping and
ligation (tying) of the cardinal ligaments. As the cervix is pulled down through the vaginal opening,
the bladder and ureters follow. Therefore, if the incision is high on the cervix, the bladder/ureters can
be incorporated in the incision. Ureteral obstruction on ligation of the cardinal ligaments is typically
due to ureteral kinking from a suture in close proximity, rather than a ligation injury. (12)
Abnormalities of the ureter and/or surrounding tissues can alter the ureter pelvic anatomy and
displace the ureter into an abnormal location, and in so doing substantially increase the risk for
ureteral injury. Such anatomic abnormalities usually are found with endometriosis or pelvic tumors.
Congenital abnormalities, such as ureteral duplication, a wide ureter, ectopic ureter (when the ureter
drains to an abnormally located opening, like the vagina) or ectopic kidney (a kidney that lies in an
abnormal position or location) make injury during surgery more likely. The ureter also is predisposed
to injury by extreme lateral displacement of the cervix, mass adherence to the pelvic peritoneum, a
fibroid uterus (tumor consisting of muscle tissue) or other tumors of the broad ligament, abscess or
mass in the broad ligament base, or cervical cancer.
However, the majority of reported ureteral injuries have occurred in patients with no identifiable risk
factors. In fact, more than 75 percent of ureteral injuries due to gynecologic surgeries occur during
procedures that surgeons describe as uncomplicated and routine and where pelvic anatomy is
normal. (10) Hemorrhage (extensive bleeding) during the operation is a clear and main risk factor for
ureteral injury. Sudden hemorrhage should never be treated with blind cautery (searing of tissue) or
suturing, but rather direct pressure, sharp dissection and exposure of the bleeding vessels followed
by accurate and precise suturing. (2,3,10)
As previously stated, abdominal hysterectomy is the most common source of ureteral injury
inadvertently caused by a surgeon. Here, the potential for ureteral injury is greatest during the
ligation and division of the uterine arteries, followed by division of the ovarian vessels and
infundibulopelvic ligament (a ligament of the ovary). In radical hysterectomy, the ureter can be
skeletonized when removing an adjacent tumor, and this can result in a lack of blood supply and
delayed death of tissue. Radical hysterectomy also may require en-bloc resection (removal as a unit)
of a ureteral segment (in order to achieve a tumor-free margin). Prior irradiation can compromise

18. ureteral blood supply, make wounds heal poorly and increase the risk of ureter injury during pelvic
surgery (after hysterectomy by three to fourfold). Fistulas (abnormal passages draining urine) from the
radiated ureter are very difficult to repair and typically require two or more operations. (13) Previous
episodes of endometriosis or pelvic inflammatory disease can lead to dense ureteral adherence and
so increase the chances for injury during surgery. Cancers can directly invade and can fix the ureter or
distort its course. Masses in the ovaries and fallopian tubes also can distort the infundibulopelvic
ligament and displace the ureter. Severe pelvic prolapse also can increase the risk of ureteral injury.
Infected or inflamed tissues are other important contributing factors for ureteral injury. (14)
Diagnosis
During the Operation
If injury to the ureter is suspected during the operation, the ureter must be meticulously examined in
the area of interest. Like others, we have found that direct exploration and visual inspection are the
most common and accurate methods for diagnosis. If no obvious urine leak is noted at the suspected
injury site, to help identify the ureteral injury, indigo carmine can be injected into the ureteral
opening (after the bladder has been opened) or injected directly into the ureter or a portion of the
kidney. The injection of indigo carmine into a vein coupled with Lasix diuretic (a substance that
increases the excretion of urine), which colors the urine blue, is also helpful. The blue-tinged urine
helps confirm injury. (15,16)
Even without urine being forced out, a ureter with a bruised appearance can have significant trauma
from either a crush or ischemic injury (an injury resulting from deficient blood supply). Ways to
determine whether a ureter has lost blood supply are to note wall discoloration, absence of refill of
the capillaries, or most reliably, by making an incision in the ureter and inspecting the ureteral edge
for bleeding. A ureter that visibly can contract, unfortunately, is not a clear indication of normal
ureteral function or of adequate blood supply. Some have advocated the use of intravenous
fluorescein and a Wood's lamp to assess whether the ureter has an adequate blood supply (15)
Postoperative
Intravenous urography (dye and X-ray study of the kidneys and ureter) findings suggestive of ureteral
injury are delayed visualization or the inability to visualize the involved kidney, hydronephrosis
(distension of both kidneys because urine is unable to drain from them) , or incomplete visualization
of the entire ureter. Retrograde urography is typically the most sensitive radiographic method to
evaluate the integrity of the ureter, and to determine if it has been damaged. Ultrasound or CT can
identify a hematoma (clotted blood), a cyst containing urine or hydronephrosis, all suggestive of
ureteral injury.

19. Signs and Symptoms
The findings associated with a missed ureteral injury are generally nonspecific. Suggestive of urinary
leak are a prolonged bowl obstruction, persistent pain in the abdomen or in the side between the
ribs and the hip, an abdominal mass that can be felt, an elevation in blood urea nitrogen, fever/body-
wide response to serious infection, an increase in white blood cells, or prolonged and persistent
drainage from the vagina or from the operative drains/drain sites. Frequently, ureteral injury is not
discovered until an obvious fistula (abnormal passage) occurs.
Types of Injury
The common types of pelvic ureteral injuries caused by surgery – in descending order of frequency –
are ligation, kinking by suture, division, partial laceration, crush and loss of blood supply (leading to
delayed death of tissue and narrowing of the ureter). (17).
Management
The method of ureteral repair is determined by many factors, including the location and length of
ureteral injury, the time of diagnosis (during the operation, early postoperative or delayed), the type
of injury and the presence of associated medical or surgical illnesses.
Clearly, the optimal time for repair of a ureteral injury is during the operation, when it initially occurs.
At the time of injury, the tissues are typically in their best condition, where the options and likelihood
for success are greatest. Immediate recognition and repair allow for better results and fewer
complications than in a delayed fashion.
Unfortunately, most ureteral injuries from gynecologic surgery (more than 80 percent) are discovered
in a delayed fashion. (1) Injuries that are detected after an operation tend to be more complex,
require more complex repairs and multiple procedures, and have more complications than those
detected and repaired during the operation. (18,19)
Laparoscopic Injury
Ureteral injuries during laparoscopic gynecologic surgeries typically occur during laser ablative
endometriosis surgery or laparoscopic-assisted vaginal hysterectomy (LAVH). (20) There are also
reports of ureteral injury during laparoscopic tubal ligation, adnexectomy (removal of one of the
uterine tubes and an ovary) and laparoscopic uterosacral ligament ablation. Most LAVH ureteral
injuries occur near the cardinal and uterosacral ligaments and are caused by either thermal-
electrocautery or sharp dissection. (20) There are also reports of ureteral injury caused by CO2 laser,
endoscopic linear stapler and loop ligature. (21,22) Ureteral injuries, ranging from small partial tear to
complete ureteral tearing away, typically occur in patients with a history of pelvic irradiation or prior

20. extensive pelvic surgery. Overall, complications often are related to surgical experience. (23)
As with open surgery, preoperative intravenous urography or ureteral stent placement are of limited
routine value in preventing ureteral injury. (24) For technically difficult cases, ureteral catheters in
laparoscopy may enhance identification and make dissection easier. Lighted ureteral catheters are
also available and may help in ureteral identification. (21,22)
Partial ureteral lacerations or thermal injuries that are diagnosed during the operation can be
managed by endoscopic placement of a ureteral stent (for four to six weeks). Laparoscopic suturing
of the lacerated ureter also has been performed successfully. When the ureter has been cut
completely, an immediate, open surgical approach is typically needed. (9) If the surgeon is especially
skilled and the injury site allows, the ureter can be repaired through the laparoscope. However, most
ureteral injuries are diagnosed in a delayed fashion, typically several days after the operation. (20, 21)
Delayed Ureteral Complications
When a ureteral injury is diagnosed and repaired at the initial presentation/exploration, rar ely is there
a high degree of sickness. However, when diagnosis is delayed, sickness including body-wide
response to serious infection, loss of kidney function and possible death can occur in up to 50
percent of patients. Rates for surgical removal of the kidney resulting from delayed diagnosis, overall,
are seven times as common as when the ureter injury is diagnosed promptly (during surgery). Urine
leakage also can cause abscess and scarring of the ureter, leading to obstruction and formation of
abnormal passages. (25)
Urinary Discharge
Initially, a ureter that is cut produces no symptoms until a cyst collecting urine causes abdominal
swelling, bowel obstruction, infection, fever or low back, side or abdominal pain and/or signs in the
membrane that lines the abdominal cavity. Persistent blood in the urine, increase in white blood cells
and/or urinary (fluid) leakage from the vagina are other reliable signs of injury. Absorption of the
urine by the abdominal membrane will often cause a rise in the serum urea nitrogen. Such injuries
have been managed successfully by a variety of methods, from ureteral stent placement for minor
injuries to open surgical repairs. When the patient is medically unstable, has a body-wide response to
infection or the injury is not detected for more than two to three weeks, the patient typically requires
proximal urinary diversion (that is, a tube leading from the kidney to the outside of the body and, if
technically possible, ureteral stent placement), as well as drain placement into the urine-containing
cyst. The discharged urine also may cause fibrosis (development of fibrous tissue) behind the
abdominal membrane severe enough to cause ureteral obstruction, particularly if the area is not
drained properly. At two to three weeks after surgery, re-exploration is typically difficult and fraught

21. with danger because of inflammation, fibrosis, adhesions, blood clotting and distorted anatomy.
Definitive repair is performed in a delayed/staged fashion. (1,26)
Fistulas
Fistulas (abnormal passages – mainly ureterovaginal) are rare after ureteral repair. They usually
develop when the ureteral injury is undiagnosed during the operation, and the ureter undergoes
delayed tissue death and/or narrowing (obstruction). Other factors that contribute to fistula formation
are infection (abscess, peritonitis), inflammation, foreign body and tumor formation. (27) A history of
prior pelvic irradiation (that is, for cervical cancer) is another independent risk factor, increasing the
risk for fistula formation after hysterectomy by three to fourfold and complicating the difficulty of
fistula repair. (10, 13,20) Ureteral fistulas usually do not require an open operation and typically close
spontaneously with proper drainage and ureteral stenting. (27,28)
Stricture
Stricture (narrowing) develops when a ureter with deficient blood supply, often from a certain type
dissection, heals by scar tissue. Side or abdominal pain and urinary tract infection/pyelonephritis
(kidney inflammation) are commonly seen. Ureteral strictures that are diagnosed early (within six to12
weeks), are in the portion away from the kidney and are relatively short in length (less than 2 cm) can
be managed successfully (in about 50 to 80 percent of cases) by balloon dilatation or endoscopic
incision and stenting for six weeks. For endoscopic failures, an open surgical repair is necessary.
When the stricture is discovered late, particularly dense or long, or radiation induced, open segmental
removal and repair are usually necessary. (27,29)
Bladder Injuries
When a bladder injury is discovered during pelvic surgery, it is wise also to investigate the possibility
of an accompanying ureteral injury. Direct inspection of the surgically exposed ureter or the ureter
after indigo carmine administration is often sufficient. If the patient had received prior pelvic
irradiation, the bladder repair should be covered with omentum or peritoneum (two types of
abdominal membrane), if available, to prevent possible formation of a fistula. Bladder rest by Foley
catheter is typically employed for seven to 14 days. A tube is generally unnecessary for female
bladder trauma unless there is a considerable amount of blood in the urine that could obstruct the
catheter. A suction drain is placed until the drainage is minimal. If drainage output remains high, the
drainage fluid should be sent to the lab to examine the concentration of the compound creatinine.
Creatinine levels greater then serum indicate a urine leak, whereas levels equal to serum indicate
peritoneal or lymphatic fluid. Persistent urinary leakage typically resolves with an additional two to
four weeks of bladder drainage. (28)

22. Abdominal Hysterectomy
In gynecologic surgery, bladder injury most commonly occurs during abdominal hysterectomy. The
bladder can be injured at four specific sites. If a bladder injury is noted at this time, it usually can be
easily managed by a two- or three-layer closure with absorbable suture and Foley catheter bladder
drainage. Retrograde bladder filling with blue-colored saline again makes bladder injury diagnosis
easier.
Vaginal Hysterectomy
Most bladder injuries during vaginal hysterectomy are in a specific area of the bladder base. (30) For
such bladder injuries, cystoscopy is often helpful to identify the location of the injury. If there is any
suspicion of an accompanying ureteral injury, indigo carmine should be injected through the veins
and the ureteral openings observed for blue dye. Once ureteral injury is ruled out, the bladder injury
can be repaired in two or three layers. The adequacy (water-tightness) of the bladder closure can be
tested by retrograde filling of the bladder with saline. A Foley catheter is typically left in place for
seven to 14 days. After the bladder laceration has been repaired, the vaginal hysterectomy can be
completed and/or anterior surgical repair of the vaginal wall performed.
Laparoscopy
When injured, the bladder is usually penetrated by, and on initial placement of, the Veress needle or
trocar (a surgical instrument). Trocar injuries are typically to the bladder dome and have an entry and
exit wound. To avoid bladder injuries, it is essential that the bladder is decompressed by a Foley
catheter at the beginning of the case. The position of the bladder should be assessed on initial
examination with the laparoscope. All secondary trocars should be placed under direct visualization.
Bladder injuries occur most often with midline and lower abdominal trocar placement. A full bladder
or one with distorted anatomy from previous pelvic surgery, endometriosis or adhesions is more
likely to be injured laparoscopically. (21)
During the operation, the diagnosis of bladder injury is suggested by the presence of gas filling up
the Foley bag or visibly bloody urine in the Foley bag. Other signs of injury are urinary/fluid drainage
from a secondary trocar site incision, or fluid pooling in the abdomen/pelvis. If a bladder injury is
suspected, the bladder should be filled with methylene blue-colored saline. The forcing out of
fluid/dye indicates a bladder injury inside the abdominal membrane. If there is no fluid forced out
and a bladder injury outside the abdominal membrane is suspected, a cystogram (X-ray of the
bladder after injection of contrast medium) should be performed. Injuries outside the abdominal
membrane are managed conservatively through prolonged Foley drainage. Delayed diagnosis of
bladder injury also is done by cystography. Irritation of the abdominal membrane that persists more
12 hours after laparoscopy also should raise suspicion of an undiagnosed bladder injury. (9,21,24)

23. Veress needle injuries and other small injuries to the bladder can be successfully managed
conservatively by catheter drainage for seven to 14 days followed by cystography. Large bladder
injuries, such as from 5 or 10 mm trocar or surgical dissection, often require suturing the injuries
closed (either laparoscopically or by open repair) and prolonged catheter drainage. A bladder injury
recognized by laser or electrocautery should be closely evaluated and typically managed with
catheter drainage for five to 10 days. Sharp dissection, electrocautery and laser bladder injuries also
have been reported during laparoscopic-assisted vaginal hysterectomy, adnexectomy (removal of one
of the uterine tubes and an ovary), diagnostic laparoscopy and endometriosis surgery. (9,21)
Delayed Bladder Injury/Diagnosis
Cystography with a post-drainage X-ray will enable the surgeon to assess injury inside and/or outside
the abdominal membrane. Injuries inside the abdominal membrane require surgical closure and
drainage, whereas injuries outside the abdominal membrane can be successfully managed through
prolonged Foley catheter drainage. Decreased urine output, absent or defective urine excretion, an
excess of urine, elevated blood urea nitrogen, the presence of blood in the urine, bruising and
abdominal swelling suggest a bladder injury has been missed.
Undiagnosed injuries to the bladder that occur during surgery typically become evident days to
weeks after surgery. In patients with previous pelvic irradiation, fistulas can occur months to even
years after hysterectomy. Typical delayed bladder complications are various forms of fistulas. For
further details on bladder fistulas,
The overall rate of urinary tract injury associated with pelvic surgery in women is approximately 1
percent]. Bladder injury is more common than ureteral injury However, the exact incidence of these
injuries is difficult to ascertain. Reported rates vary depending primarily on the approach to diagnosis
of injury and the type of surgery; other factors include patient characteristics and study design.
Injury diagnosed with cystoscopy — Markedly higher rates of urinary tract injuries have been
reported in studies in which cystoscopy was routinely performed immediately after the procedure
rather than other approaches to diagnosis (typically intraoperative visual inspection). This was
illustrated in a systematic review of 47 retrospective studies and two subsequent prospective studies
of urinary tract injury during benign gynecologic surgery For hysterectomy, studies that used routine
cystoscopy found, compared to studies that used other techniques, higher rates of ureteral injury (15
to 18 versus 0.2 to 7 per 1000 procedures) and bladder injury (17 to 29 versus 0.3 to 6 per 1000
procedures).

24. These findings demonstrate that injuries are underreported when routine cystoscopy is not performed
immediately after the procedure. The true incidence is probably higher since cystoscopy does not
detect all injuries, particularly partial ureteral obstruction or transection On the other hand, some
injuries detected with cystoscopy may be asymptomatic and/or heal spontaneously Clinical use of
cystoscopy in the diagnosis of operative urinary tract injury is discussed separately
Urethral Diverticulum
Suffering from recurrent urinary tract infections or experiencing urinary problems? Then perhaps
small, bulging pouches along the urethra are the cause. Read on to learn more about what problems
they can cause.
What is urethral diverticulum?
Urethral diverticulum (UD) is a condition in which a variably sized "pocket" or outpouching forms next
to the urethra. Because it most often connects to the urethra, this outpouching repeatedly gets filled
with urine during the act of urination thus causing symptoms.
Who usually gets urethral diverticulum?
It is much more common in females then in males and usually appears between the ages of 40 and
70. Occurrence in children is extremely rare in the absence of prior urethral surgery.
How common is urethral diverticulum?
With the development of sophisticated imaging techniques, the diagnosis of UD has become
increasingly common. However, the true prevalence in any given population is still not known since
many cases are missed or misdiagnosed simply because no one suspected it.
What causes urethral diverticulum?
The origin of acquired UD has recently been attributed to repeated infections and/or obstruction of
the periurethral glands with subsequent obstruction eventually evolving into UD. Although some
earlier studies have suggested congenital causes or trauma experienced during childbirth.
What are the symptoms of urethral diverticulum?
Although symptoms are highly variable, the most common symptoms are irritative (i.e., frequency,
urgency and dysuria) lower urinary tract symptoms (LUTS). Dyspareunia will be noted by 12 to 24

25. percent of patients and approximately five to 32 percent of patients will complain of post-void
dribbling. Recurrent cystitis or urinary tract infection is also a frequent symptom in one-third of
patients. Other complaints include pain, hematuria, vaginal discharge, obstructive symptoms or
urinary retention and incontinence (stress or urge). Up to 20 percent of patients diagnosed with UD
may not have noticeable symptoms. Some patients may also have a tender anterior vaginal wall mass,
which upon gentle compression may reveal retained urine or pus discharge through the urethral
opening.
It is important to note that the size of the UD does not correlate with symptoms. In some cases, very
large UD may result in minimal symptoms, and conversely, some UD that are non-palpable may result
in considerable discomfort and distress.
Finally, symptoms may come and go and may even disappear for long periods of time.
How is urethral diverticulum diagnosed?
Since many of the symptoms associated with UD are non-specific, patients may often be
misdiagnosed and treated for years for a number of unrelated conditions before the diagnosis of UD
is made. This may include therapies for interstitial cystitis, recurrent cystitis, vulvodynia, endometriosis,
vulvovestibulitis and other conditions.
The diagnosis and complete evaluation of UD can be made through a combination of thorough
history, physical examination, appropriate urine studies, endoscopic examination of the bladder and
urethra and selected radiologic imaging.
A number of imaging techniques have been applied to the study of UD and no single study can be
considered the gold standard or optimal imaging study for the evaluation of UD. Each technique has
relative advantages and disadvantages, and the ultimate choice of diagnostic study in many centers
often depends on several factors including local availability, cost and the experience and expertise of
the radiologist. Currently available techniques for the evaluation of UD include double-balloon
positive-pressure urethrography (PPU), voiding cystourethrography (VCUG), ultrasound (US) and
magnetic resonance imaging (MRI) with or without an endoluminal coil (eMRI).
A urodynamic study may also be used in selected cases and may document the presence or absence
of stress urinary incontinence prior to repair. A video-urodynamic study may also be used as a
diagnostic tool. The type of study combines both a voiding cystourethrogram and a urodynamic
study thus consolidating the diagnostic evaluation and decreasing the number of required urethral
catheterizations during a patient's clinical work-up. In addition, video-urodynamic evaluation may be

26. able to differentiate true stress incontinence from pseudo-incontinence related to emptying of a UD
with physical activity.
During physical examination, the urethra may be "milked" distally in an attempt to express pus or
urine from the UD cavity. For females, during physical examination, the anterior vaginal wall may be
carefully felt for masses and tenderness.
How is urethral diverticulum treated?
Although often highly symptomatic, not all urethral diverticula require surgical excision (removal).
Some patients may not have noticeable symptoms and the UD was incidentally diagnosed on
imaging for another condition or during a routine physical examination. While other patients may be
unwilling or medically unable to undergo surgical removal.
Very little is known regarding the natural history of untreated UD-whether they will grow in size,
complexity or if symptoms will increase over time is unknown. For these reasons, and due to the lack
of symptoms in selected cases, some patients may not desire surgical treatment. However, there have
been recent reports of carcinomas arising in UD thus patient counseling and ongoing monitoring is
recommended in patients who elect not to undergo surgical treatment.
Surgical options include transurethral incision of the diverticular neck, marsupialization (creation of
permanent opening) of the diverticular sac into the vagina [often referred to as a Spence procedure],
and surgical excision.
Surgical excision is the treatment of choice but it should be performed with caution. The diverticular
sac may be quite attached to the adjacent urethral lumen and careless removal of the sac may result
in a large urethral defect requiring construction of a new urethra. Other important considerations
during surgery include identification and closure of the diverticular neck (connection to the urethral
lumen), complete removal of the mucosal lining of the diverticular sac to prevent recurrence, and a
multiple layered closure to prevent postoperative urethrovaginal fistula formation (formation of an
abnormal opening between the urethra and vagina).
What can be expected after treatment for urethral diverticulum?
For those patients who elect not to undergo surgical treatment, it is recommended that they
continue to be monitored by their urologist.
Patients who are treated surgically can expect to be on antibiotics for 24 hours postoperatively and
discharged home with both urethral and suprapubic catheters. Antispasmodics are used liberally to

27. reduce bladder spasms. A VCUG is obtained at 14 to 21 days postoperatively. If there is no
extravasations, the catheters are removed. If extravasation is seen, then the urethral catheter is
reinserted and repeat VCUGs are performed weekly until resolution is noted. In the vast majority of
cases, extravasation will resolve in several weeks with this type of conservative management.
Common implications may arise from surgical treatment and may include recurrent UTIs, urinary
incontinence or recurrent UD. In females, urethrovaginal fistula is a devastating complication of
urethral diverticulectomy and deserves special mention.
Some patients will have persistence or recurrence of their preoperative symptoms postoperatively.
The finding of a UD following a presumably successful urethral diverticulectomy may occur as a result
of a new UD, or alternatively, as a result of recurrence. Recurrence of UD may be due to incomplete
removal of the UD, inadequate closure of the urethra or residual dead space or other technical
factors. Repeat urethral diverticulectomy surgery can be challenging, as anatomic planes may be
difficult to identify.
Prolapsed Uterus Overview
Your uterus (or womb) is normally held in place inside your pelvis with various muscles, tissue, and
ligaments. Because of pregnancy, childbirth or difficult labor and delivery, in some women these
muscles weaken. Also, as a woman ages and with a natural loss of the hormone estrogen, her uterus
can drop into the vaginal canal, causing the condition known as a prolapsed uterus.
 Muscle weakness or relaxation may allow your uterus to sag or come completely out of your
body in various stages:
o First degree: The cervix drops into the vagina.
o Second degree: The cervix drops to the level just inside the opening of the vagina.
o Third degree: The cervix is outside the vagina.
o Fourth degree: The entire uterus is outside the vagina. This condition is also called
procidentia. This is caused by weakness in all of the supporting muscles.
 Other conditions are usually associated with prolapsed uterus. They weaken the muscles that
hold the uterus in place:
o Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of
the bladder bulges into the vagina. This may lead to urinary frequency, urgency,
retention, and incontinence (loss of urine).
o Enterocele: The herniation of the upper rear vaginal wall where a small bowel portion
bulges into the vagina. Standing leads to a pulling sensation and backache that is
relieved when you lie down.

28. o Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into
the vagina. This makes bowel movements difficult, to the point that you may need to
push on the inside of your vagina to empty your bowel.
Prolapsed Uterus Causes
The following conditions can cause a prolapsed uterus:
 Pregnancy/childbirths with normal or complicated delivery through the vagina
 Weakness in the pelvic muscles with advancing age
 Weakening and loss of tissue tone after menopause and loss of natural estrogen
 Conditions leading to increased pressure in the abdomen such as chronic cough (with
bronchitis and asthma), straining (with constipation), pelvic tumors (rare), or an accumulation
of fluid in the abdomen
Being overweight or obese with its additional strain on pelvic muscles
 Major surgery in the pelvic area leading to loss of external support
 Smoking
Other risk factors include:
 Excess weight lifting
 Being Caucasian
Prolapsed Uterus Symptoms
Symptoms of a prolapsed uterus include:
 A feeling of fullness or pressure in your pelvis (you may describe it as a feeling of sitting on a
small ball)
 Low back pain
 Feeling that something is coming out of your vagina
 Painful sexual intercourse
 Difficulty with urination or moving your bowels
 Discomfort walking
When to Seek Medical Care
Notify your health care provider if you experience any of the following symptoms:

29.  You feel the cervix near the opening of the vaginal canal or you feel pressure in your vaginal
canal and the feeling of something coming out of your vagina.
 You suffer persistent discomfort from urinary dribbling or the urge to have a bowel
movement (rectal urgency).
 You have continuing low back pain with difficulty in walking, urinating, and moving your
bowels.
Seek medical care immediately if you experience any of the following:
 Obstruction or difficulty in urination and/or bowel movement
 Complete uterine prolapse (your uterus comes out of your vagina)
Exams and Tests
Your health care provider can diagnose uterine prolapse with a medical history and physical
examination of the pelvis.
 The doctor may need to examine you in standing position and while you are lying down and
ask you to cough or strain to increase the pressure in your abdomen.
 Specific conditions, such as ureteral obstruction due to complete prolapse, may need an
intravenous pyelogram (IVP) or renal sonography. Dye is injected into your vein, and a series
of X-rays are taken to view its progress through your bladder.
 Ultrasound may be used to rule out other pelvic problems. In this test, a wand is passed over
your abdomen or inserted into your vagina to create images with sound waves.
Prolapsed Uterus Treatment
Treatment depends on how weak the supporting structures around your uterus have become.
If the presence of a vesicovaginal or ureterovaginal fistula is in doubt, vaginal secretions and
fluid pooling in the vaginal vault should be sent for creatinine level evaluation. Serum creatinine
should be drawn simultaneously, and that level should be compared with the fluid creatinine. If
the fluid creatinine level is significantly higher than the serum creatinine, this confirms that the
fluid is urine. If fluid creatinine test result is equivocal but a fistula is still suspected, proceed
with a complete fistula workup, as discussed below.
Urinalysis and urine culture are used to rule out coexisting urinary tract infection.
Electrolyte panel (Chem 7) is used to evaluate renal function.

30. Complete blood cell (CBC) count is used to rule out systemic infection.
. The occurrence of VVF and urethrovaginal fistulas can be one of the most troublesome
complications of obstetric trauma and pelvic surgery. Appropriate management regarding timing
of repair and surgical approach remains controversial.
EPIDEMIOLOGY/ETIOLOGY
The majority of the literature reflects a particular center’s experience. Lee and colleagues found
82% of their institution’s fistulas to have resulted from gynecologic surgery, 8% from obstetric
procedures, 6% from pelvic radiotherapy, and 4% from trauma. Goodwin and Scardino found
74% of their cases to be of gynecologic origin, 14% of urologic origin, and 12% from radiation
injury
The frequencies and causes of VVF also reflect the culture and geography. Kelly showed that in
England, 95% of the VVFs occurred with nonobstetric causes. In Nigeria, 98% of the VVFs were
secondary to obstructed labor. Success rates at repair are therefore difficult to compare, and a
major contribution to the differences reported also probably reflects variations in the populations
studied.
Predisposing risk factors for VVF include a history of pelvic irradiation, cesarean section,
endometriosis, prior pelvic surgery or pelvic inflammatory disease, diabetes mellitus, concurrent
infection, vasculopathies, and tobacco abuse. In developing countries, obstetric trauma remains
the leading cause of VVFs. In some countries in Africa, it is customary for early marriages
involving adolescent girls to be contracted prior to the commencement of their menses. In sub-
Saharan Africa, nearly 50% of the women are married by age 18, some by age 15 or younger. A
recent study from Katsina, Nigeria, found that primiparous girls who married during early
adolescence were more likely to experience VVF than those who married at an older age.
Women without formal education and those married to men with unskilled jobs were 14 times
more likely to sustain a VVF than their cohorts. In this population, there can be grave social
consequences of VVF, including divorce, poverty, and depression.
Obstructed labor is a common complication of childbirth and may lead to obstetric vesicovaginal
fistula which are uniquely human. Wittman and Wall have reviewed the changes imposed on the
pelvis by assumption of an upright posture and bipedal locomotion. Vesicovaginal fistula occurs
when the baby’s head is unable to pass through the bony pelvis and impacts against an
edematous distended anterior vaginal wall with resulting pressure necrosis. Introital stenosis
secondary to female circumcision, cephalopelvic disproportion (from reduced pelvic dimensions
of early childbearing), an android pelvis, malnutrition, orthopedic disorders including rickets,
and hydrocephalus contribute to dystocia. Fistulas may be caused by forceps, destructive
instruments used to deliver stillborn infants, or surgical abortion. Symphysiotomy, the use of
postpartum vaginal caustic agents, and self-inflicted “Gishiri cuts” also have a role.

31. In countries with modern obstetric care, VVF is most commonly associated with pelvic
surgery. The majority of VVFs are related to procedures performed by obstetrician-
gynecologists; particularly total abdominal hysterectomy. The remainder are divided among
urologists and general, colorectal, and vascular surgeons The overall incidence of urinary tract
injuries during pelvic surgery is estimated to be 0.33%. The most common operation is
abdominal hysterectomy and the most common indication is benign leiomyoma. Cystotomy and
VVF account for more than three-quarters of the injuries. Predisposing factors for bladder injury
are coexisting pelvic pathology, distortion of normal anatomy, previous pelvic surgeries,
adhesions and extended surgery such as radical hysterectomy. Indeed, the incidence of bladder
injury during radical hysterectomy is three times higher than with simple hysterectomy.
However, the largest portion of VVF is associated with simple hysterectomy because of the shear
volume of surgery for benign indications
The etiology of VVF at the time of hysterectomy is uncertain. Some are the result of an
unrecognized bladder laceration at the time of dissecting the bladder off the cervix. Even
cystotomies that are repaired have a risk of fistula formation. A study in dogs report by Sokol
and colleagues showed that double layer closure of cystotomy was superior to single layer
closure.
A fistula may also arise from avascular necrosis secondary to crush injury or erosion of a vaginal
cuff suture into the bladder. While vaginal cuff sutures that are placed through the bladder are
postulated to produce fistula, Meeks and coworkers, in a rabbit model, demonstrated that suture
material placed through the vaginal cuff and the bladder was not associated with the
development of fistulas A fistula may also follow an uncomplicated operation as the result of a
pelvic hematoma that ruptures into the bladder postoperatively. Devascularizing the bladder or
vaginal cuff could lead to fistula formation and can be minimized with mobilization of tissue
planes. Tancer’s suggestions to avoid injury to the bladder during total abdominal hysterectomy
include the use of a two-way indwelling catheter, sharp dissection to isolate the bladder, an
extraperitoneal cystotomy when the dissection is difficult, retrograde filling of the bladder when
injury is suspected, and repair of an overt bladder injury only after mobilization of the injured
area. Filling the bladder can also help define the border of the bladder otherwise displaced by a
prior surgery or a lower uterine segment fibroid.
Radiation-induced fistulas are commonly associated with treatment for carcinoma of the cervix
or other pelvic malignancies. Fistulas may appear during the course of radiotherapy (usually
from necrosis of the tumor itself) or after treatment is completed. Late fistulas arise secondary to
endarteritis obliterans within the first 2 years. It is essential to rule out recurrent malignancy with
biopsies.
There are case reports of VVFs caused by vaginal foreign bodies, direct trauma from
masturbation or automobile accidents, bladder calculi, forgotten vaginal pessaries,
endometriosis, and infections such as tuberculosis, schistosomiasis, syphilis, and
lymphogranuloma venereum, and from idiopathic congenital causes. Sexual trauma through
coerced vaginal penetration and even consensual sexual intercourse have been reported to have
led to VVF. Idiopathic congenital VVF is usually associated with other genitourinary anomalies.
Placement of transobturator midurethral slings are touted as being less likely to cause bladder

32. injury. However, recent reports have documented VVF following trauma to the bladder
with trocar placement and with the presence of a foreign body in the bladder; the latter may be
caused by directly placing the tape through the bladder or erosion of the material into the bladder
wall.
Urethrovaginal fistulas may occur postpartum and are associated with operative vaginal delivery,
after surgery for urethral diverticulum, anterior vaginal wall prolapse, or urinary incontinence,
and after radiation therapy. Pressure necrosis resulting in a urethrovaginal fistula can occur with
a prolonged indwelling transurethral catheter. Urethrovaginal fistulas may also be congenital
CLINICAL PRESENTATION
Kursh and associates examined the records of 12 patients who had VVF develop after total
abdominal hysterectomy. Most of the patients had excessive postoperative abdominal pain,
distention or paralytic ileus, or both. Hematuria and symptoms of irritability of the bladder were
also noted in the fistula group, and prolonged postoperative fever and increased white blood cell
count occurred more often. The clinical course observed in these patients with VVFs suggests
that many of them had an unrecognized injury to the bladder resulting in urinary extravasation.
Theoretically, with early recognition, it may be possible to avert the formation of a VVF.
However, Tancer described a series of 110 posthysterectomy fistulas, 24 of which occurred
despite intraoperative recognition of bladder damage and prompt repair. More than 21% of
patients in this series formed a VVF despite preventive maneuvers and repair of intraoperative
bladder injury.
The most common presenting feature of VVFs is continuous leakage of urine from the vagina.
The size and location of the fistula determine the degree of leakage. Patients with small fistulas
may void normal amounts of urine and notice only slight position-dependent drainage.
Alternatively, they may have leakage only at maximal bladder capacity. The patient may
experience recurrent cystitis or pyelonephritis; unexplained fever; hematuria; flank, vaginal, or
suprapubic pain; and abnormal urinary stream. Those with larger fistulas may not void
transurethrally and may have total incontinence. Urinary leakage may make the patient a social
recluse, disrupt sexual relations, and lead to depression, low self-esteem, and insomnia.
The leakage of urine may cause irritation of the vagina and vulvar mucosa, and perineum and
usually produces a foul ammonia odor. Phosphate encrustations may be noted in more neglected
cases. These crystals serve to further irritate what can be already compromised tissue.
ASSESSMENT
In many patients the diagnosis is obvious. A complete urologic investigation is mandatory
though, especially to rule out ureterovaginal fistula. In one series, 12% of patients with VVFs
had associated ureterovaginal fistulas. The investigation should include a speculum examination
with collection of vaginal fluid for urea concentration. A urinalysis and urine culture will permit
the physician to treat an infection. Intravenous urography may aid in localizing the fistula and
determining the adequacy of renal function. Urethrovaginal fistulas are usually easily
distinguished on examination. Otherwise, the use of a Tratner catheter and contrast medium may

33. aid in the diagnosis of a urethrovaginal fistula. A caveat: Women with urethrovaginal fistulas
may frequently have a fistulous communication between the bladder and the vagina as well. Lee
and colleagues found that 10 of 53 patients (19%) with a urethrovaginal fistula had a separate
VVF.
All patients should undergo cystourethroscopy. The exact location (in relation to the ureteral
orifices), size, and underlying cause of the fistula need to be determined. Additional fistulous
communications need to be ruled out to reduce the opportunity for surgical failure. The bladder
neck should be examined thoroughly and any associated loss of urethral tissue should be noted.
Liquid-based cystoscopy may be impossible with larger fistulas. The vagina can be packed with
gauze or, with the patient in jackknife position, the bladder can be allowed to fill with air and dry
cystoscopy may be performed.
Various dye tests can be performed to elucidate the presence of a urogenital fistula Authors have
described a double dye test utilizing 1% carmine red solution instilled into the bladder and indigo
carmine injected intravenously. Moir described a three-tampon test that may aid in localizing the
fistulous tract. The vagina is packed with three tampons at different levels in the vaginal vault.
Findings can be misleading. Excretion of indigo carmine depends on intact renal function, and
occasionally red dye can reflux up a ureter and gain entry into the vagina via a ureterovaginal
fistula, a false-positive result. Alternatively, oral phenazopyridine may be used to stain the urine
orange, a tampon can be placed into the vagina, and the bladder can be catheterized, emptied,
and filled with methylene blue/saline solution. After 10 minutes, the bladder is emptied and the
tampon removed. An orange stain at the top of the tampon indicates a ureterovaginal fistula, and
a blue stain is consistent with a VVF. Instillation of sterile milk into the bladder is recommended
by some because it may be more easily seen. If a fistula cannot be documented by placing dye
into the bladder, it is possible to instill methylene blue into the vagina and document that the
urine is stained blue. Dyes are an excellent way of documenting a fistula in the office setting,
but further testing is rarely avoided because of the need to define the fistula completely.
The use of computed tomography (CT) with intravaginal contrast media to detect a VVF has
been reported with limited success. CT scanning may be most beneficial in discerning the
etiology and the extent of existing disease prior to surgical correction.
Color Doppler ultrasound with contrast media has been described as a diagnostic tool for VVF.
Sonography was positive in 11 of 12 (92%) patients with VVF. The benefits are that is it easy to
learn, is noninvasive, requires no radiation exposure, and can evaluate the distance from the
fistula to the ureteral orifices. Transvaginal sonography findings correlated well with intravenous
urography, cystogram, cystosocopy, and surgical findings.
Hilton argues for the use of urodynamics before surgical repair of urogenital fistulas to establish
abnormal lower urinary tract function in such patients. Of the 38 patients evaluated, 47% had
genuine stress incontinence, 40% showed detrusor instability, and 17% impaired bladder
compliance. The overall incidence of functional abnormality was highest in the patients with
urethral or bladder neck fistulas. After surgical treatment of the fistulas, most patients became
continent and free from lower urinary tract symptoms. Those who had urethral or bladder neck

34. fistulas had more residual detrusor instability. These findings are relevant to the counseling of
patients before repair and may be of medicolegal importance.
ANATOMIC CONSIDERATIONS
Posthysterectomy fistulas are usually supratrigonal, medial to both ureteral orifices, and lie
within the vaginal vault at the vaginal cuff (Fig. 1). Fistulas from obstetric causes may be located
more distally, typically are larger, and are more commonly associated with a urethral injury.
Obstetric fistulas have been classified according to their anatomic location in relation to the
cervix.
Fig. 1. Vesicovaginal and urethrovaginal fistula sites are demonstrated.
PREOPERATIVE CARE
Cystitis, vaginitis, and perineal dermatitis should be treated with the appropriate agent. First-line
intervention is use of perineal pads to contain the uncontrollable and constant leak of urine.
Instinctively, most women use menstrual hygiene products. These products are overwhelmed by
the large volume of fluid often associated with urinary fistula. Women should be encouraged to
use continence products which are designed to manage larger volumes. Local wound care is
important, and frequent pad changes are required to minimize inflammation, edema, and vulvar
irritation. Zinc oxide ointment is especially helpful in the treatment of perineal dermatitis.
Keeping the perineum and vulva as dry as possible is comfortable for the patient. Inventive
collection and drainage systems have been described for this purpose.
Spontaneous closure of some vesicovaginal fistula with bladder drainage alone has been
reported. Factors that may impact success are size, and interval from causative insult to initiation
of drainage. Interval to drainage is postulated to correlate with epithelialization of the fistulous
tract which interferes with healing Denuding the tract with electrosurgery, laser or direct
abrasion has been advocated as an adjunct to catheter drainage alone The denuding of the tract
has also resulted in closure of the defect. Estrogen therapy may also be used provided there are
no contraindications. There is no convincing evidence that the use of corticosteroids improves
the tissues and may interfere with healing when an early repair is attempted. Hyperbaric oxygen
treatment has also been described as an adjuvant treatment in radiation-induced fistulas. These
fistulas will not heal spontaneously or with conservative therapy, and surgical correction is
required. Obviously, in the malnourished patient, her nutrition needs to be optimized and anemia
needs to be corrected prior to surgery.
SURGICAL TECHNIQUE

35. Symmonds recommends several surgical principles to improve the success rate of any technique
for VVF repair: wide mobilization of the bladder, excision of all scar tissue at the risk of
increasing the size of the fistula in an attempt to create a “fresh bladder injury”, a tension-free
layer closure of the bladder and the vagina, nontraumatizing technique, and good hemostasis
with complete bladder drainage postoperatively. Most authors agree that the best chance at
closure of the fistula is at the first attempt.
In general, the vaginal approach avoids the potential morbidity associated with abdominal
surgery and is believed to provide a quicker recovery and a more cosmetic result. Lee and
colleagues and Tancer report vaginal success rates of 98% and 100%, respectively. However,
there are circumstances for which an abdominal approach has traditionally been favored: larger
fistulas; fistulas located high on the posterior wall; fistulas adjacent to the ureters, where
improved exposure is necessary; to correct concurrent intraabdominal pathology if it exists; and
in cases in which the vaginal vault is narrow or deep which precludes adequate access to the
fistula. Involvement of the ureter may require an abdominal approach to facilitate reimplantation
or the placement of stents. Patients with a small or contracted bladder or a very large fistula may
require augmentation with bowel. A combined vaginal and abdominal approach can be helpful in
certain circumstances. The authors have described a combined approach to the repair of a large
fistula secondary to a vaginal foreign body that involved the trigone.
Vaginal repair
The patient is placed in lithotomy position. Choice of supporting stirrups is a matter of physician
preference. The patient is examined under anesthesia. The ureteral orifices may be catheterized
cystoscopically if there is concern about the ureters, especially if they lie at the edge of the fistula
or if the fistula is high in the vaginal vault. Labial retraction sutures and an episiotomy or
Schuchardt incision may be helpful for a small introitus and vaginal vault. Placement of stay or
traction sutures at the margins of the fistula or the insertion and inflation of a Foley or Fogarty
catheter helps to identify the fistula’s edges and may bring the tract closer to the surgeon. Some
fistula surgeons infiltrate the vaginal mucosa with saline solution or a dilution of epinephrine
(1:200,000) to aid dissection and decrease oozing.
There is no consensus on the need to excise the fistulous tract. Some authors advocate its total
removal, whereas others prefer not to débride the margins, thereby avoiding an increase in the
size of the defect. Iselin and colleagues advocate the excision of the fistula tract and vaginal cuff
scar, enabling the surgeon to suture viable tissues in every layer to promote wound healing,
obviating the need for interpositional flaps or grafts. They had a 100% cure rate on first attempt.
Flynn reviewed patients who had excision of the vaginal cuff scar at the time of VVF repair.
Patients had a very high degree of success without postoperative irritative voiding symptoms or
dyspareunia.
In his series of 65 transvaginal repairs, Raz did not excise the fistula tract in any patient and had
no apparent adverse effects. Cruikshank did not excise the tract in his series of 11 patients and
had a 100% cure rate Zacharin warns that excision of the fistula scar markedly increases the risk
of operative failure. Elkins and coworkers and Lawson also advised against excising the tract in
large obstetric fistulas.

36. The two transvaginal techniques commonly performed are the flap-splitting technique and the
Latzko procedure. The flap-splitting technique involves wide mobilization of the vaginal mucosa
from the edge of the fistula. The bladder is closed in two layers. The first is submucosal with
interrupted Lembert sutures. A second layer is used to close the muscularis and reduce tension on
the first suture line. If the defect is in the trigonal area, the repair should be in a transverse
direction, because a vertical closure may draw the ureters to the midline and lead to kinking or
obstruction. The authors prefer to close the vagina using interrupted sutures to preserve vaginal
length. The flap-splitting technique does not foreshorten the vagina and has a success rate
equivalent to that of the Latzko procedure. Martius described the use of this technique for small
fistulas and Raz reported a 100% cure rate in his series of 20 patients. Disadvantages include the
possibility of mobilizing the tissues too much, leading to avascular necrosis of suture lines or
incorporating the ureters into the closure.
The Latzko partial colpocleisis is championed by many (Fig. 2). An elliptical portion of vaginal
mucosa is mobilized around the fistula tract, at least 2.5 cm in all directions. The pubovesical
fascia and vaginal mucosa are closed in layers, using interrupted sutures. The vesical edges of
the fistula are not denuded. The posterior vaginal wall becomes the posterior bladder wall and
reepithelializes with urothelium. Because the bladder musculature is not sutured to itself, there is
no tension across the suture lines. Success rates greater than 89% are reported for the first
attempt. Other advantages include short operating time, minimal blood loss, and low
postoperative morbidity. It is especially effective in patients with radiation-induced fistulas.
Disadvantages include a loss of vaginal length and possible interference with sexual function.
Fig. 2. The Latzko procedure. A. The vaginal epithelium is
removed by quadrant. A Foley catheter is placed within the
fistula for traction. B. A deep layer of sutures is placed in the
transverse axis. C. A second layer of sutures is placed,
imbricating the first. The vaginal mucosal is later closed over
the repair
Interposition flaps or grafts may be used in larger or recurrent fistulas or those involving the
urethra or bladder neck. Pedicle flaps bring additional blood supply, improve the lymphatic
drainage, and distance suture lines. In 1928, Martius first described the use of the labial fat pad
as an interposition graft. The vascular supply to the graft inferiorly is from the internal pudendal
artery and superiorly is the external pudendal artery (Fig. 3). The key is the appreciation and
preservation of one of these vascular bundles. Birkhoff and associates reported a 100% success
rate in six patients with transvaginal repairs of VVF using the Martius technique. Elkins and
colleagues reported a success/closure rate of 96% (24 of 25 procedures) in a series of mostly
postobstetric injuries Alternatively, a gracilis muscle flap may be used as first described by
Ingelman-Sundberg, and later modified by Hamlin and Nicholson. The technique involves
dissection of the gracilis muscle and separation of its attachment to the medial condyle of the
femur. The blood supply to the muscle from the femoral artery is preserved, and the graft may be
tunneled to the introitus and sutured into place at the fistula. Less invasive adjuvants to repair
include placing a fold of peritoneum over the fistula site or interposition of dura mater or other
biograft.

37. Fig. 3. Martius pedicle blood supply. A. External pudendal artery. B. Branch of
the obturator artery. C. Internal pudendal artery
The repair should be watertight and tested with the instillation of methylene blue or indigo
carmine into the bladder. The authors prefer to leave a pack in the vagina for 24 hours
postoperatively and continuously drain the bladder with a 16 French Silastic suprapubic catheter
for 3 weeks and discontinue the catheter after the patient successfully passes voiding trials. The
patient is maintained on prophylactic antibiotics while the catheter is in situ.
In general, the repair of urethrovaginal fistulas is often more difficult than the closure of VVFs
and may leave the patient incontinent. It is generally reported that the success rate of
urethrovaginal fistula repair is 73–100%. The same principles of VVF repair apply to the repair
of urethrovaginal fistulas: wide mobilization of tissue planes, layered closure, and the use of
interposition grafts when appropriate.
Noble originally described urethral reconstruction using bilateral vaginal flaps formed into a tube
around a catheter. Skin grafted from the labia aided in maintaining cosmesis. Birkhoff and
associates believe that the reestablishment of continence is facilitated by the use of the Martius
interposition flap. In addition, Gray found that 50% of his patients were incontinent
postoperatively without this added intervention. Moir described using suburethral buttressing
sutures to aid with recovery of continence Symmonds and Hill achieved continence in 37 of 50
patients (74%) with significant urethral destruction by constructing a neourethra, using smooth
muscle that remains in the urethral “roof” and the creation of a Martius-type flap to aid with
tension-free closure. They advocate delaying a retropubic suspension because concomitant
suspension may lead to disruption or attenuation of the suburethral repair or devascularize the
repair. There may also be difficulties associated in preselecting patients who would go on to
require a subsequent suspension. Leach has described a simultaneous needle suspension for
patients in whom stress incontinence is associated with a urethrovaginal fistula. A pedicle
buttock flap has also been described for the repair of larger urethrovaginal fistulas. Fernandes
and coworkers have reported the use of an anterior advancement flap of bladder and turning it
into a tube to reconstruct an entire urethra Patch grafts of bladder mucosa have also been used
with satisfactory results for urethral reconstruction in a series by Omo-Dare.
Abdominal repair
The patient should be in low lithotomy position with vaginal access. Incision type is also a
matter of physician preference. The advantage to a low midline incision is that omentum can be
mobilized for a graft, and it can be extended easily, although access to the omentum can be
achieved with Maylard or Cherney incisions. Simple fistulas can be repaired transvesically
(extraperitoneal), but an intraperitoneal approach is preferable for more complicated fistulas.
In the transvesical technique, the bladder is opened at the dome, the fistula is excised, and the
bladder muscularis is mobilized off the vagina. The defects are then closed in layers. Exposure
may be difficult, and because of this, many surgeons prefer the intraperitoneal approach. Much

38. of the early work with this technique was pioneered by O’Conor and associates (Fig. 4). The
bladder is bisected vertically down to the fistula tract. All scar is excised, and the bladder is
widely mobilized off the vagina. The bladder and vagina are closed in layers. Whereas the
O’Conor technique requires extensive dissection, Ostad and colleagues described an abdominal
approach to repair with a free bladder mucosal graft in a series of six patients There is reduced
need for extensive dissection, and it is useful for repairs close to the ureters and in large or
recurrent defects.
Fig. 4. Abdominal repair (after O’Conor). A. The
bladder is bivalved, thus exposing the fistula. B. The
fistula tract is excised, including the vaginal
epithelium. C. The bladder and vagina are closed in
layers. At this point, an omental flap may be
interposed
The use of vascularized tissue grafts can be helpful in ensuring a successful repair. One of the
more popular graft sources is the omentum (Fig. 5). It has a dual blood supply, and some
surgeons recommend dividing the splenic vessels on the left to help with mobilization. Others
prefer to base the pedicle on the gastroduodenal vessels of the right side. Rectus muscle has also
been used as graft for abdominal repairs. In a review, the use of interposition flaps was evaluated
for VVFs of benign and malignant etiologies. All repairs with interposition grafts were
successful without regard to etiology, whereas only 63% and 67% of repairs were successful for
benign and malignant fistulas, respectively. Bladder mucosa can also be harvested from the
dome of the bladder and placed over the repaired fistula. This adds a layer of tissue between the
suture lines of the bladder and vagina The authors recommended that transabdominal VVF
repairs be performed with an interposition flap regardless of the appearance of healthy
surrounding tissues and etiology.
Fig. 5. Omental graft. A. Mobilization of an omental graft is
demonstrated. 1. Right gastroepiploic artery. 2. Left
gastroepiploic artery. 3. The omental pedicle. 4. Bladder. B.
Interposition of the graft. 1. Omental flap. 2. Uterus. 3.
Omental flap sutured between the bladder and the vagina
Minimally invasive repair
While the majority of patients with VVF will have traditional surgical approaches, several
nonsurgical therapies have shown promising results when used to close fistula smaller than 8
mm. Several minimally invasive approaches have been reported to be successful in closing VVFs