Vaginal Fistula: Symptoms, Types, Causes and Treatment

Vaginal fistula is a distressing medical condition that can dramatically impact a woman's health, dignity, and quality of life. Though rare in high-resource settings, it remains a significant public health issue in many regions across the globe, especially where access to timely obstetric and surgical care is limited. This article provides a comprehensive overview of vaginal fistula, including its symptoms, types, causes, and modern treatment approaches, to shed light on a condition that is both preventable and treatable.

Symptoms of Vaginal Fistula

When a vaginal fistula forms, it creates an abnormal passage between the vagina and another organ, allowing fluids like urine or feces to leak uncontrollably. This can be physically uncomfortable, emotionally distressing, and socially isolating for affected women. Recognizing the symptoms early is key to seeking effective treatment and restoring quality of life.

Symptom	Description	Frequency/Prevalence	Source
Urinary leakage	Continuous or uncontrollable urine leakage	Most common symptom	1 2 3
Fecal leakage	Involuntary passage of stool through vagina	Occurs in rectovaginal fistula	1 7
Vaginal discharge	Persistent, often foul-smelling discharge	May be present with infection	9
Skin irritation	Soreness, rash, or ulceration around vulva	Results from constant moisture	1 2
Social withdrawal	Avoidance of social situations	Due to embarrassment and odor	1 14

Table 1: Key Symptoms

Understanding and Identifying Symptoms

Vaginal fistula symptoms are usually unmistakable and profoundly affect daily living.

Urinary and Fecal Incontinence

• Vesicovaginal fistula (VVF): This is the most common form, where urine continuously leaks from the bladder into the vagina, making it impossible for women to control urination, regardless of bladder fullness or position. This constant moisture often leads to skin breakdown and secondary infections 1 2 3.
• Rectovaginal fistula: In this type, feces or gas may pass through the vagina involuntarily, leading to persistent vaginal soiling and odor 1 7.

Secondary Symptoms and Complications

• Vaginal discharge: Chronic infection or the presence of necrotic tissue can result in a foul-smelling discharge 9.
• Skin irritation: The constant leakage of urine or feces causes maceration and inflammation of the vulvar skin, sometimes progressing to ulceration 1 2.
• Social and psychological distress: Many women with vaginal fistula face social stigma, isolation, and even abandonment by families due to the odor and misconceptions about the condition. Psychological stress and depression are common consequences 1 14.

Impact on Quality of Life

The combination of physical discomfort and social isolation often exacerbates the emotional burden, making early recognition and support crucial.

Types of Vaginal Fistula

Vaginal fistulas are classified based on the organs involved and their anatomical location. Understanding the types is essential for diagnosis and guiding treatment.

Type	Description	Prevalence/Notes	Source
Vesicovaginal	Between bladder and vagina	Most common (up to 78% of cases)	2 7 8
Rectovaginal	Between rectum and vagina	Second most common	1 7
Ureterovaginal	Between ureter and vagina	Less common, surgical etiology	11 12
Urethrovaginal	Between urethra and vagina	Rare, often surgical cause	2 4
Vagino-cutaneous	Between vagina and skin surface	Extremely rare	6
Pouch-vaginal	Between ileal pouch and vagina (post-surgery)	Rare, complex to treat	13

Table 2: Main Types of Vaginal Fistula

Detailed Overview of Vaginal Fistula Types

Let’s explore these types in more detail:

Vesicovaginal Fistula (VVF)

• Definition: An abnormal connection between the bladder and vagina, resulting in continuous urinary leakage 2 7 8.
• Prevalence: Most common type; accounts for the majority of cases worldwide, especially in areas with limited obstetric care 2 7.
• Subtypes: Can be further classified based on location (trigonal, supratrigonal, circumferential, etc.) and severity 2 4.

Rectovaginal Fistula

• Definition: A tract between the rectum and vagina, leading to passage of stool or gas through the vagina 1 7.
• Frequency: Second most common; may coexist with VVF in complex obstetric injuries 7.

Ureterovaginal and Urethrovaginal Fistula

• Ureterovaginal: Occurs when the ureter is inadvertently connected to the vagina, often after pelvic surgery; leads to continuous, but sometimes less obvious, urinary leakage 11 12.
• Urethrovaginal: Involves the urethra and vagina, typically as a surgical complication or due to trauma 2 4.

Vagino-cutaneous and Pouch-vaginal Fistulas

• Vagino-cutaneous: Extremely rare, involving a tract from the vagina to the skin surface; often follows trauma or infection 6.
• Pouch-vaginal: Seen after complex surgeries such as ileal pouch-anal anastomosis, particularly in bowel disease management; closure is challenging with high recurrence 13.

Causes of Vaginal Fistula

The causes of vaginal fistula are diverse and vary according to geographic and healthcare settings. Understanding these causes is vital for prevention and early intervention.

Cause	Mechanism/Description	Relative Frequency	Source
Obstructed labor	Prolonged pressure during childbirth	Leading cause globally	2 7 10
Surgical injury	Accidental injury during pelvic/gynec surgery	Common in developed countries	2 8 11 12
Gynecologic malignancy	Tumor invasion or radiotherapy	Important in older women	8 12
Pelvic trauma	Direct injury (e.g., sexual violence, accident)	Less common, but significant	2 9
Infection	Tissue necrosis after severe infection	Rare, usually with poor hygiene	6
Foreign body	Forgotten or inserted object causing erosion	Uncommon, but reported	9
Congenital	Developmental abnormality present at birth	Very rare	6

Table 3: Key Causes of Vaginal Fistula

Exploring the Underlying Causes

Obstructed Labor

• Prolonged or obstructed labor is the most common cause worldwide, particularly in low-resource settings. Prolonged pressure from the fetal head cuts off blood supply to soft tissues, leading to tissue necrosis and subsequent fistula formation 2 7 10.
• Epidemiology: In sub-Saharan Africa, the prevalence remains high due to limited access to emergency obstetric care 1 2.

Surgical Injury

• In high-resource settings, gynecologic or pelvic surgery (especially hysterectomy and cesarean section) is now the leading cause 2 8 11 12.
• Mechanism: Accidental damage to the bladder, ureter, or rectum during surgery can create a fistula. Risk increases with prior surgeries, malignancy, or radiotherapy 8 12.

Gynecologic Malignancy and Radiotherapy

• Cancers of the cervix, uterus, or bladder may erode into the vagina, or radiotherapy may damage tissue, increasing fistula risk 8 12.
• Special consideration: Radiated fistulas are more complex and often harder to treat 12.

Trauma, Infection and Foreign Bodies

• Pelvic trauma: Includes sexual violence, accidents, or improper medical procedures 2 9.
• Infections: Severe, untreated infections or non-healing wounds can occasionally result in fistula 6.
• Foreign bodies: Forgotten objects, such as pessaries or intentionally inserted items, can cause tissue breakdown and fistula formation 9.

Congenital Causes

• Rare developmental anomalies can result in fistulas present from birth, but these are exceedingly uncommon 6.

Treatment of Vaginal Fistula

Restoring continence and dignity to women with vaginal fistulas is possible with timely and appropriate treatment. Advancements in surgical techniques and postoperative care have made cure rates high, especially when the underlying cause is not malignant or radiated.

Treatment Approach	Description/Details	Success Rate/Outcomes	Source
Conservative	Catheter drainage, observation	Select cases, up to 93%	11 12
Transvaginal surgery	Vaginal repair (e.g., Latzko, flap, Martius)	91–97% (non-radiated)	3 12 14
Abdominal surgery	Abdominal/bladder approaches (open or minimally invasive)	91–97% (non-radiated)	2 12 14
Flap transfer	Use of tissue flaps to reinforce repair	Up to 92%	14
Urinary diversion	Urinary rerouting in complex/radiated cases	Variable, last resort	12
Imaging diagnosis	CT/MRI/CT vaginography for mapping fistula	Accurate localization	5

Table 4: Treatment Modalities

Treatment Pathways and Approaches

Conservative Management

• In select, small, and newly formed fistulas (especially after surgery), prolonged bladder catheterization may allow spontaneous healing. This is most effective for simple, non-radiated fistulas and newly recognized injuries 11 12.
• Success rates as high as 93% have been reported in carefully selected cases 11.

Surgical Repair

• Timing: Most guidelines recommend waiting 4–6 weeks after the injury to allow inflammation to resolve and tissue to stabilize before attempting repair 12.
• Transvaginal repair: Preferred for most vesicovaginal fistulas due to lower morbidity, high success rates (91–97% in non-radiated cases), and quicker recovery 3 12 14. Techniques include the Latzko procedure, layered closure, and use of Martius flaps to reinforce healing 12 14.
• Abdominal or minimally invasive approaches: Used when the fistula is not easily accessible vaginally or involves the upper urinary tract. Laparoscopic and robotic-assisted repairs are increasingly used where available 2 11 14.
• Flap transfer coverage: Advanced technique where tissue flaps are used to support the repair and maintain vaginal anatomy, especially in complex or recurrent cases. High success rates with minimal complications have been reported 14.

Management of Complex Fistulas

• Radiation-induced or large, complex fistulas may require individualized approaches, including combined abdominal-vaginal repairs or urinary diversion if tissue healing is poor 12.
• Repeat repairs: Even after failed attempts, repeat vaginal repairs are acceptable and often successful 12.

Diagnostic Imaging

• CT vaginography, MRI, and cystoscopy are used to accurately map fistula tracts, which is essential for planning effective surgical repair 5.

Psychological and Social Support

• Holistic care: Addressing the psychological and social impact is crucial. Support groups, counseling, and community reintegration programs play a vital role in restoring quality of life 1 14.

Conclusion

Vaginal fistula remains a significant but treatable health problem, especially in resource-limited settings. Prompt recognition, accurate diagnosis, and tailored treatment can restore continence, dignity, and hope to affected women.

Key Points:

• Symptoms include continuous urinary or fecal leakage, skin irritation, vaginal discharge, and significant social distress 1 2 7 9 14.
• Types are classified by the organs involved, with vesicovaginal being the most common 2 7 8.
• Causes vary by setting: obstructed labor dominates in the developing world, while surgical injuries prevail in more developed countries 2 7 8 10 11 12.
• Treatment options range from conservative catheter drainage to complex surgical repairs, with transvaginal procedures preferred in most cases and high cure rates achieved when expert care is available 3 11 12 14.
• Holistic support is essential for recovery and social reintegration.

Through increased awareness, improved access to skilled obstetric and surgical care, and ongoing support, the burden of vaginal fistula can be dramatically reduced—restoring lives, families, and communities.