Vesicovaginal Fistula: Symptoms, Types, Causes and Treatment

Vesicovaginal fistula (VVF) is a distressing medical condition that affects millions of women worldwide, particularly in regions with limited access to quality gynecological care. Characterized by an abnormal connection between the bladder and the vagina, VVF can cause significant physical discomfort and lead to profound social and psychological consequences. In this article, we explore the symptoms, different types, underlying causes, and evidence-based treatments for vesicovaginal fistula, drawing on the latest research to provide a comprehensive overview.

Symptoms of Vesicovaginal Fistula

VVF can dramatically affect a woman’s quality of life, but the extent and nature of symptoms can vary from patient to patient. Understanding these symptoms is crucial for timely diagnosis and effective management.

Main Symptom	Description	Impact	Source(s)
Urinary Leakage	Continuous involuntary urine flow from vagina	Major social/physical burden	6, 7, 10
Absence of Micturition	Inability to pass urine normally	Diagnostic clue	6, 10
Vaginal Discharge	Watery, sometimes intermittent	Discomfort, hygiene	2
Constipation	Frequently reported alongside VVF	Affects well-being	1
Fecal Incontinence	Rare unless other fistulas are present	Impacts quality of life	1
Suprapubic Tenderness	Discomfort above pubic bone	May indicate complications	2

Table 1: Key Symptoms

Continual Urinary Leakage

The classic symptom of vesicovaginal fistula is the continuous, involuntary leakage of urine from the vagina. This occurs because the abnormal connection bypasses the natural sphincter mechanisms of the urethra, making voluntary control of urination impossible. Women often report that they are unable to pass urine in the normal way (absence of micturition), with all urine exiting directly via the vaginal canal instead 6, 7, 10. This symptom can be profoundly stigmatizing, leading to isolation and mental health challenges.

Vaginal Discharge and Other Symptoms

Some women notice intermittent, watery vaginal discharge, which may be mistaken for other conditions if not recognized promptly. Infections and stone formation in the bladder or vagina can also occur in chronic cases, occasionally resulting in suprapubic tenderness or discomfort 2.

Bowel Symptoms

While fecal incontinence is rare in isolated VVF (more often seen in rectovaginal fistulas), constipation is surprisingly common, with up to half of women in some studies reporting this symptom. It is believed to be related to pelvic floor trauma rather than the fistula itself 1.

Social and Psychological Impact

The constant urine leakage frequently leads to unpleasant odor, skin irritation, and social withdrawal. Stigmatization, divorce, and exclusion from community life are unfortunately common, especially in regions with limited social support 8, 9.

Types of Vesicovaginal Fistula

VVFs are classified based on their anatomical location, size, complexity, and associated injuries. Understanding these categories helps guide treatment decisions.

Type	Location/Description	Severity/Complexity	Source(s)
Trigonal	At bladder trigone	Moderate	4
Supra-trigonal	Above bladder trigone	Common, variable	4
Circumferential	Encircles bladder neck/urethra	Complex	4, 5
Juxta-cervical	Near cervix	Variable	4
Transection Types I-IV	Based on extent of tissue damage	Severe	5
Continent VVF	No urinary leakage	Rare, unique	6

Table 2: VVF Types and Features

Anatomical Classification

VVFs are most commonly described by their location relative to the bladder:

• Trigonal fistulas occur at the trigone, the base of the bladder.
• Supra-trigonal fistulas are found above the trigonal area and represent the most frequent type.
• Circumferential, juxta-cervical, and juxta-urethral fistulas are described by their proximity to key anatomical landmarks 4.

Transection Types

A more detailed classification, particularly for severe obstetric injuries, divides VVFs into four transection types based on the involvement of the urethra, vagina, peri-fistulous tissue, and presence of associated lesions. Type I is least severe, while Type IV represents extensive tissue destruction and complex repair needs 5.

Simple vs. Complex Fistulas

A "simple" VVF is generally small, has healthy surrounding tissue, and is not associated with previous radiation or extensive surgery. "Complex" fistulas are larger, may involve tissue loss, scarring, or are recurrent, and often require more advanced surgical intervention 10.

Special Types: Continent VVF

Rarely, a VVF may be “continent,” meaning the woman does not experience urinary leakage despite the abnormal connection. Such cases are exceptional and may not require urgent intervention 6.

Causes of Vesicovaginal Fistula

VVF can arise from a variety of causes, which differ significantly between high- and low-resource settings.

Cause	Setting/Context	Frequency/Importance	Source(s)
Prolonged Obstructed Labor	Developing countries	Leading cause (65–97%)	4, 7, 8, 9, 10
Gynecological Surgery (e.g., hysterectomy)	Global, esp. developed countries	Most common in developed world	2, 4, 6, 10, 12
Cesarean Section	Both settings	13–31% in fistula series	4, 8
Advanced Cervical Cancer	Developing countries	Less common, serious	8
Radiation Therapy	Cancer treatment	Complex, late-onset	10, 13
Foreign Body/Instrumentation	Iatrogenic or abusive	Rare, risk for stones	2
Trauma (including Gishiri cut)	Certain regions	Rare, cultural practices	8

Table 3: Main Causes of VVF

Obstetric Causes

In many low-resource settings, particularly sub-Saharan Africa and South Asia, the overwhelming majority of VVFs are the result of prolonged obstructed labor. When labor is not relieved promptly, the baby’s head compresses the bladder and vagina against the pelvic bones, cutting off blood flow and causing tissue death. This results in a fistula forming, typically within a few days after delivery 7, 8, 9, 10. Young, first-time mothers (primiparae) are at greatest risk, often due to early marriage and lack of skilled birth attendance 8, 9.

Surgical and Iatrogenic Causes

In developed countries, most VVFs are a complication of pelvic surgery, especially hysterectomy for benign or malignant gynecological conditions. Injury to the bladder during surgery can go unrecognized, leading to fistula formation days to weeks later. Cesarean section, though less common as a cause, is also a notable risk factor 2, 4, 6, 10, 12.

Malignant and Radiation Causes

Advanced cervical cancer can invade the bladder and create a fistula. Similarly, radiation therapy for pelvic cancers can damage tissues and create a delayed, difficult-to-treat VVF 8, 10, 13.

Other Causes

Rare causes include traumatic injury, foreign bodies (sometimes resulting in stone formation), and traditional harmful practices like the “Gishiri cut” in some regions 2, 8.

Predisposing Social Factors

Poverty, low literacy, early marriage and childbearing, malnutrition, and lack of access to emergency obstetric care all increase the risk of developing VVF 2, 8, 9.

Treatment of Vesicovaginal Fistula

The management of VVF is a nuanced process that depends on the fistula’s size, location, underlying cause, and the patient’s overall health. Despite the complexity, most VVFs are amenable to successful closure.

Treatment Approach	Key Features	Success Rate (%)	Source(s)
Surgical Repair	Transvaginal, transabdominal, laparoscopic; interposition flaps	70–98%	4, 11, 12, 13, 15
Conservative (Catheter)	Prolonged bladder drainage for small/recent fistulas	~93%	3, 12
Electrocoagulation	Fulguration of small fistula tracts	~73%	14
PRP Injections	Platelet-rich plasma, minimally invasive	Case-based	3
Urinary Diversion	Reserved for complex/radiated cases	Variable	13

Table 4: VVF Treatment Modalities

Timing and Initial Management

• Delay before surgery: It is generally recommended to wait at least 4–6 weeks after fistula onset before attempting surgical repair, allowing inflammation to subside and tissues to heal 13. Early intervention may be considered in select cases.
• Conservative management: Small, recent, or post-surgical fistulas may close spontaneously with prolonged bladder drainage using a Foley catheter. This approach avoids surgery and has reported success rates of up to 93% in appropriate cases 3, 12.

Surgical Approaches

Vaginal Repair

• Transvaginal repair is the preferred method for most VVFs, offering high success rates (91–97%) with minimal patient morbidity. Techniques include the Latzko procedure, layered closure, and use of vascularized flaps (e.g., Martius flap) to reinforce the repair 12, 13.
• Complex or recurrent VVFs may require interposition of healthy tissue, such as the Martius or omental flap, to improve healing 13, 15.

Abdominal, Laparoscopic, and Robotic Repair

• Transabdominal/transvesical approaches are used for high, complex, or recurrent fistulas. Laparoscopic and robotic techniques offer minimally invasive alternatives with excellent outcomes and faster recovery in experienced hands 11, 12.
• Combined approaches may be needed for extensive or complicated cases 12.

Special Techniques

• Electrocoagulation (fulguration): For very small fistulas (<3.5mm), ablation of the fistula tract via endoscopic or vaginal access may close the defect. This method has a 73% success rate in selected patients 14.
• Platelet-rich plasma (PRP): Emerging as a minimally invasive option, PRP injections can promote healing in small, recent, or oligosymptomatic fistulas 3.

Management of Complex and Radiated Fistulas

• Complex or radiated VVFs are more challenging, often requiring individualized surgical plans, and sometimes urinary diversion if closure is not feasible 13.
• Use of absorbable suture material and meticulous surgical technique are critical to prevent stone formation and recurrence 2.

Prognosis and Follow-up

• High rates of cure: Most women can be cured with one attempt; success rates are 87–98% in non-radiated cases 4, 12, 13, 15.
• Recurrence: Repeat repairs are often successful, and the vaginal approach can be used again even after initial failure 13.
• Complications: These include infection, stone formation, and persistent incontinence (if the continence mechanism is damaged) 2, 15.

Conclusion

Vesicovaginal fistula remains a major source of suffering for women worldwide, particularly in regions lacking access to skilled obstetric care. Early recognition and expert management can restore continence and quality of life for most affected women. Awareness, prevention, and improved surgical training are critical steps toward eliminating this preventable condition.

Key Points Covered:

• VVF presents primarily as continuous urinary leakage, with profound physical and social consequences 6, 7, 8.
• The majority of VVFs in developing countries are due to obstructed labor, while surgical injury is the leading cause in developed settings 4, 7, 8, 10.
• VVFs are classified by anatomical location and complexity, helping to guide treatment 4, 5.
• Most VVFs are treatable, with surgical repair (especially via the vaginal route) achieving high success rates 4, 12, 13, 15.
• Conservative management, fulguration, and novel therapies like PRP injections are suitable for select cases 3, 12, 14.
• Prevention depends on access to skilled obstetric care, improved education, and surgical safety 7, 8, 9.

With concerted global efforts, the burden of vesicovaginal fistula can be dramatically reduced, restoring dignity and health to millions of women.