Unlocking the Challenges of Diagnosing Fistulas in the Pelvis

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1 Unlocking the Challenges of Diagnosing Fistulas in the Pelvis Lucy Chow, MD & Simin Bahrami, MD Department of Radiological Sciences David Geffen School of Medicine at UCLA

2 Goals and Objectives Understand the anatomy, clinical presentation, and causes of fistulas in the pelvis. Review the imaging findings of pelvic fistulas in different imaging modalities, such as CT, MR, and fluoroscopy Discuss potential diagnostic pitfalls and the management of pelvic. Disclosure: None of the authors have any financial conflicts of interest to disclose.

3 Introduction Fistula formation in the pelvis is a devastating condition that causes significant morbidity. Different pelvic fistulas have different etiologies, vary in anatomy, and have distinct clinical presentation. Causes significant physical and psychological impact on the patient s quality of life. Imaging is crucial for identification of site and course of fistulas.

4 Anatomy Fistula: abnormal connection between two or more epithelial surfaces. ureter urethra colon Genitourinary A) Vesicouterine B) Vesicovaginal C) Urethrovaginal D) Ureterovaginal Intestinogenitourinary E) Colouterine F) Colovaginal G) Colovesical H) Rectovaginal Genitocutanous I) Perineovaginal

5 Clinical Presentations Vesicouterine Vesicovaginal Ureterovaginal Incontinence Vaginal urine leakage Localized pain Pruritis vulvae Bladder Perineal skin irritation Genitourinary tract infections Colovesical Enterovesical Pneumaturia Fecaluria Rectum Rectouterine Rectovaginal Colovaginal Ureterovaginal Vaginal discharge Vaginal infection Passage of stool, mucus or flatus through vagina

6 ACQUIRED ETIOLOGIES Malignancy Gynecological Processes Infectious Inflammatory Uterine, Cervical, Vaginal, Bladder, Colorectal, Prostate Birth Trauma Endometriosis Fibroids Retained Foreign Bodies Chronic Granulomatous Disease Diverticulitis Inflammatory Bowel Disease Tuberculosis Schistosomiasis Actinomycosis IATROGENIC ETIOLOGIES Radiation Therapy Late Complication 1-2 years Post Treatment Gynecological Surgery Early Complication <30 days Post Operative External Beam Brachytherapy Hysterectomy Birth Trauma Pelvic Mesh Implants Vaginal Vault Prostate Instrumented Vaginal Delivery Cesarean Sections

ACQUIRED Malignancy Fistulas occur in 2.

Vesicovaginal and colovaginal are most common types.

Birth trauma Common in developing countries Tissue

fistula formation Bladder Fetus Pathophysiology Rectum

Bladder injury in hysterectomy Forceful blunt dissection

cuff suture into bladder causes tissue ischemia and

Chemoradiation Alters the anatomy Causes increased

7 ACQUIRED Malignancy Fistulas occur in 2.5% of patients with gynecological malignancy. Vesicovaginal and colovaginal are most common types. Causes fistula by direct invasion to adjacent structures Birth trauma Common in developing countries Tissue compression during labor leads to ischemia, necrosis and fistula formation Bladder Fetus Pathophysiology Rectum IATROGENIC Post-surgical Common in developed countries Bladder injury in hysterectomy Forceful blunt dissection results in bladder wall tear or devascularization Vaginal cuff suture into bladder causes tissue ischemia and necrosis leads to fistula Surgery involving vaginal wall Chemoradiation Alters the anatomy Causes increased fibrosis and loss of soft tissue planes Causes endarteritis obliterans and ischemic necrosis resulting in fistula formation

8 Common Imaging Findings Focal wall thickening Fistulous tract Presence of air or contrast material Loss of soft tissue plane

9 Non-Imaging Examinations Physical examination Vaginal fluid analysis Test fluid for urea, creatinine, and potassium Pyridium test Administer oral phenazopyridine and examine tampon for red staining (pyridium) Cystoscopy Direct visualization of the urethra and bladder through a cystoscope Methylene blue test Instill methylene blue into bladder and examine vagina for its presence

Fluoroscopy Types of Studies q Cystogram q Excretory urography q Vaginography q Water-soluble enema q Fistulograms Benefits/Tips ü Real time imaging ü

visualize associated complications ü Limited anatomic detail CT Types of studies q Multiple Phases: Unenhanced, contrast enhanced, and delayed excretory

when compared to fluoroscopy ü Determine presence and location of leaks ü Image reconstruction in multiple planes Limitations ü Visualization dependent

administration of intravenous gadoliniumbased contrast Benefits/Tips ü Excellent soft tissue contrast to delineate tract ü Multi-planar sequences

10 Fluoroscopy Types of Studies q Cystogram q Excretory urography q Vaginography q Water-soluble enema q Fistulograms Benefits/Tips ü Real time imaging ü Different projections, patient positioning and maneuvers can provoke fistula visualization ü Oblique and lateral views useful Limitations ü Incompletely visualize associated complications ü Limited anatomic detail CT Types of studies q Multiple Phases: Unenhanced, contrast enhanced, and delayed excretory q Genitourinary Fistulas: Use bladder or vaginal contrast q Enteric Fistulas: Use rectal contrast Benefits/Tips ü Increased sensitivity and accuracy when compared to fluoroscopy ü Determine presence and location of leaks ü Image reconstruction in multiple planes Limitations ü Visualization dependent on contrast timing MRI Helpful Sequences q Fistulous tract high-signal intensity on T2-weighted or STIR sequences q T1-weighted images after administration of intravenous gadoliniumbased contrast Benefits/Tips ü Excellent soft tissue contrast to delineate tract ü Multi-planar sequences helpful, particularly sagittal plane ü Delayed sequences for contrast excretion Limitations ü Visualization dependent on contrast timing ü Motion artifact degrade image quality

resolution Allows better visualization of

later, repeat CE-CT shows interval erosion of

thickening, mucosal enhancement and foci of

confirm fibroid erosion into the bladder with

11 a a d * * Vesicouterine Fistula b e * * Teaching point: MR provides superior contrast resolution Allows better visualization of fistulous tract f c * * 70F with fibroids and pain. (a) Sagittal CE-CT demonstrates calcified uterine fibroid (*) (b, c) One year later, repeat CE-CT shows interval erosion of the fibroid (*) into the bladder with wall thickening, mucosal enhancement and foci of air. (d-f) T2 and postcontrast T1 images confirm fibroid erosion into the bladder with a fistulous connection between the uterus and bladder dome (arrow), compatible with a vesicouterine fistula. Patient underwent fibroid removal, hysterectomy, and bladder repair.

12 Vesicovaginal Fistula 71F with cervical cancer s/p hysterectomy and radiation. (a) Sagittal CT Cystogram. Contrast in the vagina (*) with fistulous connection to bladder (arrow), compatible with a vesicovaginal fistula. (b-c) Oblique and lateral Cystogram. Contrast instilled into the bladder with leakage into vagina (*) through the vaginal cuff. a * b c * 24F with Crohn s disease. (d-f) MR enterography axial and sagittal delayed images demonstrates contrast in the bladder and vagina (*) suggesting a vesicovaginal fistula. d * * e f

13 Vesicovaginal Fistula Pre and Post Repair a b c d e f g 65F with cervical cancer s/p radiation with subsequent radiation-induced vesicovaginal fistula in the region of the bladder base. (a-d) CT Cystogram shows contrast extending from the bladder into the region of the vagina and introitus. After fistula repair, (e) CT shows a clear fat plane between the vagina and bladder. (f-g) Mild irregular thickening of the posterior bladder (arrow) is compatible with post surgical changes of vesicovaginal fistula repair.

Urethrovaginal Fistula a c b d 47F s/p retropubic mesh sling placement

Cystogram demonstrates eccentric irregular accumulation of contrast

14 Urethrovaginal Fistula a c b d 47F s/p retropubic mesh sling placement (a) Cystoscopy show subsequent mesh erosion into the urethra (b-d) Cystogram demonstrates eccentric irregular accumulation of contrast along the left posterior aspect of the bladder neck/proximal urethra, in the region of the vagina. On the magnified images, a thin sinus tract is identified (arrow). On the post-void images, the structure retains contrast.

thin tract of hyperintense fluid extending

Small collection of T2 hyperintense fluid is

15 Urethrovaginal Fistula a c b 51F with history of periurethral and perivaginal mesh excision. (a-b) Axial and (c) sagittal MR demonstrate thin tract of hyperintense fluid extending down the patulous urethra (yellow arrow). Small collection of T2 hyperintense fluid is seen in the lower vagina (white arrow). This likely indicates a urethrovaginal fistula.

Fistulous tract (yellow arrow) is at the

The left distal ureter drains directly to

16 Ureterovaginal Fistula a b c d 69F with ovarian cancer status post TAH-BSO and tumor debulking presented with vaginal fluid leakage. (a-d) Axial, sagittal, and coronal CT Urogram delayed images show contrast opacifying the bilateral ureters and bladder with leakage into the vagina. Fistulous tract (yellow arrow) is at the level of the distal left ureter. (e-f) Nephrostomy tube was placed. Left nephrostogram shows contrast opacifying the left renal pelvis and ureter. The left distal ureter drains directly to the vagina (V). No communication seen between the left distal ureter and the bladder. Ureter was subsequently implanted into the bladder dome over a stent. e f V

(c) An air-filled tract extends from this

17 Enterovesical Fistula c a b d 66F with rectal cancer s/p chemoradiation. Subsequently developed small bowel obstruction and enterovesical fistula. (a-b)) CT Abdomen with oral contrast demonstrates small bowel superior and ventral to the bladder with surrounding inflammatory changes. (c) An air-filled tract extends from this loop of bowel to the bladder (arrow). (d) Air and contrast in the bladder is enteric in origin.

18 a Colouterine Fistula b d e f Teaching point: T2-weighted or STIR sequences are helpful to evaluate for fistulous tract c 61F with pain and feculent vaginal drainage. (a-c) CE-CT. Sigmoid colonic wall thickening and soft tissue stranding consistent with acute sigmoid diverticulitis. Associated abscess and soft tissue contiguity with locules of gas between the inflamed sigmoid colon and uterine fundus concerning for a colouterine fistula (red arrow). (d-f) MR. Axial and sagittal T2 images show a fistulous tract between the uterus and sigmoid colon. T2-fat saturated images show a hyperintense tract (yellow arrow).

19 Colovaginal Fistula a c b d Teaching point: Ensure adequate opacification of proximal colon to identify colovaginal fistulas c e 85F with air and feculent vaginal discharge. (a, b) CT with oral contrast show posterior sigmoid diverticulum tethering the superior aspect of the vaginal cuff (arrows) with trace extravasation into the vagina. (d, e) Contrast instilled through the rectum shows extravasation through a fistulous tract (arrow), extending from the colon to the vagina.

Rectovaginal fistula V R A B 61F with colon cancer s/p radiation and low anterior

A) Sagittal CE-CT shows direct communication of the anterior lower rectum with the

Feculent material and air is seen in the vaginal canal.

leaking into the vagina (V) through a narrow fistula (red arrow) extending from

20 Rectovaginal fistula V R A B 61F with colon cancer s/p radiation and low anterior resection and subsequent development of radiation-induced rectovaginal fistula. A) Sagittal CE-CT shows direct communication of the anterior lower rectum with the vaginal canal (yellow arrows) and discontinuity of the intervening fat plane. Feculent material and air is seen in the vaginal canal. B) Gastrograffin enema demonstrates contrast material filling the rectum (R) and leaking into the vagina (V) through a narrow fistula (red arrow) extending from the upper rectum near the rectosigmoid junction to the vaginal fornix, findings consistent with a rectovaginal fistula.

21 Colovesical Fistula a b c 86F with diverticulosis. (a-b) Coronal CT shows a fistulous tract containing fluid and air (yellow arrow) extending from the bowel into the bladder wall. (c) Axial CT shows focal bladder wall thickening at the fistula site. The bladder also contains air. (d-e) Cystogram shows contrast injection though the Foley catheter, opacifying the bladder and rectosigmoid colon. (f) Post drainage image shows residual colonic contrast. d e f

(a) CT Cystogram shows opacification of the

colovesical fistula located at the level of the

b e c (b) Contrast extravasation from the

(yellow arrow), compatible with a colovaginal

(c) Residual contrast identified within the

(d, e) Large bowel is closely adherent to the

22 d a Multiple Complex Fistulas 50F s/p hysterectomy. (a) CT Cystogram shows opacification of the bladder and rectosigmoid colon, suggestive of a colovesical fistula located at the level of the vaginal apex. b e c (b) Contrast extravasation from the anterior sigmoid colon to the vaginal apex (yellow arrow), compatible with a colovaginal fistula. (c) Residual contrast identified within the introitus of the vagina. (d, e) Large bowel is closely adherent to the anterior pelvic wall with adjacent increased soft tissue thickening, foci of gas and contrast in the low anterior pelvic wall. Findings suggestive of a colocutaneous fistula (white arrow). Contrast again seen in vagina (red arrow).

Multiple Fistulas a c 62F with a history

fistulas and vesicovaginal fistulas have a

23 Multiple Fistulas a c 62F with a history of vaginal wall squamous cell carcinoma. Sagittal (a, b) and axial (c, d) PET-CT images demonstrates intensely FDG-avid urine within the bladder, vagina, and large bowel consistent with vesicovaginal and colovaginal fistulas. b d Teaching point: Ureterovaginal fistulas and vesicovaginal fistulas have a 10% association. If one type of fistula is visualized, look for other types.

Interesting Case #1 a c b d 68F with diverticulosis and

(a, b) Short colovesical sinus tract (arrows) extending

bladder dome extends to the sigmoid mesenteric fat and

bladder (arrowheads) which were identified as calcified

24 Interesting Case #1 a c b d 68F with diverticulosis and occasional fecaluria. CT Cystogram was obtained. (a, b) Short colovesical sinus tract (arrows) extending from a focal region of tenting at the left posterior bladder dome extends to the sigmoid mesenteric fat and through the sigmoid colon wall without definite intraluminal extension. (c, d) Additional hyperdensities also seen adjacent to the bladder (arrowheads) which were identified as calcified fibroids on the noncontrast images, and were not extraluminal contrast. Teaching point: Use initial unenhanced CT images to problem solve.

25 Interesting Case #2 c a b d 60F with history of cervical cancer and invasion into the rectosigmoid. A colonic stent was placed for large bowel obstruction. Sagittal (a, b) and axial (c, b) CT images demonstrates a moderate amount of debris and gas within the vagina. The rectal stent appears to have migrated into the vagina through the known rectovaginal fistula.

Interesting Case #3 a b 50F with history of vesicovaginal fistula after

(a) Axial CT Abdomen demonstrated a bladder stone posterior to the bladder

(b) Cystoscopy demonstrated a defect in the bladder wall related to a sinus

26 Interesting Case #3 a b 50F with history of vesicovaginal fistula after hysterectomy which was subsequently repaired. Patient presented with dysuria. (a) Axial CT Abdomen demonstrated a bladder stone posterior to the bladder adjacent to the left vaginal cuff. (b) Cystoscopy demonstrated a defect in the bladder wall related to a sinus tract from the previous vesicovaginal fistula repair. Surgery was later performed and the stone removed from the bladder sinus tract.

27 39F s/p myomectomy with new fever and abdominal pain. (a-d) CT Abdomen demonstrates a large gas and fluid collection within the posterior fundus at the site of the myomectomy. There is an area of disruption through the left aspect of the fundus which tracks into a gas and fluid collection in the left adnexal region (arrow). The collection is not contiguous with the bowel. The abscess may be mistaken for a colouterine fistula. Pitfalls: Mimics a b Teaching point: Carefully identify the site and examine the full course of potential fistulas c d

CONSERVATIVE MANAGEMENT Indications q Simple fistulas q Small size q Unrelated to

Not amenable to conservative management Treatments Antibiotics Sitz bath for

post-menopausal patients Urinary diversion: Transurethral or suprapubic catheter,

spontaneously Proceed to surgery if not improved Percutaneous Treatments Covered stent

closure with sutures Surgical debridement of the fistula edges without full excision

28 CONSERVATIVE MANAGEMENT Indications q Simple fistulas q Small size q Unrelated to malignancy or XRT OPERATIVE MANAGEMENT Indications q Complex fistulas (>2 tracts) q Not amenable to conservative management Treatments Antibiotics Sitz bath for symptomatic relief Estrogen therapy to improve tissue vascularization in post-menopausal patients Urinary diversion: Transurethral or suprapubic catheter, nephrostomy Percutaneous drainage, if an abscess is present Outcomes Some may resolve spontaneously Proceed to surgery if not improved Percutaneous Treatments Covered stent placement Ureteral occlusion Surgical Treatments Excision of fistulous tract and closure with sutures Surgical debridement of the fistula edges without full excision Covering the fistula by mobilizing normal tissue (fat pad graft) adjacent to the fistula causing subsequent scarring and healing

29 Conclusion Pelvic fistula is a devastating condition that causes significant morbidity. Evaluation of pelvic fistulas is challenging. Imaging can assist in making the correct diagnosis, describing the course of the fistula, and demonstrating associated complications. This information is important for guiding treatment.

30 References 1. Lee JK and Stein SL. Radiographic and Endoscopic Diagnosis and Treatment of Enterocutaneous Fistulas. Clin Colon Rectal Surg. 2010;23(3): Addley HC et al. Pelvic Imaging Following Chemotherapy and Radiation Therapy for Gyne- cologic Malignancies. RadioGraphics. 2010;30: Avritscher R et al. Fistulas of the Lower Urinary Tract: Percutaneous Approaches for the Management of a Difficult Clinical Entity. RadioGraphics. 2004; 24:S217 S Outwater E and Schiebler ML. Pelvic Fistulas: Findings on MR Images. AJR. 1993;160: Papadopoulou I et al. Post Radiation Therapy Imaging Appearances in Cervical Carcinoma. RadioGraphics. 2016; 36: Paspulati RM and Dalal TA. Imaging of Complications Following Gynecologic Surgery. RadioGraphics. 2010; 30: Yu NC et al. Fistulas of the Genitourinary Tract: A Radiologic Review. RadioGraphics. 2004; 24: Titton RL, et al. Urine leaks and urinomas: diagnosis and imaging-guided intervention. RadioGraphics. 2003; 23:

Case Based Urology Learning Program

Case Based Urology Learning Program Resident s Corner: UROLOGY Case Number 19 CBULP 2011 044 Case Based Urology Learning Program Editor: Associate Editors: Manager: Case Contributors: Steven C. Campbell,