Urethral Diverticula, Urethro-Vaginal Fistulae, Vesico-Vaginal Fistulae

EAU Update Series 1 (2003) 178 185 Urethral Diverticula, Urethro-Vaginal Fistulae, Vesico-Vaginal Fistulae C.R. Chapple * Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield S10 2JF, UK Abstract This review considers the management of urethral diverticula, urethro-vaginal fistulae, and vesico-vaginal fistulae. The aim of this is to provide the reader with an overview of the current management of these pathologies, with reference to pertinent literature. # 2003 Elsevier B.V. All rights reserved. Keywords: Trauma; Vesico-vaginal fistulae; Urethro-vaginal fistulae; Urethral diverticula 1. Urethral diverticula Female urethral diverticula are estimated to occur in between 1% and 6% of all adult females and are usually diagnosed after the age of 20, the majority of the cases being in the 4th decade of life. Whilst the majority of urethral diverticula are undiagnosed as they prove to be asymptomatic, they may be complicated by infection, stones or rarely malignancy and by virtue of their size may produce obstruction to the bladder outlet. Diverticula most commonly present with symptoms relating to their size, with discomfort or with episodes of repeated inflammation and infection. If a diverticulum is asymptomatic and causing the patient no concern then there is no indication for its further treatment. The presenting symptoms can be summarised as the three D s, Dysuria, postvoid Dribbling and Dyspareunia. It has been suggested that diverticula are congenital in origin. There is no evidence to support this view as they are rarely found in children but this doesn t preclude the fact that an early diverticulum or weakness might have been present albeit undiagnosed. It is tempting to attribute the development of diverticula to the trauma of childbirth and whilst diverticula often present in women following childbirth it has been shown that urethral diverticula are just as likely to arise in nulliparous patients. A strong possibility is that repeated infection and obstruction of the periurethral glands results in the * Tel. þ44-114-2712559; Fax: þ44-1144-2798318. E-mail address: c.r.chapple@sheffield.ac.uk (C.R. Chapple). formation of a cyst which eventually ruptures and drains back into the urethral lumen. Another possibility is that some cases may be due to embryological remnants e.g. Gartner s duct or vestigial Wolfian ducts which may act as a precursor to the diverticulum formation. Urethral diverticula invariably communicate with the urethral lumen and by virtue of their position protrude through and stretch the periurethral smooth muscle (bearing in mind that the favoured hypothesis is that they are based on obstructed periurethral glands). The periurethral glands are tubuloalveolar structures that predominate in the distal two thirds of the urethra and not surprisingly up to 90% of diverticula open into the mid or distal urethra. Occasionally diverticula by virtue of their size extend proximally and extend beneath the bladder neck and trigonal area (Fig. 1). The diagnosis of urethral diverticula used to be based on a combination of clinical observation and urethrography but more recent work in this area had clearly demonstrated that a postvoiding sagittal MRI scan is the most accurate way of finding their size and position (Fig. 2). Urethroscopy whilst often performed usually fails to be helpful particularly if the diverticulum is collapsed as the internal communication between the diverticulum and the urethra is often not visible. Having identified a diverticulum which is asymptomatic then the treatment of choice is the excision of the diverticulum. Simple marsupialisation of a diverticulum is one of the commonest causes of development of a urethro-vaginal fistulae. My standard management of 1570-9124/$ see front matter # 2003 Elsevier B.V. All rights reserved. doi:10.1016/s1570-9124(03)00040-0

C.R. Chapple / EAU Update Series 1 (2003) 178 185 179 Fig. 3. Surgery in the prone position, showing infiltration with lignocaine and adrenaline, raising the anterior vaginal flap and the excellent view and access to the diverticulum seen with this patient positioning. Fig. 1. A diverticulum usually extends through all layers of the urethra, therefore marsupialisation may lead to a fistula. A diverticulum stretches through all layers of the urethra and surgery on it will tend to weaken the urethral sphincter. these patients is to excise the diverticulum via a vaginal approach using the prone position (Fig. 3). The most definitive excision of a diverticulum is to carry out a full excision with a full opening of the urethra but this does carry with it morbidity even in experienced hands and having discussed this with the patient the majority will elect for simple diverticulectomy with insertion of a Martius flap (Fig. 4). Using this approach urethro-vaginal fistula formation is exceedingly rare. All patients however prior to surgery should be warned that there is a risk of incontinence either because it becomes unmasked as a consequence of removing the swollen diverticulum in a patient who already had a tendency to stress incontinence or may result from damage to the urethral sphincter mechanism during removal of the diverticulum. The patients should therefore be aware that a secondary procedure, in particular a sling procedure may be necessary at a later date and certainly this is facilitated by the positioning of the Martius flap at the time of the diverticulectomy. For more information on urethral diverticula and urethro-vaginal fistulae see [1 12]. 2. Urethro-vaginal fistulae and urethral sphincter deficiency Fig. 2. Sagittal MRI scan demonstrating the presence of a diverticulum arising from the posterior aspect of the urethra and extending upwards towards the base of the bladder ( diverticulum with arrows around it). Urethro-vaginal fistulae are happily uncommon but invariably associated with a defect in the posterior section of the urethral sphincter mechanism. Patients presenting with the consequences of a fistula, namely incontinence, in any repair of these fistulae will require

180 C.R. Chapple / EAU Update Series 1 (2003) 178 185 Fig. 4. Plane of dissection for a diverticulum and the advantage of a full opening of the urethra to facilitate complete excision of the diverticulum. definitive repair of the sphincter in order to restore continence. Urethro-vaginal fistulae may result as the consequence of prolonged labour or complicated vaginal delivery where there is damage to the urethra or following surgery, particularly excision of the urethral diverticulum or surgery to the anterior vaginal wall (cf. anterior repair). Urethral damage consequent upon pelvic fracture injuries is extremely rare. Management of a urethro-vaginal fistula therefore requires urethral reconstruction with careful attention to reconstructing the integrity of the urethral sphincter mechanism using a Young Dees urethral tailoring procedure (Fig. 5). Such surgery should be carried out by those familiar with the principles and practice of urethral reconstruction. 3. Vesico-vaginal fistulae Vesico-vaginal fistulae are uncommon in contemporary practice in Europe today. In developing countries where obstetric services are limited then such injury usually follows from prolonged or difficult vaginal delivery whereas in Europe the commonest cause of vesico-vaginal fistulae is gynaecological surgery complicated by damage to the bladder base usually just above the trigone. (See [13 28] for more information on vesico-vaginal fistulae.) The majority of vesico-vaginal fistulae are easy to identify and indeed some bladder fistula may be large enough to feel with a tip of a finger in the vagina. Conversely, when a long established pin hole fistula is present in the base of the bladder it may be difficult to identify. Traditionally the three swab test has been used to identify the cause of a small vesico-vaginal fistula that is difficult to locate (Fig. 6). Cystography is another useful adjunct to diagnosis and will show the presence of leakage from the bladder. Intravenous urography should be carried out to image the upper tracts in all cases presenting with lower urinary tract trauma. Prior to repair however patients should be examined endoscopically using either flexible

C.R. Chapple / EAU Update Series 1 (2003) 178 185 181 Fig. 5. Principles of Young Dees urethral tailoring (reduction sphincteroplasty). Reducing the diameter of the urethra by tailoring the urethral roof strip, removing the damaged ventral urethra and basing the reconstruction on the intact and anyway more robust dorsal component of the sphincter. or rigid cystoscopes. Where the fistula is very small then a fine ureteric catheter or guideline can be passed through the fistula to clearly demonstrate its position. The use of the cystoscope as a vaginoscope should not be forgotten as this will often allow careful examination of the anterior vaginal wall and can be particularly useful in identifying a fistula which is not immediately apparent on cystoscopy; likewise a guide-wire or ureteric stent can be passed using the cystoscope via this route. The majority of vesico-vaginal fistulae can be closed by an appropriate surgical repair. It is however useful to consider them as being either simple or complex. Simple fistulae result from surgical injuries to the bladder and can usually be closed by a definitive suture approximation of the normal tissue margins using a layered closure with the interposition of vascularised tissue such as omentum or a Martius flap between the vaginal and bladder suture margins. Complex fistulae are associated with greater local tissue destruction

182 C.R. Chapple / EAU Update Series 1 (2003) 178 185 Fig. 6. The three swab test. Tying knots in the strings attached to the swabs helps with subsequent interpretation of the results. Note the false positive with a urethro-vaginal fistula associated with vesico-ureteric reflux. either resulting from infection, infestation, irradiation, extensive trauma or failure of previous surgery repair. In some such cases malignancy is another additional feature which needs to be considered in the overall management of patients. The presence of malignancy is not an exclusion criterion as such but may well dictate the nature of the subsequent reconstruction as many of these patients require exenterative surgery. 3.1. Timing of repair Fistulae should be repaired either within two weeks of their development or after a three month period. Operating in the intervening period increases the complexity of surgery and lessens the likelihood of success as the tissues that are present are rather friable and adequate surgical closure is extremely difficult. There is no clear evidence in the literature to support surgery during this intervening period. patients have had prior gynaecological surgery then an incision via the suprapubic pfannenstiel scar avoids the disfigurement of an additional abdominal incision and is easily achieved by dissecting the skin and fat off the anterior abdominal wall and then carrying out a midline incision. This can be supplemented by an additional incision higher up in the abdomen if necessary though this has rarely proven to be the case in my experience (Fig. 8). When using an abdominal approach the transvesical approach provides the best exposure. The bladder is 3.2. Surgical approach The choice of approach will depend upon the surgeon s training and hence preference but also should be particularly dictated by the position and size of the fistula (Fig. 7). 4. Abdominal approach In cases where the fistula is either large of high up on the bladder then a transabdominal approach provides excellent exposure and access. Since the majority of Fig. 7. Surgical approaches to fistula repair.

C.R. Chapple / EAU Update Series 1 (2003) 178 185 183 Fig. 8. The mid-line laparotomy via a pfannenstiel incision. split through the mid-line down to the fistulae and bivalved. This facilitates the dissection between bladder and vagina and it is best to develop this plane for 2 3 cm distal to the fistula to allow interposition of vascularised tissue particularly omentum. Other tissues suggested for use include fat patches, peritoneum and striated muscle but in my experience omentum provides the most robust and easily available tissue and provides excellent success rates. It is usually not necessary to develop a full abdomino-perineal tunnel but in complex cases this may prove to be the case and the omentum can be pulled through right to the perineum (Fig. 9). 5. Vaginal approach Many fistulae are amenable to a vaginal repair which I find particularly facilitated by using the prone position. The importance of repair is to achieve adequate separation of the two suture margins i.e. bladder and vagina with interposition of vascularised tissue which is easily achieved by the use of a Martius flap (Fig. 10). Others have suggested the use of other tissues in particular peritoneum with good results. Recent cases of laparoscopic repair have been published but no other significant contributions have appeared in the literature relating to surgical techniques for fistula repair in recent years. Following any fistula repair I leave both a suprapubic and urethral catheter in situ and carry out a cystogram at 10 days to check that the repair is sound. Following these basic principles is simple and the majority of complex fistulae can be dealt with with very high success rate. Certainly approximating to 100%. Fig. 9. Transabdominal transvesical approach to vesico-vaginal fistula repair supported by omental interposition.

184 C.R. Chapple / EAU Update Series 1 (2003) 178 185 Fig. 10. Vaginal approach to vesico-vaginal fistula repair using a Martius flap. Acknowledgements The figures in this paper are from Turner- Warwick and Chapple s. Functional Reconstruction of the Urinary Tract and Gynaecourology. Blackwell, Oxford, 2002. The reader is advised to consult this text for a more detailed exposition of the subject. References [1] Anderson MJF. The incidence of diverticula in the female. J Urol 1967;98:96 8. [2] Aspera AM, Rackley RR, Vasavada SP. Contemporary evaluation and management of the female urethral diverticulum. Urol Clin North Am 2002;29(3):617 24. [3] Blander DS, Rovner ES, Schnall MD, Ramchandani P, Banner MP, Broderick GA, et al. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology 2001;57(4): 660 5. [4] Candiani P, Austoni E, Campiglio GL, Ceresoli A, Zanetti G, Colombo F. Repair of a recurrent urethrovaginal fistula with an island bulbocavernous musculocutaneous flap. Plast Reconstr Surg 1993; 92(7):1393 6. [5] Davis RS, Linke CA, Kraemer GK. Use of labial tissue in repair of urethrovaginal fistula and injury. Arch Surg 1980;115(5):628 30. [6] Debaere C, Rigauts H, Steyaert L, Pattyn G, Ampe J. MR imaging of a diverticulum in a female urethra. J Belge Radiol 1995;78(6):345 6. [7] Ganabathi K, Leach GE, Zimmern PE, Dmochowski RR. Experience with the management of urethral diverticula in 63 women. J Urol 1994;152:1445 52. [8] Khati NJ, Javitt MC, Schwartz AM, Berger BM. MR imaging diagnosis of a urethral diverticulum. Radiographics 1998;18(2):517 22. [9] Krogh J, Kay L, Hjortrup A. Treatment of urethrovaginal fistula. Br J Urol 1989;63(5):555. [10] Leach GE, Schmidbauer CP, Hadley HR, Staskin DR, Zimmern P, Raz S. Surgical treatment of female urethral diverticulum. Semin Urol 1986;4(1):33 42. [11] Leach GE, Sirls LT, Ganabathi K, Zimmern PE. L N S C3: a proposed classification system for female urethral diverticula. Neurourol Urodyn 1993;12(6):523.

C.R. Chapple / EAU Update Series 1 (2003) 178 185 185 [12] Woodhouse CR, Flynn JT, Molland EA, Blandy JP. Urethral diverticulum in females. Br J Urol 1980;52(4):305 10. [13] Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996;51(9):568 74. [14] Badenoch DF, Tiptaft RC, Thakar DR, Fowler CG, Blandy JP. Early repair of accidental injury to the ureter or bladder following gynaecological surgery. Br J Urol 1987;59(6):516 8. [15] Blandy JP, Badenoch DF, Fowler CG, Jenkins BJ, Thomas NW. Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 1991;146(3):761 5. [16] Dupont MC, Raz S. Vaginal approach to vesicovaginal fistula repair. Urology 1996;48(1):7 9. [17] Hilton P. Vesico-vaginal fistula: new perspectives. Curr Opin Obstet Gynecol 2001;13(5):513 20. [18] Mondet F, Chartier-Kastler EJ, Conort P, Bitker MO, Chatelain C, Richard F. Anatomic and functional results of transperitonealtransvesical vesicovaginal fistula repair. Urology 2001;58(6):882 6. [19] Muleta M, Williams G. Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991 97. Lancet 1999;354(9195):2051 2. [20] Naude JH. Reconstructive urology in the tropical and developing world: a personal perspective. BJU Int 2002;89(Suppl 1):31 6. [21] Nesrallah LJ, Srougi M, Gittes RF. The O Conor technique: the gold standard for supratrigonal vesicovaginal fistula repair. J Urol 1999;161(2):566 8. [22] Romics I, Kelemen Z, Fazakas Z. The diagnosis and management of vesicovaginal fistulae. BJU Int 2002;89(7):764 6. [23] Sims JM. On the treatment of vesico-vaginal fistula. 1852. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(4):236 48. [24] Thomas K, Williams G. Medicolegal aspects of vesicovaginal fistulae. BJU Int 2000;86(3):354 9. [25] Turner-Warwick R. The use of the omental pedicle graft in urinary tract reconstruction. J Urol 1976;116(3):341 7. [26] Turner-Warwick RT, Wynne EJ, Handley-Ashken M. The use of the omental pedicle graft in the repair and reconstruction of the urinary tract. Br J Surg 1967;54(10):849 53. [27] Walker RM, Worth PH. Medicolegal aspects of vesicovaginal fistula. BJU Int 2001;87(1):127. [28] Wein AJ, Malloy TR, Carpiniello VL, Greenberg SH, Murphy JJ. Repair of vesicovaginal fistula by a suprapubic transvesical approach. Surg Gynecol Obstet 1980;150(1):57 60. CME questions Please visit http://www.uroweb.org/updateseries to answer these CME questions on-line. The CME credits will then be attributed automatically. 1. Urethral diverticula A. are rare occurring in less that 1% of the female population. B. usually present at some stage with symptoms. C. invariably communicate with the urethral lumen. D. protrude through and stretch the surrounding urethral smooth muscle. E. can be usually visualised on urethroscopy. 2. Surgical repair of A. a urethral diverticulum may result in the development of incontinence. B. a urethral diverticulum is usually most appropriately formed by marsupialisation. C. a urethral fistula rarely requires a Martius flap interposition procedure. D. urethral fistula almost never requires a formal urethral tailoring procedure. E. urethral fistula is commonly consequent upon a pelvic fracture injury in the female. 3. Vesico-vaginal fistulae A. are best managed initially by conservative treatment. B. to be repaired easily between 2 6 weeks after injury. C. usually require surgical repair. D. are rarely associated with other injuries to the urinary tract. E. are best managed by an abdominal approach. 4. Diagnosis of a vesico-vaginal fistula is often confirmed by A. a clinical history. B. a two swab test. C. CT scanning. D. 3D MRI scanning. E. ultrasound. 5. Surgical repair of vesico-vaginal fistulae A. is improved by tissue interposition. B. is contraindicated in the presence of malignancy. C. is usually associated with a 20% failure rate. D. should be carried out abdominally via a mid-line skin incision. E. is difficult via the vaginal route with the patient in the prone position.