(Poster 02) Misdiagnosed Vesicovaginal Fistula After Cerclage Placement: A Case Report

Objectives: A vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina, resulting in uncontrollable, continuous leakage of urine. VVFs are rare in developed countries and often result from gynecologic surgeries, including cerclage placement. We report a case of VVF secondary to a prior cervical cerclage placement. We discuss important physical exam findings, diagnostic workup, and treatment for VVF. We also review similar cases of VVFs after cerclage in the literature.

Methods: Medical records from a urogynecology office were reviewed for this case report. The search terms “vesicovaginal fistula” “VVF” and all forms of “cerclage” were used in PubMed to identify relevant studies, without time restrictions. Case reports and literature reviews were included.

Results: A 31-year-old woman G2P2002 with a history of modified McDonald cerclage presented to a urogynecologist with symptoms of mixed urinary incontinence for nine years. She had a cesarean section and subsequent vaginal birth after cesarean section. She experienced bladder issues after her first delivery, including continuous wetness and incomplete bladder emptying, but denied urgency symptoms. In the nine-year period of symptoms, she saw multiple urologists who diagnosed her with urge urinary incontinence. She failed medical management and percutaneous tibial nerve stimulation. When she presented to the urogynecologist, she was changing multiple diapers daily. Her exam was notable for a hypermobile urethra and stage II pelvic organ prolapse. Vaginoscopy and cystoscopy revealed a fistula tract. CT Urogram was performed with evidence of a likely VVF, and a subsequent cystoscopy under anesthesia confirmed these findings. Transvaginal VVF repair was performed. Lacrimal probes were used to dilate the tract. A fogarty catheter was used to cannulate the tract, and a two-layer closure was completed. Tiseel was placed over this repair. Anterior and posterior flaps were created around the fistula to create a tension free, mobile closure. A drip test and backfilling of the bladder, and a repeat cystoscopy revealed a closed fistula tract with watertight approximation. A voiding cystourethrogram performed three weeks postoperatively did not demonstrate any extravasation into the vagina from the bladder. The patient denied any further leaking of urine per vagina. Six months after surgery the patient was doing well with minimally bothersome systems associated with stress urinary incontinence.

Conclusions: Many patients with fistulas are misdiagnosed with incontinence and experience delays in appropriate treatment. A history of cerclage should be considered a key factor in maintaining a heightened index of suspicion for a VVF. A thorough physical exam focused on the urogenital system is the mainstay for diagnosis, and the primary symptom of a fistula is continuous wetness. Cystoscopy and vaginoscopy are key supplementary diagnostic tools. Prompt diagnosis and surgical repair can alleviate symptoms and improve patient outcomes.