Basics
Description
Urinary tract fistulas can form between any part of the urinary tract and structures in the thoracic cavity, the abdominal cavity, the pelvis, and the skin.
Etiology
- Colovesical fistula:
- Usually complication of primary GI disease such as diverticular disease (most common), Crohns disease, or colon carcinoma
- Iatrogenic (postsurgical or radiation treatment most common)
- Urethral disruption from trauma
- More common in males
- Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
- Vesicovaginal fistula is the most common acquired fistula of the urinary tract
- Etiology varies with geography (developed vs. developing countries):
- In developed countries it is usually due to injury to the structures during surgery, pelvic pathology, radiation therapy, or injuries incurred in the healing process. Radiation-induced fistulas may not present for months to years after exposure.
- In developing countries it is usually due to obstructed labor and obstetric trauma.
Diagnosis
Signs and Symptoms
- Colovesical fistula:
- Chronic or recurrent UTIs
- Suprapubic pain
- Abnormal urine: Pneumaturia, fecaluria, hematuria, malodorous urine, debris in the urine (food particles)
- Vesicovaginal fistula:
- If after surgical procedure, may present on removal of urinary catheter or 1 " 3 wk post procedure
- Usually painless
- Constant urine leakage from the vagina (may be confused with urinary incontinence)
- Perineal skin irritation due to urine leakage
- Urethrovaginal fistula:
- Symptoms largely dependent on size and location of fistula
- May be asymptomatic or with continuous vaginal urine drainage
- Ureterovaginal fistula:
- Usually a history of recent surgery, particularly a complicated hysterectomy
- Abdominal or flank pain, fever, and ileus. If these symptoms present, likely due to urinoma or renal obstruction
- Intermittent urine leakage from vagina
History
- A thorough past medical, surgical, and obstetric history to determine risk factors
- Description and timing of presumed urinary discharge: Intermittent or positional usually due to ureterovesical fistula; continuous flow more likely to be from vesicovaginal fistula.
- Characteristics of presumed urinary discharge
- Associated symptoms
Physical Exam
- Colovesical fistula:
- There might be findings consistent with the primary GI disease; otherwise physical exam is frequently unremarkable
- Vesicovaginal, urethrovaginal, ureterovaginal fistulas:
- Speculum exam may reveal a small reddened area of granulomatous tissue at site of the fistula opening. May also see pooling of the urine in the vaginal vault.
Essential Workup
Must evaluate for associated urinary infection, renal obstruction, or acute emergencies related to primary disease processes (e.g., complications from a malignancy or Crohns disease).
Diagnosis Tests & Interpretation
Lab
- Urinalysis:
- Colovesical fistula:
- WBCs, bacteria, and debris
- Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
- BUN and creatinine:
- If renal obstruction is present, might be abnormal.
Imaging
- Usually not an emergent need to image and would discuss with specialist
- Colovesical fistula:
- CT of the abdomen and pelvis with contrast
- Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
- Cystoscopy with retrograde pyelography or IVP
Diagnostic Procedures/Surgery
- Usually an outpatient workup
- Colovesical fistula:
- Oral administration of activated charcoal will result in black particles in urine, which can be diagnostic.
- Vesicovaginal, urethrovaginal, ureterovaginal fistulas:
- Double-dye test: (1) Tampon is placed in vagina, (2) oral phenazopyridine is administered, (3) methylene blue or indigo carmine is instilled into the bladder, (4). if, after an hour, tampon is yellow-orange at the top, ureterovaginal fistula is suggested. Midportion blue discoloration suggests vesicovaginal fistula. Distal blue discoloration suggests urethrovaginal fistula.
Differential Diagnosis
- Colovesical fistula:
- Recurrent UTI
- Other causes of pneumaturia:
- UTI with gas-forming organism such as clostridia
- Fermentation of diabetic urine
- Recent urinary tract instrumentation
- Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
- Urinary incontinence
- Normal vaginal discharge
- Vaginitis
Treatment
Initial Stabilization/Therapy
Treat urosepsis (rare) with IV fluid bolus, pressors, and IV antibiotics as appropriate.
Ed Treatment/Procedures
- Colovesical fistula:
- Evaluate for complications from patients primary disease.
- Obtain cultures if there are signs of UTI.
- Initiate antibiotic if infection is found.
- Urgent urologic referral for further management and possible surgical treatment.
- Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
- Consider placing urinary catheter
- Initiate antibiotics if a UTI is present.
- Urgent referral to urologist and gynecologist for further care
Follow-Up
Disposition
Admission Criteria
- Sepsis
- Inability to take oral antibiotics if needed
- Acute emergencies from primary GI disease or malignancies
Discharge Criteria
- No evidence of sepsis
- Able to tolerate oral antibiotics if UTI present
Followup Recommendations
Urogenital specialist (Urology or Gynecology) follow-up is required.
Pearls and Pitfalls
- Suspect a urinary tract fistula in the patient with the appropriate risk factors (usually a complicated recent pelvic surgery) and recurrent UTIs
- In the presence of urinary tract fistula, malignancy is always an important diagnostic consideration
- Urine leakage from the vagina may be confused with urinary incontinence
Additional Reading
- Basler J. (2012, Jan 23). Enterovesical fistula. Retrieved from www.emedicine.com.
- Garely AD, Mann WJ Jr. (2012, Jul 30). Vesicovaginal, urethrovaginal, and ureterovaginal fistulas. Retrieved from www.uptodate.com.
- Katz VL. Urinary fistula. In:
Comprehensive Gynecology. 5th ed. St. Louis, MO:
Mosby; 2007. - Vasavada SP. (2011, Sep 14). Vesicovaginal and ureterovaginal fistula. Retrieved from www.emedicine.com.
- Wein AJ. Urinary tract fistula. In: Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders; 2007.
See Also (Topic, Algorithm, Electronic Media Element)
UTIs, Adult
Codes
ICD9
- 596.1 Intestinovesical fistula
- 599.1 Urethral fistula
- 619.0 Urinary-genital tract fistula, female
- 596.2 Vesical fistula, not elsewhere classified
ICD10
- N32.1 Vesicointestinal fistula
- N36.0 Urethral fistula
- N82.0 Vesicovaginal fistula
- N82.8 Other female genital tract fistulae
- N82.1 Other female urinary-genital tract fistulae
SNOMED
- 57243009 urinary fistula (disorder)
- 28626004 Vesicocolic fistula (disorder)
- 89405008 Vesicovaginal fistula (disorder)
- 37532005 Ureterovaginal fistula (disorder)
- 236697004 Acquired urethral fistula (disorder)
- 50477003 Urethrovaginal fistula (disorder)