Endoscopic Conservative Treatment for an Ureterovaginal Fistula Caused by Foreign Body

Deleon E

doi:10.23937/2377-9004/1410020

Abstract

Foreign body placement in the vagina is a rare cause of ureterovaginal fistula. A fistula is often due to an unrecognized injury to the ureter, most commonly after gynecologic pelvic surgery, such as during hysterectomy for benign indications. This manuscript will discuss a case of a 34-year-old African American female who presents with a history of sexual assault and a one month history of urinary incontinence. Physical examination revealed clear liquid in the vaginal vault and a malodorous foreign body embedded in the vaginal mucosa. Cystoscopy ultimately confirmed a left ureterovaginal fistula. A CT cystogram was performed after removal of the foreign body, which demonstrated the size and location of the fistula. A cystoscopy, retrograde pyelography and fistulography were all performed. The patient’s kidney function was determined to be adequate with estimated creatinine clearance and the appearance of symmetric uptake of contrast on CT scan. The patient’s symptoms resolved after conservative treatment with JJ catheter stent placement for six weeks. Therefore, conservative endoscopy treatment should be considered for small fistulae. Trauma from sexual assault may be physical and emotional, and therefore, a multidisciplinary approach to treatment is paramount.

Highlights

Urogenital fistulae are abnormal connections between the urogenital system and adjacent structures and organs
The ureter is at greatest risk of injury in the distal three centimeters, as it courses through a tunnel in the cardinal ligament over the anterior vaginal fornix to enter the bladder near the cervix
The types of injury leading to ureterovaginal fistulae include: partial and complete ureteral transection, thermal injury from electrocautery, ischemic injury caused by suture ligation, crush injury from clamp trauma or damage to the delicate periureteral blood supply

Summary

Introduction

Urogenital fistulae are abnormal connections between the urogenital system and adjacent structures and organs These fistulae are often caused by an unrecognized injury to the ureter. The ureter is at greatest risk of injury in the distal three centimeters, as it courses through a tunnel in the cardinal ligament over the anterior vaginal fornix to enter the bladder near the cervix. The patient stated a history of sexual assault during which a foreign object was placed in the vagina and was not removed. Pelvic CT scan revealed a thin curvilinear shaped foreign body within the vagina containing internal fluid and air and an increased soft tissue thickening between the urinary bladder and anterior vaginal wall. The patient received a CT cystogram after removal of the foreign body, which demonstrated the size and location of the fistula.

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Findings

Discussion