Sexual Function After Vaginal and Abdominal Fistula Repair

Abstract

Vesicovaginal fistulae (VVFs) are uncommon. Urinary loss in women with VVF occurs immediately after surgical trauma, at 7 to 30 days after hysterectomy or cesarean delivery, and up to 30 years after irradiation. Permanent urinary leakage has a devastating impact on a woman’s health, hygiene, psyche, quality of life, and sexuality. Initial management usually includes a trial therapy with bladder drainage. Because spontaneous closure with drainage occurs in only 7% to 15% of patients, most fistulae are managed surgically. Two surgical routes are used: transvaginal and transabdominal. The latter allows for an open, laparoscopic, or robotic procedure. Studies assessing fistula repair usually report anatomical outcomes without examining quality of life or sexual function outcomes. Despite the adverse impact of incontinence on sexual function, few data are available that analyze sexual function before and after fistula repair. The aim of this study was to compare clinical outcomes and sexual function between the transvaginal and transabdominal repair procedures in women with VVF. Between January 2002 and May 2013, 99 women with VVF were treated at a tertiary referral center in Switzerland. Initial treatment was use of urinary catheterization for 12 weeks. Patients whose fistula did not heal underwent surgical repair with either the transvaginal (Latzko) (n = 60) or transabdominal (n = 31) technique. Both subjective and objective clinical outcomes were analyzed. Subjective outcomes were recorded prospectively before surgery and at the 6-month follow-up examination using the female sexual function index to evaluate sexual function and the visual analog scale to assess general disturbance by the fistula. The primary study outcome was sexual function. Secondary outcomes included continence, quality of life, operation time, blood loss, and length of hospital stay. There was spontaneous fistula closure after 12 weeks of bladder drainage in 8 of the 99 patients. Demographic variables were evenly distributed in both the transvaginal and the transabdominal repair groups. Prior to surgery, 64 of the 99 patients were sexually active with a greater percentage active in the abdominal group. Patients in the transvaginal group had significantly shorter operation times, less blood loss, and shorter hospital stay than those in the transabdominal group (P < 0.001 for all comparisons). Six months after surgery, continence was achieved in 82% of the transvaginal and 90% of the transabdominal group (P = 0.28). With both operative techniques, there was a significant improvement in sexual function in the 64 sexually active patients, as well as a reduction in the overall disturbance by the fistula. Neither surgical intervention showed superiority to the other with respect to sexual function or visual analog scale scores. These data show significant improvement in sexual function and quality of life with both fistula repair methods, with no significant differences in outcomes between the routes. Because of the shorter operating time, length of stay, and reduced blood loss with the transvaginal approach, this route is preferred for VVF repair provided that fistula and patient characteristics are suitable.