Fistulous Connection Research Articles

Clinical presentation and treatment outcomes of spinal epidural arteriovenous fistulas.

OBJECTIVE Spinal epidural arteriovenous fistulas (SEDAVFs) constitute a rare but treatable cause of vascular myelopathy and are a different subtype from the more common Type I spinal dural AVFs. The purpose of this study was to review a consecutive series of SEDAVFs from a single institution and report on the clinical presentations, functional status, and treatment outcomes. METHODS The authors identified all SEDAVFs treated at their institution from 2005 to 2015. SEDAVFs were defined as spinal AVFs in which the fistulous connection occurred in the epidural venous plexus. The clinical presentation, functional status, immediate treatment outcomes, and long-term neurological outcomes were analyzed. RESULTS Twenty-four patients with SEDAVFs were included in this study. The patients' mean age at presentation was 66.9 years. The most common presenting symptoms were pain and numbness (22 patients, 91.7%), followed by lower-extremity weakness (21 patients, 87.5%). The mean duration of symptoms prior to diagnosis was 11.8 months. Eighteen patients (75.0%) were treated with endovascular therapy alone, 4 (16.7) with surgery, and 2 (8.3%) with a combination of techniques. There was 1 major treatment-related complication (4.2%). Fifteen patients (62.5%) had improvement in disability, and 12 patients (54.5%) had improvement in sensory symptoms. CONCLUSIONS SEDAVFs often present with lower-extremity motor dysfunction and sensory symptoms. With the availability of newer liquid embolic agents, these lesions can be effectively treated with endovascular techniques. Surgery is also effective at treating these lesions, especially in situations where endovascular embolization fails or is not safe and in patients presenting with mass effect from compressive varices.

The prevalence of coronary artery anomalies on CT scan; Experience from a tertiary care center in Pakistan (RCD code: I-1C.1)

Objectives This study is an effort to bridge the gap regarding the data of prevalence of coronary anomalies in South Asian countries by utilizing coronary CT angiography. Methods This is a cross sectional, descriptive study done at Aga Khan University Hospital Karachi, Pakistan. All adult patients who underwent coronary CT angiography from 1-1-2005 to 1-11-2016 were included in the study. Results Among 897 patients undergoing CCTA, 36(4.01%)patients were identified as having coronary artery anomalies(CAA). The mean age of patients was 48.3±11.9 years. Male to female ratio was 3:1. Among patients with coronary anomalies, the most common indication for CCTA was screening for coronary artery disease(58.3%). 33 patients(3.67%) showed coronary origin and course anomalies, whereas coronary artery fistula were identified in 3 patients(0.3% of cases). The most common anomaly identified was the anomalous origin of coronary artery from opposite coronary sinus with anomalous course(1.4%) with anomalous origin of RCA from the left coronary sinus with an inter-arterial course seen in 9 patients. Single coronary artery was seen in three cases(0.3%), in all these cases the single coronary artery originated from the right coronary cusp. In one patient (0.1%) dual LAD system was identified. Coronary artery fistulas were seen in 3 patients (0.3%).In two cases(0.2%) fistulous connection of LAD with pulmonary artery was seen, while fistula from LAD to coronary sinus was identified in one patient. Conclusions This study highlights the fact that the prevalence of coronary anomalies on CCTA in this region is similar to the reported data from rest of the world.

Application of fluorescein sodium videoangiography in surgery for spinal arteriovenous malformation

We present our recent experience with fluorescein sodium videoangiography (FLVA) in the intra-operative evaluation of a patient with conus medullaris arteriovenous malformation (AVM). To our knowledge this is the first report in the literature of use of FLVA in the surgery of spinal AVM. Intra-operative FLVA was done to identify an early filling vessel and to obliterate the site of fistulous connection. This was correlated and confirmed with simultaneous indocyanine green videoangiography (ICGVA). The conus and cauda equina roots could be appreciated and manipulated in relation to this fluorescence. Obliteration was confirmed with FLVA and correlated with ICGVA. There was no untoward reaction to the dye injection. We conclude that FLVA is a useful adjunct in the surgical treatment of conus medullaris AVMs since it is a real time, noninvasive, radiation-free, easily reproducible technique allowing surgical manipulation through the operating oculars with simultaneous visualization of surrounding critical structures.

The dual microcatheter technique for transvenous embolization of dural arteriovenous fistulae

BackgroundDural arteriovenous fistulae (dAVFs) comprise 10–15% of all intracranial arteriovenous malformations. The goal of surgical or endovascular intervention is complete obliteration of the fistulous connection(s). In cases where dAVF venous...

A rare case of congenital thoracic arteriovenous fistula between the brachiocephalic truncus and the superior vena cava resulting in heart failure

Abstract We present a case of a full-term 13 days old female baby administered to the PICU with extreme tachypnea with suspicion of a huge left-to-right-shunt at vascular or cardiac level. Echocardiography revealed an open arterial duct and a huge arterio-venous fistula from the proximal right subclavian artery directly into the superior vena cava. The fistula was cross-clamped, resected and both vesselstumps were oversewn. Histopathologically the fistula presented either as an artery of the elastic type or an arterialized vein, which is a typical finding in fistulas. The patient was extubated shortly after repair and referred home five days after surgery. To the best of our knowledge, this is first report of a direct fistulous connection between the brachiocephalic trunk (proximal to the right subclavian artery) and the SVC with congestive heart failure and ASD.

P.119 Minimally invasive surgical disconnection of a spinal dural arteriovenous fistula with the use of intraoperative digital subtraction angiography

Background: Spinal dural arteriovenous fistulas (dAVF) are a significant but treatable cause of progressive myelopathy. The goal of treatment is disconnection of the fistula, which is often accomplished through an open surgical approach. We report two cases using a minimally invasive surgical (MIS) approach for dAVF ligation with intraoperative digital subtraction angiography (DSA) to confirm occlusion. Methods: Case report. Results: Two patients presented with progressive thoracic myelopathy and were identified to have fistulous connections at the left L1 and T8 levels respectively. Intraoperatively, a left femoral puncture was performed and a 5-French (40 cm) sheath was inserted. Patients were positioned prone and intraoperative spinal DSA was performed using the Siemens Zeego. Once the feeding radicular artery was visualized, image overlay and cross-hair laser was used to trace and localize the fistulous zone. A unilateral single level MIS hemi-laminectomy was performed. The fistulous zone and accompanying nerve root were exposed and small hemostatic clips were applied followed by surgically disconnection. Finally, intraoperatively video angiography as well as spinal DSA were performed for confirmation. Conclusions: MIS disconnection with intraoperative DSA is a safe and effective technique for treating spinal dAVFs. Patients benefit from quicker recovery and shorter hospital stay.

Spinal vascular malformations: treatment strategies and outcome.

Spinal vascular malformations (SVMs) are a heterogeneous group that can cause acute, subacute, or chronic spinal cord dysfunction. The majority of the patients present to neurosurgical attention after a protracted course with severe neurological dysfunction. Spinal vascular lesions comprise approximately 3-4% of all intradural spinal lesions. They are pathologically similar to their intracranial counterparts, but their clinical impact is often comparatively worse. Early, correct recognition of the pathology is mandatory to halt the progression of the disease and minimize permanent spinal cord injury. The first clinical observation of a SVM was published in 1890, but it was not until 1914 that the first successful surgical treatment of a spinal vascular malformation was reported. Intervention-either by microsurgical or endovascular means-aims to halt or reverse the progressive neurological deterioration by eliminating flow through the abnormal fistulous or nidal connections, and restoring normal spinal cord perfusion and intravascular pressures. In fact, complex spinal arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) frequently require a multimodality approach that utilizes both microsurgery and endovascular embolization effectively. The goal of this review is to describe the various types of vascular malformations of the spine, their pathophysiology, clinical presentation, treatment strategies, and outcome. For purposes of discussion on the current manuscript, vascular malformations of the spine were divided into arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs). Spinal cord aneurysms are extremely rare, and the majority of the lesions that come to the neurosurgeon's attention are concomitant to a spinal AVM.

Surgical Management of Spinal Dural Arteriovenous Fistulae with Intraoperative Indocyanine Green Angiography: Single Institute Experience

Introduction Spinal dural arteriovenous fistula (DAVF) is the most common vascular malformation of the spinal cord. We performed an observational study of patients with spinal DAVF who were treated by microsurgical obliteration with intraoperative indocyanine green (ICG) angiograph with the aim of complete obliteration of the fistulae. Material and Methods 10 patients were included from May 2012 to May 2015. They were treated surgically with intraoperative intravenous administration of ICG. Direct microsurgical exploration was employed to identify the intradural fistulous connection and intravenous ICG was then injected to verify the identification of the lesion. Repeat ICG angiography was performed after the fistula had been obliterated using bipolar electrocautery. Results In all patients, ICG angiography correlated reliably with preoperative catheter angiography and intraoperative direct visualization and the fistulous connection was identified and successfully treated surgically. Conclusion ICG angiography in the setting of surgical management of spinal DAVF is a simple and effective technique for intraoperative confirmation of the relevant lesion. Post resection ICG angiography reliably demonstrated technical success and may replace formal postoperative catheter angiography.

An unusual cause for recurrent perianal sepsis in Currarino syndrome: Case report and review of the literature

Abstract Currarino syndrome (CS) is a rare symptom complex comprising an anorectal malformation, a sacral bone abnormality and a presacral mass. Recurrent sepsis of the perianal area is a well-described post-operative morbidity. We report the case of a 4-year-old boy with CS and chronic perianal sepsis in the form of a draining sinus at the level of S5, which had plagued him since removal of a benign sacrococcygeal teratoma at the age of 1 year. Normal alfa feto protein and beta-human chorionic gonadotropin levels ruled out malignant recurrence of a sacrococcygeal teratoma, whilst an MRI showed a large presacral abscess with no fistulous connection to the rectum. Biopsy and drainage of the abscess was performed through a posterior sagittal approach and pus was sent for microscopy, culture and sensitivity. Microscopy demonstrated the presence of acid-fast bacilli, confirming infection with Mycobacterium tuberculosis (TB). A review of the literature revealed paucity in the documentation of microbes related to this common complication with no previous reports of TB as the aetiological pathogen. This case is of particular interest as the patient was not immunocompromised, had no TB contacts or history of previous TB infection, and highlights the importance of actively excluding the cause of recurrent perianal sepsis, particularly in syndromes where sepsis is a common complication.

Portal Vein Thrombosis and Arterioportal Fistula in Post Liver Transplant Recipient: A Case Report

An intrahepatic Arterioportal Fistula Refers (APF) to abnormal shunt or fistulous connection between the portal venous system and a hepatic arterial system within the liver. Here, we present a case of portal vein thrombosis with APF in post-transplant liver, developed 2 years and 6 months after transplantation. The condition was diagnosed by Triphasic CT angiography. In this case report we have discussed various causes and pathophysiology of APF with its imaging findings.

Surgical Strategies for Acutely Ruptured Arteriovenous Malformations.

Brain arteriovenous malformations (AVMs) are focal neurovascular lesions consisting of abnormal fistulous connections between the arterial and venous systems with no interposed capillaries. This arrangement creates a high-flow circulatory shunt with hemorrhagic risk and hemodynamic abnormalities. While most AVMs are asymptomatic, they may cause severe neurological complications and death. Each AVM carries an annual rupture risk of 2-4%. Intracranial hemorrhage due to AVM rupture is the most common initial manifestation (up to 70% of presentations), and it carries significant morbidity and mortality. This complication is particularly important in the young and otherwise healthy population, in whom AVMs cause up to one-third of all hemorrhagic strokes. A previous rupture is the single most important independent predictor of future hemorrhage. Current treatment modalities for AVM are microsurgery, endovascular embolization, and radiosurgery. In acutely ruptured AVMs, early microsurgical excision is usually avoided. The standard is to wait at least 4 weeks to allow for patient recovery, hematoma liquefaction, and inflammatory reactions to subside. Exceptions to this rule are small, superficial, low-grade AVMs with elucidated angioarchitecture, for which early simultaneous hematoma evacuation and AVM excision is feasible. Emergent hematoma evacuation with delayed AVM excision (unless, as mentioned, the AVM is low grade) is recommended in patients with a decreased level of consciousness due to intracranial hemorrhage, posterior fossa or temporal lobe hematoma of >30 ml, or hemispheric hematoma of >60 ml. The applicability of endovascular techniques for acutely ruptured AVMs is not clear, but feasible options, until a definitive treatment is determined, include occluding intranidal and distal flow-related aneurysms and 'sealing' any rupture site or focal angioarchitectural weakness when one can be clearly identified and safely accessed. Radiosurgery is not performed in acutely ruptured AVMs because its therapeutic effects occur in a delayed fashion.

Triple Lumen Esophagus

A 55 year-old-lady with history of HIV (CD 4+ count 268/ μL) was evaluated for a one day history of hematemesis. She had long-standing history of dysphagia and had history of G tube placement as a child. EGD on admission revealed ulcerated and friable distal esophageal mucosa. Blood was seen in the stomach and the area could not be examined well due to blood clots. Biopsy specimens from esophagus showed acute and chronic inflammation. Candida was seen however the stains for CMV, HSV I and II were negative. AFP smear and cultures were negative. An Esophagram was performed which showed collection of contrast material at aortic arch, likely secondary to contrast within a fistulous connection. There were also a few linear collections of contrast in the expected location of the gastroesophageal junction, also likely within tiny fistulous tracts. [Figure 1A].Figure 1Follow up EGD at 10 weeks showed a long mucosal bridge in the mid esophagus, giving esophagus a shape of double lumen [Figure 1B]. The distal esophagus near the GE junction separated into three lumens. [Figure 1C] One was true GE junction and other two were fistulous tracts. The gastroscope itself could not be traversed through the fistulous tracts. Retroflexion showed openings of both fistulous tracts into stomach evident from secretions coming out of fistulous tracts. [Figure 1D]. Biospy specimens from the mucosal bridge in mid esophagus showed squamous mucosa with atypia and parakeratosis. Esophagogastric fistula is a rare condition. Term double lumen esophagus has been used for esophagogastric fistulas in literature when a neo-lumen is formed in the esophagus due to fistula. Only a few cases have been reported in literature. Our patient has two esophagogastric fistulas giving rise to a triple lumen esophagus. Typically patients with EG fistulas present with symptoms of dysphagia and have history of GERD, esophageal ulcers, strictures and dilations. Esophageal Crohn's disease, carcinoma, fungal and viral infections needs to be ruled out in these patients with biopsy specimens and special staining. Treatment options include aggressive control of reflux disease and treatment of specific etiologies, which may be responsible for fistulas. Surgery remains the last option since these patients are generally poor surgical candidates due to repeated interventions and presence of inflammation. Our patient was treated with PPI BID. She has improved symptoms of dysphagia. She is scheduled for a CT scan of chest and abdomen and a repeat EGD to access for healing and repeat biopsies.

An Case of Perforated Gastric Gastrointestinal Stromal Tumor (GIST) Complicated by Bacteremia and Liver Abscess

Introduction: GIST is one of the most common mesenchymal tumors in the gastrointestinal (GI) tract closely related to the interstitial cells of Cajal and generally express c-KIT (CD114), a tyrosine kinase receptor. The most common locations are the stomach (40%-60%), small intestine (30%-40%), anorectum (7%), colon, and esophagus, as well as in extra-GI locations such as mesentery, omentum, and peritoneum(< 5%). We report a case of metastatic and perforated gastric GIST complicated by streptococcus bacteremia and hepatic abscess. Body: A 73 year old male presented with generalized weakness. At admission, he was febrile to 100.7F with RUQ tenderness. Imaging revealed peritoneal implants, a mass like process with air inseparable from the wall of the stomach near the fundus measuring 10 cm and left lobe liver mass measuring 6.4 cm (Fig 1). The patient was started on broad spectrum antibiotics. Blood cultures grew streptococcus intermedius (viridans group). Liver mass biopsy specimen revealed fragments of necrotic tissue and liver parenchyma without viable tumor. Endoscopy revealed a ˜3 cm perforated ulcer which appeared to be communicating with fundal mass (Fig 2). Pathologic showed poorly differentiated tumor with epithelioid and stromal features, CD117 +, CD34 +, cytokeratin - and CD45- compatible with GIST. Patient was ruled out for endocarditis and received antibiotics for total of 6 weeks. The patient was managed non surgically and repeat imaging (Fig 3) at 3 months showed marked improvement on Imatinib.Figure 1Figure 2Figure 3Discussion: GIST are well circumscribed tumors which may exhibit an exophytic or an endophytic pattern compromising bowel lumen patency. Mucosal necrosis and ulceration can be seen in GISTs with an endophytic component. Approximately 10-30% of GISTs are malignant and have intra-abdominal spread. The propensity of a GIST to become malignant depends on the primary anatomic site. Regardless of size and malignancy status, GISTs have a tendency to disrupt GI mucosal integrity, forming a conduit through which colonizing bacteria gain access to the portal and systemic circulation, resulting in bacteremia and liver abscess. A hematogenous source should be suspected if streptococcus or staphylococcous species are identified. Cystic degeneration, necrosis, and focal hemorrhage have been described in larger GIST accounting for the observed central necrotic cavitation resulting in fistulous connections with nearby structures, including the gastric lumen. There are only few case reports of a perforated gastric GIST, despite a higher overall incidence of GISTs in stomach. In our case, we suspect that the infection seeded from the GIST and should be included in the differential diagnosis in patients with suspected abdominal neoplasm and bacteremia.

A Rare Cause of Chronic Post-prandial and Recumbent Cough: Gastro-pulmonary Fistula Post Oesophagectomy

We present a case of 75 years old male who underwent oesophagectomy for T3N2 adenocarcinoma. He developed post-op anastomotic leak requiring further surgery and subsequent covered oesophageal stent insertion, which was removed 4 months later. He required multiple OGDs and balloon dilatation for anastomotic stricture. 8 months post-op, an OGD showed non-malignant peptic ulceration of upper stomach. This healed subsequently. He then developed recumbent cough and was treated with multiple courses of antibiotics for x-ray proven right basal pneumonia. He improved clinically, however he continued to have cough which particularly comes when he lies down or after his meals. Repeat OGD showed a rare appearance of a gastro-pulmonary fistula as a cause for his symptoms. This was confirmed on CT. The biopsies were negative for malignancy. He was discussed in MDT and was seen by upper GI surgeons who are managing him conservatively due to his comorbidities. Our patient presented with 2 month history of cough after meals and on lying flat. He denied any significant reflux symptoms. He was given repeated courses of antibiotics by GP for chest infection which temporarily improved his symptoms. Past medical history includes myocardial infarction, protein C deficiency, recurrent DVTs and pulmonary emboli, IVC filter in situ. He was a non-smoker and drank alcohol only on occasions. His investigation consisted of, Blood tests showed mild leucocytosis, normocytic anaemia, raised CRP. CXR showed right basal consolidation. OGD showed fistulous connection between proximal stomach and lungs, the gastropulmonary fistula (Figure 1). A CT scan showed fistulous connection of stomach with right lung, right basal consolidation and effusion (Figure 2 & 3).Figure 1

Register based study of anorectal anomalies over 26 years: Associated anomalies, prevalence, and trends.

Anorectal anomalies are atresias or stenoses of the anal canal and rectum with or without fistulous connections with the bladder, urethra, perineum, or vestibule. The aim of this study was to describe the epidemiology of anorectal anomalies, including associated anomalies, prevalence, and temporal trends. Anorectal anomalies occurring in late miscarriages (>20 gestation weeks), terminations of pregnancy for fetal anomaly (any gestation), stillbirths (≥24 gestation weeks) and live births, delivered from 1985 to 2010, notified to the Northern Congenital Abnormality Survey (NorCAS) were included in this population-based case series. There were 278 cases among 892,194 live births. Twenty (7.2%) cases occurred in twin pregnancies and 24 (8.7%) with chromosomal anomalies/genetic syndromes were excluded. There were 234 cases (total prevalence = 2.7, 95% confidence interval [CI]: 2.4, 3.1 per 10,000 live and stillbirths). There was no evidence of a trend in prevalence over time (Chi(2) test for trend: p = 0.789). There was a male predominance (70.9%). Of the 234 cases, 167 (71.4%) were live born, two (0.9%) were late miscarriages, seven (3.0%) were stillbirths, and 58 (24.8%) were terminations of pregnancy for fetal anomaly. There was no significant association with maternal age at delivery (p = 0.095). 7.2% of isolated cases (cases with no other congenital anomalies) were diagnosed prenatally. The prevalence of anorectal anomalies in this study is comparable to other case series. There was no evidence of a temporal increase in prevalence. We confirmed a male predominance of anorectal anomalies and no significant association with maternal age. Birth Defects Research (Part A) 103:597-602, 2015. © 2015 Wiley Periodicals, Inc.

Fatal Hemoptysis Due to Undiagnosed Pulmonary Tuberculosis

Although tuberculosis is a major infectious cause of morbidity and mortality worldwide, death from tuberculosis is uncommon in the United States. Sudden death due to this infection is most frequently a result of tuberculous pneumonia or massive hemoptysis. There are multiple etiologies for massive hemoptysis in pulmonary tuberculosis, including aneurysm formation, bronchial arteritis, lung cavitation, and tuberculous lymphadenitis. The identification of the exact anatomic etiology of massive hemoptysis, such as a fistulous connection or erosion of a pulmonary artery into a bronchus, is rare. We present a case of sudden death due to massive hemoptysis due to erosion of a pulmonary artery into a bronchus as a result of undiagnosed pulmonary tuberculosis.

Spontaneous intracranial hemorrhage in children – ruptured lobar arteriovenous malformations: report of two cases

Abstract Brain arteriovenous malformations (AVMs) are lesions thought to be primarily congenital in origin, consisting of fistulous connections of abnormal arteries and veins, without normal intervening capillary beds and no cerebral parenchyma between vessels. In the pediatric population, AVMs represent the most common cause of spontaneous intracranial hemorrhage (ICH), with a high recurrent bleeding risk. The aim of this paper is to report 2 cases of ruptured lobar AVMs in children, presenting with spontaneous ICH. Due to the patients’ neurological status, the only imaging examination performed preoperatively was a CT scan, showing intraparenchymal hemorrhage. Thus, there was no MRI/angiographic examination to prove the existence of a brain AVM prior to the surgical interventions. Also, the cerebral angiography performed after the surgery showed, in both patients, no signs of residual vascular malformations. Therefore, the diagnosis of AVM was certified by macroscopic and microscopic pathological findings, with no brain imaging suggestive of a vascular malformation.

Ruptured Sinus of Valsalva Aneurysm into the Left Atrium with Multiple Fistulous Communications: A Rare Cause of Heart Failure.

Ruptured noncoronary sinus of valsalva aneurysm with fistulous connections to multiple cardiac chambers has not been reported previously. We report a 66-year-old man who presented with worsening cough and exertional dyspnea. Transesophageal echocardiogram confirmed a large aneurysm involving the noncoronary cusp of the aortic sinus with aneurysmal extension to the left atrium. There were also two fistulous communications with the left atrium and one small fistulous connection with the right atrium. Open-heart surgery with aortic root replacement and reimplantation of coronary arteries along with primary closure and repair of aorta to the left atrial fistula was performed.

Rare congenital cardiac anomaly presenting with predominant respiratory complaint: A case report

Introduction: coronary cameral fistula is a rare anomaly where there is a fistulous connection between coronary artery and one of the cardiac chambers. It generally presents with predominant cardiac complaints or as accidental finding in an asymptomatic individual. Our patient presented chiefly with respiratory complaint and was misdiagnosed as tuberculosis. case report: A 22-year-old female presented in chest OPD with complains of cough and fever since one month and was started on anti-tubercular treatment since one month. On examination there was continuous murmur, thrill and coarse crackles in right axillary area. On chest X-ray there was a multi-lobulated mass in the right side with upper zone linear and cystic opacities. computed tomography (ct) scan of thorax showed right

Transverse vaginal septum with menouria and unilateral renal agenesis-case report

Transverse vaginal septum is a rare condition that results from abnormalities in the vertical fusion between the vaginal components of the Mullerian ducts and the urogenital sinus. Associated menouria as a result of a fistulous connection of the vagina with the bladder is even rarer. A case is presented of a 22 year old unmarried woman who in addition to presenting with primary amenorrhea, complete transverse vaginal septum and cyclic hematuria, also had unilateral renal agenesis and a corrected congenital imperforate anus. A surgical correction is described as well as simple measures during follow-up that ensured non-contracture of the excision site. The fistulous connection between the bladder and upper vagina closed spontaneously. The patient has since been having normal menses for the past 15 months with no associated hematuria. The vagina has remained patent since. We conclude that for cases of transverse vaginal septum associated with menouria excision of the septum that ensures normal outflow of menstrual blood is sufficient to facilitate spontaneous closure of the fistulous connection between the bladder and vagina.