• Most common is vesicovaginal fistula
• Industrialized - 2/2 iatrogenic
• Other - 2/2 childbirth (obstructed labor)
• Pressure necrosis and tissue ischemia to pelvic floor
• 12% of vesicovaginal fistula will have ureterovaginal fistula
• Ureterovaginal
• Urethrovaginal
• Enterovesical fistula
• Diverticulitis most common (1-4% rate of fistulas after)
• Crohn's (2-5%)
• Maligancy (0.5%)
• Rectourethral fistula
• 0.2-3% after prostatectomy, increase with HIFU, brachytherapy
• Urovascular fistula
• Uretero-iliac artery fistula
• Hx indwelling stents, radiation, vascular disease/surgery
• Vigorous hematuria...
• Vesicouterine fistulas (most common after C sections)
• Cyclic hematuria

• Constant/intermittent wetness
• Perineal skin irritation/fungal infections
• Recurrent UTI
• Pain is not as common
• Symptom onset can be immediately after catheter removal to 3 weeks post-op if iatrogenic (eg cautery injury); if 2/2 radiation can be years later

• Exam - speculum exam, can give pyridium or put methylene blue in the bladder
• Double dye test - give pyridium PO and methylene blue in bladder, and tampon in vagina. If vesicovaginal, will be blue. If ureterovaginal, will be orange (pyridium)
• Other tests - VCUG, CT IVP, MR, CT cystogram, cystoscopy (needs to have distended bladder)
• SUI (intrinsic sphincter deficiency) can be mistaken for fistula
• ?malignancy as etiology
• Ureterovaginal fistula - unilateral hydronephrosis/flank pain from partial obstruction; clear vaginal drainage
• Urethrovaginal fistula - VCUG. If distal to sphincter then usually no symptoms/no intervention needed

Colovesicular fistula - recurrent UTI, fecaluria, pneumaturia, hematuria

• Poppy seed test is most sensitive/specific test; cystoscopy, barium enema, cystogram
• Need to exclude malignancy
• Bowel rest, TPN, surgery (colorectal surgery)

• Small VVF (< 3-5 mm)
• Indwelling Foley (most successful if 2-3 mm)
• If remains after 3 weeks of Foley, unlikely to close
• If < 5 mm, fulguration (to get rid of epithelium)/fibrin glue plug?
• Surgical management
• If inflamed/infected - wait 3-6 months. Otherwise early intervention
• Transabdominal vs transvaginal based on comfort of surgeon
• Treatment principles: excise the tract, absorbable sutures, multiple layer closure with tension free non-overlapping suture lines, tissue interposition
• Transabdominal 
• Pfannenstiel vs lower midline incision
• Dissect to bladder, cystotomy
• Find fistula, develop plane between bladder and vagina
• Tissue interposition with omentum, peritoneum, or rectus flap
• Transvaginal
• Cysto to find fistula, pass wire through
• Incise around fistula, excise tract
• Multiple layers - bladder, perivesical fistula, flap (Martius, peritoneal, gracilis muscle), close vaginal wall (perpendicular lines to not overlap)
• Martius flap (labial fat pad) - prefer to keep on blood supply from internal pudendal, so keep the pedicle inferior
• Post-op - FOley 2-3 wks with cystogram prior to removal, leave an abdominal drain, anticholinergics/b3 agonist

Ureterovaginal fistula

• Stent 6-8 weeks, perc if not getting better
• Definitive repair - any ureteral reconstruction (reimplant, psoas hitch, Boari, etc)