Bladder Fistulas

A bladder fistula (also called enterovesicular fistula) is an abnormal channel between the interior of the urinary bladder and other areas.

The channel (fistula) may form as a result of a birth (congenital) defect, damage done during surgery (surgical trauma), prolonged labor, or as a result of certain diseases that can occur in the genital/urinary (genitourinary) system. There are a number of different types of bladder fistulas. These fistulas may form a connection between the bladder and the vagina (vesicovaginal), the skin of the abdomen (vesicocutaneous), or the intestinal tract. Fistulas that connect to any part of the intestine are collectively referred to as vesicoenteric fistulas. Fistulas between the bladder and intestine can occur at the colon (colovesical, most common), rectum (rectovesical), ileum (ileovesical), or the appendix (appendicovesical). The result of any of these conditions is a free exchange of fluids between the bladder and the area connected by the fistula.

Risk Risk factors for vesicovaginal fistulas include gynecological procedures such as surgical removal of the uterus (hysterectomy), pelvic or uterine surgery, pelvic irradiation, pelvic infections (pelvic inflammatory disease), congenital abnormality, or obstetric trauma. Other risk factors may include cancer (malignancy) in the pelvic region, prolonged labor, physical distortion of the bladder or uterus by an abnormal growth (mass) on the ovary, or abnormal tissue growth in the pelvic region (endometriosis).

Risk factors for colovesical, rectovesical, ileovesical, or appendicovesical fistulas include gastrointestinal inflammatory diseases (diverticulitis, Crohn's disease, ulcerative colitis, appendiceal/pelvic abscess, Meckel's diverticulum), diseases that produce abnormal growth in the gastrointestinal or urogenital tracts (colorectal cancer, lymphoma, AIDS, cervical cancer, leiomyosarcoma of the bladder), and trauma to organs within the pelvic region (gunshot wound, penetrating injury, pelvic fracture, open surgery).

Vesicocutaneous fistula is a less severe type of bladder fistula. Risk factors include obstruction of the urinary bladder or bladder cancer and trauma.

Colovesical fistula is the most common type of vesicoenteric fistula, affecting men 3 times as often as women, presumably because the uterus helps prevent fistula formation between the urinary bladder and large intestine.

Incidence and Prevalence Estimated incidence of vesicovaginal fistula after hysterectomy is from 1 to 10 women per 1,000 (Harris 1995; Gilmour 1999).

Approximately 50% to 70% of enterovesicular fistulas are caused by diverticulitis. Bowel cancer accounts for another 20%, and 10% are due to Crohn's disease {"Bladder Fistula"}.

History Individuals with a vesicovaginal fistula complain of urinary drainage from the vagina; there may be an unpleasant ammonia odor associated with the drainage. Individuals with enterovesicular fistulas may report pain in the lower abdomen, chills, fever, diarrhea, constipation, blood in the urine (hematuria), increased frequency and urgency of urination, and pain during urination (dysuria). They also may notice passage of urine through the rectum or the presence of mucus or feces in their urine.

Physical exam There are few physical findings with bladder fistula. A vesicovaginal fistula may be observed on gynecologic examination, especially if dye is used. An abdominal mass is felt (palpated) in a third of individuals. There may be some abdominal tenderness and tightening of the abdominal muscles (guarding) in response to pressure. In females, a pelvic examination may reveal inflammation and tenderness. Irritation of the abdominal skin may be observed in individuals with vesicocutaneous fistula.

Tests Tests may include urinalysis, urine culture, and observation of the inside of the urinary bladder by insertion of a flexible fiber-optic microscope through the urethra and into the bladder (cytoscopy). Adding a dye to the bladder can help to localize the site of the fistula in the vagina. A retrograde pyelogram, an x-ray using a contrast dye to enhance the images of the ureters and bladder, is also useful. A CT scan is the preferred imaging study for colovesical fistulas. Injection of barium (a contrast medium) into the large intestine followed by x-rays (barium enema) may help to distinguish diverticular disease from cancer.

In some cases, a small (less than 1 centimeter) bladder fistula will close and heal spontaneously after insertion of a urinary catheter (conservative treatment) to divert the urine. Bladder fistulas must usually be repaired surgically either as a single operation (single-stage) or multiple operation (multistage) procedure. A single-stage procedure is recommended for healthy individuals with good nutrition, no areas of infection (abscess) or severe inflammation, and without multiple organ involvement. Multistage procedures may be used for complicated bladder fistula.

A vesicovaginal fistula can be repaired surgically using a vaginal, abdominal, or combined approach. A vesicoenteric fistula is repaired surgically using a low abdominal incision and the diseased bowel and part of the bladder is removed (York-Mason procedure). For all surgical treatments of bladder fistula, an indwelling urethral catheter allowing urine to pass is necessary during the healing period.

Surgical treatment of bladder fistula corrects the condition most of the time. In a few cases, the fistula recurs and can usually be managed conservatively with bladder catheterization and observation. Spontaneous closure of a bladder fistula after insertion of a bladder catheter occurs in some cases.

Restrictions on heavy physical labor such as lifting and climbing may be needed after surgery for bladder fistula repair. Bathroom facilities should be readily available. No work restrictions or special accommodations should be required after the individual makes a complete recovery.

Possible complications of bladder fistulas include spontaneous bleeding (hemorrhage), inflammation of tissues in the abdominal cavity (peritonitis) and infection of the fistula itself. Any underlying conditions that cause an increase in urinary bladder distention and pressure such as bladder neck obstruction may impact an individual's ability to recover and further lengthen disability.

A bladder fistula is usually the result of an underlying disease state. The severity of this underlying condition influences the length of disability. Type of surgical treatment (i.e., single-stage or multistage procedure) also affects length of disability. Older individuals may have a longer disability time following surgery, since postoperative recovery times are often slower. Duration of disability depends on job requirements and treatment.

Heavy labor is restricted following surgery until recovery is complete.

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

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