Urinary Fistula

Introduction

A urinary fistula is a devastating condition that causes urine to leak out from the bladder or urethra into an unwanted area such as the vagina or rectum. They are often associated with recurrent urinary tract infections and/or leakage. The most common causes of urinary fistula are from prior surgery or radiation.

Anatomy

Bladder Fistula. This a connection between the bladder and an another location such as the colon or vagina. Urine from the bladder leaks out into the unwanted area.

Ureteral Fistula. This is a connection between the ureter (the drainage tube from your kidney to your bladder) and another location such as an artery, vein, colon, small intestine, and/or vagina.

Urethral Fistula. This is a connection from your urethra (the channel you urinate from) to another location - typically the skin also known as a urethrocutaneous fistula. Alternatively, the urethral can fistulize to your rectum which results in leakage of urine in your stool.

Prostatic Fistula. This is a connection between a man’s prostate and usually the rectum. This is often a complication from prior surgery or radiation.

Causes

The most common cause of a urinary fistula is prior surgery. This may go unrecognized for several weeks or months or even years until you develop leakage of urine or other symptoms. Alternatively, another common cause is radiation to the pelvis.

Symptoms

The most common symptoms of a urinary fistula are leakage of urine and recurrent urinary tract infections. You may also experience air bubbles in your urine (called pneumaturia) or seeing stool material in your urine (called fecaluria).

Work up and Evaluation

The diagnosis of a urinary fistula requires a thorough understanding of your anatomy and prior surgeries or radiation.

• A urine sample will be sent to a lab for analysis. This test checks for infection or other issues in the urinary tract.

  Complete blood count. Another way to look for indicators of infection.

• Dye test. The patient’s bladder is filled with a dye and the patient coughs or bears down. The doctor then can look for bladder leakage from a fistula by checking for dye in the vagina.

• Cystoscopy (a long, thin device with a camera) to view inside the urethra and bladder to look for fistulas or other damage.

• Retrograde pyelogram. Similar to the excretory urogram, this test uses dye and x-rays to check specifically for leakage between the vagina and a ureter.

• A fistulogram is an x-ray image specifically of the fistula(s) that can indicate whether one or more fistulas exist, and which organs the fistula affects.

• Computerized tomography (CT) urogram. This test is similar to an excretory urogram, but uses dye injected into a vein so the physician can evaluate the vagina and lower urinary tract. The images are created via CT scan rather than x-ray.

• Cystogram: Bladder fills with contrast dye to evaluate for the location of urinary leakage with x-rays.

Treatment

Surgical treatment of a urinary fistula is dependent on many factors including the location of the fistula, the patient’s anatomy, the types of prior surgeries, prior radiation, and overall health.

Bladder Fistula. Repair of a bladder fistula is often performed with surgery. If the fistula is small, endoscopic repair may be considered. If the fistula is large, excision of the fistula tract and closure is often most successful. Placing healthy donor tissue (i.e. muscle or fat) in between the excised fistula tract will prevent recurrence. Often, the DaVinci Robot is used to perform this operation in the least invasive fashion.

Ureteral Fistula. This is a rare fistula that may often go misdiagnosed for many months. New and small fistulas may heal themselves simply by diverting the urine with a ureteral stent which can be placed endoscopically. Larger and more chronic ureteral fistulas must be repaired with surgery. In some instances, a segment of the ureter must be removed and reconstruction of the urinary tract is necessary.

Urethral Fistula. A urethral fistula can be repaired by removing the open tract between your urethra and skin. Depending on the location and size of your urethral fistula, a graft or local tissue may be used to help strengthen the repair.

Prostatic Fistula. Repair of a prostatic fistula is often accomplished with surgery. Depending on a patient’s goals and prior treatment(s), surgery may be performed to re-route the urinary system completely away from the bladder altogether (urinary diversion). Alternatively, a definitive repair of the fistula may be performed. In the later case, often a healthy graft of muscle from the thigh is used to separate the prostate from the rectum to prevent fistula recurrence.