| Vesicouterine fistula | |
|---|---|
| Other names | Youssef syndrome[1] Menouria |
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| Specialty | Urogynaecology |
| Causes | Lower segment caesarean section |
| Differential diagnosis | Endometriosis |
Vesicouterine fistula refers to an abnormal communication between the bladder and uterus. The first case of vesicouterine fistula was reported in 1908.[2] It was however first described in 1957 by Abdel Fattah Youssef, an obstetrician and gynaecologist in Kasr el-Aini hospital,Cairo,Egypt. It is characterized by a vesicouterine fistula above the level of the internal os,absence of menstrual bleeding, cyclicalpresence of blood in urine and absence ofurinary incontinence with a patentcervical canal following a lower segment caesarean section.[1][3] Six of such cases had been reported by other clinicians before the term Menouria was coined by Youssef.[3]
Vesicouterine fistula is the least common type of urogenital fistula accounting for 1-4% of urogenital fistulas.[1] It occurs followinglower segment caesarean section and the incidence is increasing due to the increasing incidence of caesarean deliveries. The occurrence of menoruria in the absence of vaginal bleeding or passage of urine from the vagina is attributed to a sphincteric mechanism of theuterine isthmus.[3]
Jozwik and Jozwik classified vesicouterine fistula into three types based on the route of menstrual flow;[4]
Youssef syndrome corresponds to a type I vesicouterine fistula.[5]
Vesicouterine fistulas occur most commonly after lower segment caesarean sections (about 83-93% of cases).[2] The possible mechanisms by which vesicouterine fistulas occur following caesarean sections include undetected bladder injury during caesarean section, inadvertent placement of a suture through the bladder during the repair of the uterus and abnormal blood vessel connections following multiple caesarean sections.[5]
It may also present following use ofobstetric forceps,manual placenta removal,external cephalic version,morbidly adherent placenta,surgical removal of fibroids,rupture of the uterus,perforation of the uterus andradiation therapy in the treatment of cervical cancer.[1]
Vesicouterine fistula can also occur as abirth defect in conjunction withvaginal atresia.[6][7]
The diagnosis of a vesicouterine fistula is made by demonstrating an abnormal connection between the cavities of the bladder and uterus.[2] It can be diagnosed usinghysterosalpingography, hysterography, cystography,magnetic resonance imaging (MRI) andcomputerised tomography.[1] MRI has been found to have 100% accuracy in the diagnosis of vesicouterine fistula. It is also less invasive than other modalities and is considered thegold standard for diagnosis.[8]
The options of treatment includewatchful waiting for spontaneous resolution of the fistula, use of medications that can stop menstrual periods such asoral contraceptive pills,progesterone and gonadotropin releasing hormone analogs. Surgery can be carried out through the vagina, bladder or peritoneum and can be done vialaparoscopic or robotic surgery.[8]
Watchful waiting is the treatment of choice in case of small fistulas. The bladder iscatheterised for a period of 4 to 8 weeks in order to allow spontaneous closure of the vesicouterine fistula.Fulguration of the fistula can also be done via cystoscopy in cases of small fistulas.[2]