Transperineal ultrasonographic diagnosis of vesicovaginal fistula.

Abstract

Vesicovaginal fistula is a known postoperative complication of gynecologic and obstetric abdominal and vaginal procedures. 1,2 Infrequently, vesicovaginal fistulas may result from bladder invasion by pelvic organ malignant processes. 2 We present an unusual case in which a patient with advanced vaginal squamous cell carcinoma had presenting features of urinary incontinence, vaginal bleeding, and pain. A vesicovaginal fistula was depicted by transperineal ultrasonography. CASE REPORTA 44 year old para 1 woman was referred because of complaints of constant urinary incontinence, vaginal pain, and bleeding of 6 months' duration. Her past medical history consisted of benign thyroid goiter, current cocaine abuse, and cigarette smoking of 10 years' duration. Physical examination on admission revealed a cachectic female in no acute distress, weighing 85 lb, with normal vital signs. Pertinent physical findings included a soft, nontender abdomen with no palpable masses. Pelvic examination disclosed a normal introitus and a 3 to 4 cm fungating mass replacing the lower anterior vaginal wall, encasing the urethra, with a palpable indentation suggestive of a possible urinary fistula. The uterine cervix was normal in appearance, size, and palpation. A normal-sized uterus and adnexa were palpated. Biopsy of the vaginal mass revealed squamous cell carcinoma. Cervical Papanicolaou smear was indicative of high-grade squamous epithelial lesion, for which the patient underwent a loop electroexcision procedure, which was negative for invasion. Owing to the lower location of the tumor, the constant urinary incontinence, and the concern about a possible vesicovaginal fistula, transperineal ultrasonography was performed. A 5 MHz transvaginal probe attached to an ATL Ultramark 9 HDI machine (Advanced Technology Laboratories, Bothell, WA) was placed transperineally and axial, sagittal, and parasagittal views were obtained. Varying degrees of angulation were used for the axial views. This procedure allowed the imaging of a vesicovaginal fistula (Figs. 1, 2).After extensive counseling the patient underwent examination under anesthesia and proctoscopy. Cystoscopy, although planned, was not attempted owing to the tumor's obstruction of the urethra. Exploratory laparotomy was performed, and multiple positive bilateral pelvic lymph nodes were encountered. Because of advanced metastatic disease, pelvic exenteration was not attempted. However, a diverting transverse colon conduit was performed. The patient's postoperative course was complicated by febrile morbidity of unknown cause. She was discharged after an otherwise uneventful postoperative course.

Transvaginal sonographic diagnosis of a tumor fistula

“…Traditionally, the imaging modalities employed to make the diagnosis of a urinary‐vaginal fistula would include intravenous pyelography, cystography and cystoscopy. It has been shown that this diagnosis can be made by transvaginal and transperineal sonography3, 4. Color Doppler with contrast media was shown to facilitate the diagnosis5.…”

“…Urogenital fistula is an infrequent complication of obstetric, gynecological and urological surgery as well as of genitourinary malignancy1, 2. Abulafia et al described a case of a cancer‐related vesicovaginal fistula diagnosed by transperineal sonography3.…”