Shereen Zulfiqar Bhutta ( Department of Obstetrics and Gynaecology. Jinnah Postgraduate Medical Centre, Karachi. )
Vesicouterine fistulae account for Ito 4% genitourinaiy fistulae1. They are primarily a complication of lower segment Caesarean section and were extremely rare till 19472 . The incidence has gone up since then, because of increasing rates of Caesarean sections2-5. Unlike other gcnitourinaiy fistulac, urinary incontinence is not an integral feature ofavesicouterine fistula1,2,4,6. When the defect is above the level of internal os, the woman is continent but the menstrual flow is diverted to the bladder causing haematuria. This phenomenon of cyclic haematuria, apparent amenorrhoea, in the presence of a patent cervix with urinazy continence is referrd to as Youseff’s syndrome7. Youseff coined the term \\\'Menouria\\\' for vesical menstruation in these cases. This article describes five women with Menouria presenting to the department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi over the last seven years.
A 28 year old pam 3+0 presented with painless haematuria lasting 5 days for the last 3 months. The last delivery was 8 months earlier, her third Caesarean section with tubal ligation. There was no other urinar complaint. She was amenorrhoeic since delivery. Physical examination, laboratory investigations and intravenous pyelogram (IVP) were unremarkable. Ultrasound examination showed a communication between the bladder and uterus just above the cervix (Figure 1).
This was confirmed by hysterography and cystoscopy. A total abdominal hysterectomy with bladder repair in two layers was done. The bladder was drained for 10 days with a Foley’s catheter. She remains free of symptoms 7 years later.
A 41 year old pam 6+0 admitted in shock following prolonged obstructed labour at home, had emergency laparatorny. The stillborn foetus weighing 4.2 kg was removed from the peritoneal cavity. The transverse rupture in the lower uterine segment resembling a Caesarean section incision, as well as a 4 cm transverse rupture in the bladder base were repaired in two layers and tubal ligation was done. Bladder was drained continuously with a Foley’s catheter. Despite a patent catheter, urinary leakage through the vagina was noticed on the seventh post-operative day. A gentle examination through the still open cervical os revealed the bulb of the catheter palpable through a small defect through the site of the rupture. Bladder drainage was continued for another three weeks. Urinaiy leakage ceased and she went home completely continent. She reported back after 12 weeks, with two episodes of frank haematuria lasting 4 days at a month’s interval. Cystoscopy showed a 2 cm central vesicouterine fistula 2 cm above the trigone. The patient refused further evaluation and treatment. She remains well 6 years later with persistent cyclic haeniaturia, preferring it to the previous more cumbersome way of managing her menstmal periods.
A 22 year old para 2+0 had delivered by second Caesarean section 9 months back. For the last 3 months she had frank painless haernaturia lasting 4 to 5 days every month and was amenorrhoic since Caesarean section. The physical examination, laboratory investigations and IVP were normal. Cystoscopy showed a 1 cm vesicouterine fistula 1.5 cm above the trigone and hysterography demonstrated spill of contrast medium into the bladder (Figure 2).
She was prescribed the combined oral contraceptive containing 0.05mg oestradiol, continuously for 6 months to suppress menstruation. She remained asymptomatic during this period but haematuria recurred on stopping the pill. Repair was carried out through the transabdominal transperitoneal route, exposing the fistulous tract, mobilising the bladder off the uterus, cervix and uppervagina Both the organs were repaired in two layers. The bladder was drained for 12 days by Foley’s catheter. Normal menstruation resumed following surgety. She has subsequently had deliveiy of a term baby by elective caesarean section alongwith tuballigation.
A 26 year old pam 1+0 had an elective caesarean section for breech presentation 10 months earlier. She presented with painless gross haematuria lasting 6 days on two occasions a month apart and was amenorrhoic since Caesarean section. No abnormality was detectable on examination, laboratory investigations and IVP. Cystoscopy showed a 0.5 cm vesicouterine fistula 2 cm above the trigone, which was also demonstrable on hysterography (Figure 3).
Continuous administration of the combined oral contraceptive containing 0.05 mg ocstradiol, resulted in resolution of cyclic haematuria and return of normal menstruation. She has since had a live birth by an elective Caesarean section at term and remains free of symptoms.
A 26 year old para 2+0 had second Caesarean section 20 months. earlier. She remained amenorrhoeic after stopping breast feeding but had frank painless haematuria every month lasting 3 to 4 days. The examination and IVP were uninformative. Ultrasound cystoscopy and hysterography confirmed the fistula between the bladder base and uterus above the cervix. Examination under anaesthesia after instilling 150 ml of dye showed no abnormality, but on putting another 300 ml of dye into the bladder, the same was seen escaping through the cervix7. A transperitoneal abdominal repair of the bladder and uterus after adequate mobilisation was carried out in two layers (Figure 4).
Foley’s catheter was left in the bladder for 12 days. There was no haematuria post-operatively and normal menstruation resumed. The couple are using barrier contraception presently.
A vesicouterine fistula presenting with vesical menstruation and urinary continence was first reported in 19358. Various mechanisms have been postulated for this. These include the presence of an isthniic sphinctor7, granulations on the posterior uterine wall occluding the internal uterine orifice1,9 and the intrauterine pressure being higher than the intravesical pressure6. Diagnosis can be made by a non-invasive technique like ultrasound, as in two of our cases, but the mainstay remains hysterography and cystoscopy. The latter is essential to determine the exact. location of the fistula in the bladder and determine its relationship to the uretenc orifices. An 1\\\\TP may not assist in diagnosis, but is mandatory to know the status of the upper urinary tract.
Spontaneous closure of the fistula has been reported4,10-13 and is worth waiting in fistulae presenting early. Suppression of menstruation with hormone therapy is another conservative treatment associated with favourable outcome3,5,7 and cured one of our patients. interestingly vesical menstruation itself does not necessarily cause harm14-17.
Cystopscopic fulgration of the fistula is a feasable option18 for women not desiring further pregnancies3. An- other alternative for them is abdominal hysterectomy and bladder repair. For those who wish to retain fertility, repair should be able to svithstand the stress of subsequent pregnancies. This is best carried out transperitoneally thmugh thc abdominal route, with or without an interposed omental graft1-3 Fertility following repairwas thought to be extremely low19, but this is not çormboratcd by others20 or us. The two women in this report who had subsequent pregnancies conceived within three months of discontinuing contraception.
Vesicouterine fistual is a rare but largely preventable complication of Caesarean section. Complete preoperative emptying and adequate intraoperativereflectionofthebladder from the uterus, with timely recognition and repair of any injury to the bladder minimises such complications.
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