Ureterovaginal Fistula Following Hysterectomy – A Clinical and Nursing Management Case Report
Najrin1, Pavithra2, Rn Gowdham P3
1Registered Nurse, Kauvery Hospital, Marathahalli
2Registered Nurse, Kauvery Hospital, Marathahalli
3Senior Nurse Educator, Kauvery Hospital, Marathahalli
Abstract
Background:
Ureterovaginal fistula (UVF) is a rare urogenital complication that results from abnormal communication between the ureter and the vagina. It most commonly occurs as an iatrogenic injury following pelvic surgeries such as hysterectomy. This condition leads to continuous leakage of urine from the vagina, which can severely affect a woman’s quality of life if left untreated.
Case Presentation:
A 43-year-old female presented with continuous urinary leakage for 1.5 years following abdominal hysterectomy. There were no symptoms of infection or pain. Clinical examination and cystoscopy confirmed a ureterovaginal fistula. The patient underwent vesicovaginal repair with bilateral DJ stenting under general anesthesia. Postoperative management included antibiotics, analgesics, antispasmodics, and intensive nursing care.
Conclusion:
Early diagnosis and surgical correction are key to successful outcomes. This case highlights the importance of careful surgical technique during hysterectomy, multidisciplinary postoperative management, and the critical role of nurses in infection prevention, psychological support, and rehabilitation.
Keywords: Ureterovaginal fistula, hysterectomy complication, vesicovaginal repair, nursing care, DJ stenting
Introduction
A ureterovaginal fistula (UVF) is an abnormal tract between the ureter and vagina that causes continuous urinary leakage while the patient continues to void normally through the bladder.
The majority of cases are iatrogenic and occur after pelvic surgeries such as total abdominal hysterectomy, caesarean section, or other gynecological procedures.
Although uncommon, the psychosocial and hygienic implications are profound. Continuous leakage leads to perineal irritation, infection, embarrassment, and psychological distress.
Surgical repair remains the mainstay of treatment, and early diagnosis combined with comprehensive nursing care greatly improves the prognosis.
Anatomy and Physiology
Anatomy of the Female Urinary System
The urinary system consists of:
Kidneys — Bean-shaped organs filtering blood to form urine.
Ureters — Muscular tubes (~25–30 cm long) that convey urine from the kidneys to the bladder.
Urinary Bladder — A hollow, muscular organ that stores urine.
Urethra — Conducts urine from the bladder to the exterior.
The ureters pass close to the uterine arteries near the cervix — an important surgical landmark. During hysterectomy, inadvertent ligation or thermal injury to the ureter can result in ischemia or transection, leading to fistula formation.
Physiology of Micturition
Formation: Urine forms in nephrons and flows via ureters to the bladder.
Storage: The bladder holds 400–600 mL of urine.
Emptying: Stretch receptors trigger the micturition reflex → detrusor contracts, sphincter relaxes.
Control: Parasympathetic stimulation initiates voiding; sympathetic and somatic nerves inhibit it.
In UVF:
Urine from one ureter bypasses the bladder entirely → continuous leakage through the vagina, independent of bladder control.
Kidney → Ureter → (Fistulous connection to Vagina)
↓
Continuous leakage
History of Present Illness
The patient presented with a complaint of continuous urine dripping for 1.5 years following abdominal hysterectomy.
There was no fever, dysuria, hematuria, or suprapubic pain. The leakage was continuous and unrelated to micturition urge, suggestive of a fistulous communication.
Past History
Surgical: Hysterectomy 1.5 years ago
Medical: No diabetes, hypertension, or tuberculosis
Family History: Non-contributory
Assessment findings
| Parameter | Finding |
|---|---|
| Height | 155 cm |
| Weight | 58 kg |
| Appearance | Alert, oriented |
| Vital Signs | Stable |
| Scalp/Eyes/Ears/Nose | Normal |
| Chest | Clear; S₁ and S₂ present |
| Abdomen | Soft, mild tenderness present in hypogastric region , no organomegaly |
| Urethra | Continuous urine dribbling |
| Back & Extremities | Normal symmetry |
| Perineum | Wet, no ulceration or wound |
Investigation :
| Parameter | Result | Reference | Interpretation |
|---|---|---|---|
| Hemoglobin | 11.6 g/dL | 12–15 | Mild anemia |
| WBC Count | 8,680 cells/µL | 4,000–11,000 | Normal |
| Platelets | 2.3 × 10⁵/µL | 1.5–4.5 × 10⁵ | Normal |
| Differential Count | N 64.8%, L 22.4%, E 6.0% | Normal range | Mild eosinophilia |
RFT
| Parameter | Result | Reference Range |
|---|---|---|
| Urea | 21.4 mg/dL | 10–50 |
| Creatinine | 0.75 mg/dL | 0.5–1.4 |
| Uric Acid | 4.3 mg/dL | 2.6–6.0 |
Serum electrolytes
| Parameter | Result | Reference Range | Interpretation |
|---|---|---|---|
| Sodium (Na⁺) | 140 mmol/L | 132 – 145 mmol/L | Normal |
| Potassium (K⁺) | 3.7 mmol/L | 3.5 – 5.0 mmol/L | Normal |
| Chloride (Cl⁻) | 103 mEq/L | 98 – 107 mEq/L | Normal |
PT / INR
| Test | Result | Reference Range | Interpretation |
|---|---|---|---|
| PT (Prothrombin Time) | 13.6 sec | 10.5 – 13.5 sec | Within normal limits |
| INR (International Normalized Ratio) | 1.16 | 0.8 – 1.2 | Normal coagulation profile |
Serology
| Test | Result | Reference / Expected | Interpretation |
|---|---|---|---|
| HIV (Rapid) | Non-reactive | Non-reactive | Negative |
| HBsAg (Hepatitis B Surface Antigen) | Negative | Negative | Non-infected |
| HCV (Hepatitis C Virus) | Non-reactive | Non-reactive | Negative |
Diagnostic Imaging
Cystoscopy: Demonstrated ureteric leakage into the vaginal vault confirming ureterovaginal fistula.
Final Diagnosis
Ureterovaginal fistula secondary to hysterectomy.
Treatment and Surgical Management
Surgical Procedure
Vesicovaginal fistula (VVF) repair with bilateral DJ stenting under general anesthesia.
Steps:
- Identification and mobilization of fistula tract.
- Dissection of bladder from vaginal wall.
- Layered closure of bladder and ureteral repair.
- Insertion of DJ stents bilaterally.
- Foley catheter for continuous drainage.
Other surgical considerations
| Surgical Measure | Indication / Use | Brief Description |
|---|---|---|
| Ureteroneocystostomy (Ureteric Reimplantation) | For fistulas involving the distal ureter (near bladder wall). | The affected ureter is reimplanted into a new site on the bladder wall to restore proper drainage. Often combined with a psoas hitch to reduce tension. |
| Psoas Hitch Procedure | When the ureter length is shortened or tension exists after injury. | The bladder is mobilized and sutured to the psoas muscle to bridge the gap between ureter and bladder for tension-free anastomosis. |
| Boari Flap (Bladder Tubularization Flap) | For long ureteric defects (middle or upper third). | A tubular flap of bladder wall is created and extended upward to reimplant the ureter; maintains good blood supply. |
| Transureteroureterostomy (TUU) | For extensive ureteral injury or when bladder mobilization is not possible. | The injured ureter is connected to the opposite healthy ureter, allowing urine drainage into the contralateral side. |
| Ureteroureterostomy | For localized mid-ureteral injuries. | Direct end-to-end anastomosis of the healthy ureteral ends after excising the damaged segment. |
| Laparoscopic / Robotic Repair | For patients requiring minimally invasive approaches. | Fistula closure and ureteric reimplantation can be performed laparoscopically, offering less pain, blood loss, and quicker recovery. |
| Martius Flap Interposition | For recurrent or radiation-induced VVF. | A vascularized labial fat pad flap (Martius flap) is interposed between bladder and vagina to reinforce healing and prevent recurrence. |
| Omental or Peritoneal Flap Interposition | For high or complex fistulas. | A segment of omentum or peritoneum is used between bladder and vaginal suture lines for added vascularity. |
| Transvaginal VVF Repair | For low, simple fistulas. | Done through vaginal approach; less invasive, faster recovery, suitable for small, non-radiation-induced fistulas. |
| Transabdominal VVF Repair | For high, complex, or multiple fistulas, or when ureteric involvement is present. | Requires abdominal access for exposure, often combined with ureteral reimplantation and stenting. |
| Diversion Procedures (Temporary) | In cases where definitive repair is delayed or infection persists. | Temporary urinary diversion using percutaneous nephrostomy (PCN) or ureteric stent to allow healing and protect kidneys before final surgery. |
| Latzko Partial Colpocleisis | For high vaginal or small vesicovaginal fistulas. | Partial closure of upper vaginal vault while preserving urinary tract function — used in select cases. |
| Endoscopic Fulguration / Fibrin Glue Closure | For very small fistulas (<5 mm). | Minimally invasive method where the fistula tract is cauterized or sealed endoscopically with fibrin glue. |
| Augmentation Cystoplasty (if bladder capacity reduced) | For recurrent or radiation-induced fistulas with bladder contracture. | Bowel segment is used to enlarge bladder volume and facilitate closure. |
Reason behind the selection of the surgery is Vesicovaginal fistula (VVF) repair with bilateral DJ stenting.
| Reason | Explanation |
|---|---|
| Low, localized fistula | Best managed by direct VVF repair |
| Healthy tissue, no infection | Allows successful primary closure |
| Normal kidney function | No need for upper-tract reconstruction |
| No prior radiation | Simple closure suffices without tissue flaps |
| Single, small fistula | Direct repair gives high success |
| Bilateral DJ stents | Ensures ureteral drainage and protection during healing |
| High success rate, low morbidity | Evidence-based standard for such cases |
Postoperative Care and Nursing Management
| Category | Care / Medication |
|---|---|
| Antibiotics | Inj. Supacef 1.5 g IV 12-hourly |
| Analgesics | Inj. Paracetamol 1 g IV, Inj. Metrogyl 500 mg, Jonac suppository 100 mg |
| Proton Pump Inhibitor | Inj. Pantoprazole 40 mg |
| Antispasmodic | Tab. Soliten 5 mg OD |
| Laxative | Cremalax 10 mg HS |
| Iron Supplement | Oral |
| Diet | Soft diet, high protein |
| Local Care | Sitz bath twice daily, perineal hygiene |
Nursing Interventions
1. Preoperative Care
- Explain procedure and reduce anxiety.
- Maintain hydration and bowel preparation.
- Ensure perineal hygiene to prevent infection.
- Educate patient about postoperative catheterization.
2. Postoperative Care
- Maintain aseptic dressing and catheter care.
- Record intake and output meticulously.
- Observe urine flow, color, and stent patency.
- Provide analgesics and monitor pain scale.
- Encourage early ambulation once stable.
- Support emotional well-being and privacy.
3. Health Education
- Advise on genital hygiene.
- Avoid sexual activity until complete healing.
- Report symptoms like fever, pain, or discharge.
- Continue follow-up for stent removal and evaluation.
Discussion
This case illustrates a delayed presentation of ureterovaginal fistula post-hysterectomy — one of the recognized iatrogenic complications of pelvic surgery.
The ureter’s proximity to uterine vessels during hysterectomy makes it susceptible to inadvertent injury. If unrecognized intraoperatively, leakage typically manifests days to months later.
In this patient, normal renal function indicated no obstruction, supporting early repair. Cystoscopy confirmed diagnosis and localization.
The VVF repair with DJ stenting provided excellent recovery.
Nursing care was pivotal in postoperative management — ensuring infection control, maintaining catheter patency, and providing psychological comfort to restore the patient’s dignity and self-esteem.
Conclusion
Ureterovaginal fistula is a rare but distressing postoperative complication. Early recognition and prompt surgical repair ensure complete recovery and preservation of renal function.
This case emphasizes:
The importance of surgical precision during hysterectomy, Early cystoscopic evaluation in cases of continuous leakage, and holistic nursing care as a cornerstone for recovery and quality of life restoration.
References
- Berek JS. Berek & Novak’s Gynecology, 17th ed. Lippincott Williams & Wilkins, 2020.
- Campbell MF, Wein AJ. Campbell-Walsh Urology, 12th ed. Elsevier, 2021.
- Mahapatra S, et al. Urogenital fistulas following obstetric and gynecologic surgery. Indian J Urol. 2023;39(2):89-95.
- World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection, 2023.
