© 2002 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 21:817-819 • 0278-4297
Sonographic Diagnosis of a Uterovesical Fistula
Shankar Ramamurthy, MD, DMRD,
Padmanabha Vijayan, MS, FRCS and
Shashikala Rajendran, MD, DGO
Saint Philomena's Hospital (S.Ram., P.V., S.Raj.) and Hopkins Memorial Ultrasound Scan Centre (S.Ram.), Bangalore, India.
Address correspondence and reprint requests to Shankar Ramamurthy MD, DMRD, Hopkins Memorial Ultrasound Scan Centre, 10/3 Queens Rd, Bangalore 560 052, India.
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Introduction
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A uterovesical fistula is a rare complication after cesarean delivery or difficult labor. We present a case of uterovesical fistula diagnosed on the basis of sonohysterography.
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Case Report
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A 24-year-old woman, gravida 3, para 3, had cyclic menouria. She had undergone a lower segment cesarean delivery in 1997, followed by a normal vaginal delivery 1 year later. The following year, she had a traumatic delivery by forceps resulting in neonatal death. The cyclic menouria developed after that. Clinical examination and laboratory investigations were unremarkable.
Abdominal and endovaginal sonography showed a large defect in the anterior myometrium in the lower body of the uterus (Fig. 1 ). The adjacent wall of the urinary bladder also appeared deficient without any area of thickening in the adjacent bladder wall. The rest of the endometrium, myometrium, and urinary bladder wall appeared normal. Both kidneys were normal without obstruction.
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Figure 1. Sagittal abdominal sonogram of the pelvis showing a large defect (arrow) in the anterior uterine wall and adjacent wall of the urinary bladder. CX indicates cervix; UB, urinary bladder; and UT, uterus.
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Sonohysterography was performed at the time of menses. The patient was placed in the lithotomy position, and the cervix was visualized with the help of a Sims speculum and an anterior vaginal wall retractor. The cervix was grasped with Volsellum forceps. It was cleaned with povidone-iodine. A Leech-Wilkinson– type cannula was introduced into the cervical canal after expelling air from it with saline. The speculum was removed carefully, and an ATL C9-5 endovaginal probe (Philips Ultrasound, Bothell, WA) was introduced into the vagina. Saline was injected into the cannula, and simultaneously the uterus was scanned in the longitudinal plane. The saline freely entered the urinary bladder in a jet through the deficiency in the myometrium, confirming the uterovesical fistula (Fig. 2).
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Figure 2. Sonohysterogram showing saline jetting into the bladder (arrow). CX indicates cervix; UB, urinary bladder; and UT, uterus.
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Cystoscopy revealed a hyperemic area with granulation tissue measuring about 5 mm on the posterior wall of the bladder, cranial to the trigone on the left side above and medial to the left ureteral orifice. A 5F infant feeding tube could be advanced through this area for a distance of about 2 cm. Surgical repair was done, which produced complete relief of symptoms.
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Discussion
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A uterovesical fistula is known to be a complication after cesarean delivery, curettage,1–3 difficult vaginal delivery, migration of an intrauterine contraceptive device,4 and high delivery by forceps.5 The condition is rare, representing about 1% to 4% of urogenital fistulae. To our knowledge, only about 30 cases have been reported, and other background information has also been published in the literature.6–9 Our case followed difficult delivery by forceps. The patient had no urinary incontinence.
Modalities for diagnosing and showing the fistula have included abdominal and endovaginal scanning,10 contrast-enhanced hysterosalpingography,10 cystoscopy, intravesical instillation of methylene blue,1 intrauterine insufflation of air, transperitoneal transvesical fistulography, and, rarely, intravenous urography. In this case, abdominal and transvaginal sonography gave fairly confirmatory evidence of the uterovesical fistula. Sonohysterography further confirmed the fistula by showing the actual flow of saline from the uterine cavity into the urinary bladder.
We have presented the sonographic and sonohysterographic findings in a case of a uterovesical fistula. To our knowledge, this is the first report of the sonohysterographic diagnosis of a uterovesical fistula. Because visualization of the pathologic areas in the uterus and bladder was so good on abdominal and endovaginal sonography, we thought that sonohysterography might show the fistula in real time.
The advantages of this procedure are that it is simple to perform, it can be done on an outpatient basis, and the fistula can be visualized in real time. There are no hazards of radiation, and our patient tolerated the procedure well, with no side effects. We do not foresee any disadvantage to this procedure.
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Footnotes
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Received December 3, 2001, from Saint Philomena's Hospital (S.Ram., P.V., S.Raj.) and Hopkins Memorial Ultrasound Scan Centre (S.Ram.), Bangalore, India.
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References
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- Kafetsoulis AA. A case of vesico-uterine fistula. Br J Urol 1974; 46:587.[Medline]
- Henriksen HM. Vesicouterine fistula following cesarean section. J Urol 1981; 125:884.[Medline]
- Buckspan MB, Simha S, Klotz PG. Vesicouterine fistula: a rare complication of cesarean section. Obstet Gynecol 1983; 62(suppl 3):64s–66s.[Abstract]
- Nel JT, Louw NS, Winterbach HP. Youssef's syndrome: a case report. J Urol 1985; 133:95–96.[Medline]
- Falk HC, Tancer ML. Management of vesical fistulas after cesarean section. Am J Obstet Gynecol 1956; 71:97–106.[Medline]
- Hache L, Pratt JH, Cook EN. Vesicouterine fistula. Mayo Clin Proc 1966; 41:150–158.[Medline]
- Mohan V, Gupta SK, Arora M. Cysto-uterine fistula. Br J Urol 1983; 55:245–246.[Medline]
- Pawar HN. Management of vesicouterine fistula following cesarean section. Urology 1985; 25:66–68.[Medline]
- Park BK, Kim SH, Cho JY, Sim JS, Seong CK. Vesicouterine fistula after cesarean section: ultrasonographic findings in two cases. J Ultrasound Med 1999; 18:441–443.[Medline]
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Introduction
Case Report