Prevention of the development of a vesicovaginal fistula.

The cause of vesicovaginal fistulas after hysterectomy is not clearly understood. In an attempt to determine its cause, the records of 12 patients who had vesicovaginal fistula develop (after total abdominal hysterectomy) were compared with 12 consecutive patients who underwent total abdominal hysterectomy without fistula formation. Most of the patients who had vesicovaginal fistulas develop had excessive postoperative abdominal pain, distension or paralytic ileus, or both. Hematuria and symptoms of irritability of the bladder were also noted in the fistula group and prolonged postoperative fever and increased white blood cell count occurred more often. In contrast, the postoperative course was uncomplicated in the nonfistula group. The clinical course observed in many of the patients with vesicovaginal fistulas suggests that the patients had an unrecognized injury to the bladder resulting in urinary extravasation. It is postulated that the fistula develops when the urinoma drains into the vaginal cuff which is dependent and usually not closed. It may be possible to abort the development of many vesicovaginal fistulas by early recognition and treatment of an unsuspected bladder injury. It is suggested that patients with severe abdominal pain, distension, paralytic ileus, hematuria or symptoms of severe irritability of the bladder after abdominal hysterectomy be investigated early for a possible bladder injury.