AJR 2005; 184:139-142
© American Roentgen Ray Society
Vesicouterine Fistulas: Imaging Findings in Three Cases
Tarek Smayra1,
Michel A. Ghossain1,
Jean-Noël Buy2,
Maroun Moukarzel3,
Denis Jacob4 and
Jean-Bernard Truc4
1 Department of Radiology, Hôtel-Dieu de France, Blvd. Alfred Naccache,
Achrafieh, PO Box 16-6830, Beirut, Lebanon.
2 Department of Radiology, Hôtel-Dieu de Paris, Cedex 04, Paris 75181,
France.
3 Department of Urology, Hôtel-Dieu de France, Beirut, Lebanon.
4 Department of Obstetrics and Gynecology, Hôpital Lariboisière,
Cedex 10, Paris 75475, France.
Received February 24, 2004;
accepted after revision April 30, 2004.
Address correspondence to T. Smayra.
Abstract
OBJECTIVE. The objective of our report is to present three cases of
vesicouterine fistulas secondary to a cesarean delivery, a uterine rupture
during labor, and radiation therapy. The delay between the onset of symptoms
and the diagnosis varied between 3 and 7 years. Different techniques such as
color Doppler sonography, excretory urography, cystography, CT, MRI,
cystoscopy, vaginoscopy, and hysterography were performed with variable
results, mostly negative and sometimes undefined.
CONCLUSION. The definitive diagnosis was made with contrast-enhanced
helical CT after cystography in one case, unenhanced helical CT after
hysterography in another case, and cystography in the third case.
Vesicouterine fisula rarely is thought of in the differential diagnosis
because of its rarity and negative results on radiologic and endoscopic tests.
The diagnosis is made on imaging after opacification of the uterus or the
bladder depending on the pressure gradient obtained and the location of the
fistula in relation to the uterine isthmus.
Introduction
Urogenital fistulas usually are ureterovaginal, vesicovaginal, or
urethrovaginal. Vesicouterine fistulas represent no more than 4% of all
urogenital fistulas [1]. In
some cases, the clinical findings of menouria and urinary leakage from the
vagina are suggestive of a urogenital fistula. In other cases, the clinical
presentation is nonspecific, and findings on examinations classically used to
depict the fistula are negative, leading to considerable delay in diagnosis.
The usefulness of more recent imaging studies such as color Doppler
sonography, helical CT, or MRI in the diagnosis of vesicouterine fistulas is
not well documented in the radiology literature. We report three cases of
vesicouterine fistulas depicted on recent imaging techniques.
Subjects and Methods
Case 1
A 39-year-old woman complained of stress incontinence and recurrent urinary
tract infections after her second low-segment cesarean delivery 8 years
earlier. Vaginoscopy, pelvic sonography, and excretory urography findings were
normal. Seven years later, she had right pyelonephritis; during the subsequent
days, at the expected time of her period, she developed hematuria for 4 days
with no vaginal bleeding. Findings from a second excretory urography
examination were normal. Cystoscopy showed a small outgrowth on the posterior
aspect of the superior wall of the bladder that was proved to be endometriosis
on microscopic examination. The patient was treated with luteinizing
hormone-releasing hormone analogues.
One year later, because periodic hematuria and amenorrhea persisted, the
patient underwent pelvic MRI. It showed only a focal hypointense area in the
anterior wall of the isthmus and an alteration of the bladder wall signal
facing it (Fig. 1A).
Transvaginal sonography displayed an abnormal hypoechoic line between the
anterior part of the isthmus and the posterior wall of the bladder
(Fig. 1B). Color Doppler
sonography revealed numerous vessels surrounding this line. Hysterography
depicted leakage of contrast material between the isthmus and the bladder.
That examination was followed immediately by helical CT of the pelvis with
sagittal reformations that clearly depicted the fistulous tract
(Fig. 1C). At laparotomy, the
fistula was confirmed to be at the upper part of the isthmus and was closed.
On microscopic examination, endometriosis was seen along the entire fistulous
tract.
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Fig. 1A. —39-year-old woman with vesicouterine fistula (case 1).
Sagittal spin-echo T2-weighted MR image (TR/TE, 1,880/100) shows abnormal
hypointense area (arrow) in anterior part of uterus at level of
isthmus. Bladder wall facing this area has heterogeneous and discontinuous
signal.
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Fig. 1B. —39-year-old woman with vesicouterine fistula (case 1).
Transvaginal sonogram shows bladder invaginated into uterine isthmus. Bladder
wall is disrupted, with hypoechoic line (arrow) joining bladder and
uterus lumina.
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Fig. 1C. —39-year-old woman with vesicouterine fistula (case 1).
Helical CT scan with sagittal reformation obtained after hysterography without
IV contrast material clearly depicts opacified fistulous tract
(arrow) between isthmus of uterus and posterosuperior part of
bladder. Contrast material also is present in vagina (arrowhead).
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Case 2
A 36-year-old woman was referred to the radiology department for suspicion
of a vesicovaginal fistula. Seven years earlier, she had a bladder and uterine
rupture during natural childbirth delivery. One year later, she was
complaining of a "wet vagina" after emptying the bladder and
walking. She developed several urinary tract infections. Findings on a recent
excretory urography examination were normal. Transvaginal sonography showed an
abnormal hypoechoic line between the upper part of the uterine cervix and the
posterior wall of the bladder (Fig.
2A). Color Doppler sonography revealed numerous vessels around
this abnormal area. Abdominopelvic helical CT with IV contrast injection
showed a focal area of decreased attenuation between the lumen of the upper
cervix and the left border of the uterine wall, but no definite fistula was
visualized.
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Fig. 2A. —36-year-old woman with vesicouterine fistula (case 2).
Transvaginal sonogram shows irregular, ill-defined, hypoechoic line
(arrow) joining upper part of uterine cervix and posterior wall of
bladder that appears to be focally disrupted and encased in uterine wall.
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In view of the clinical findings, the patient was asked to walk around, let
the bladder fill, then empty it partially. Immediately after, another helical
CT examination was performed that showed leakage of contrast medium from the
bladder into the upper part of the cervix
(Fig. 2B). At laparotomy, a
vesicouterine fistula at the level of the upper uterine cervix was confirmed
by a methylene blue test, which immediately depicted a second hole on the left
side of the first one. Both lesions were repaired.
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Fig. 2B. —36-year-old woman with vesicouterine fistula (case 2).
Delayed CT scan obtained 1 hr after IV injection and incomplete emptying of
bladder clearly depicts encasement of opacified bladder in uterus and leak of
contrast medium into upper part of cervix (arrow). On lower slices
(not shown), contrast material also was seen in inferior part of cervix.
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Case 3
A 78-year-old woman underwent uterine interstitial radiation therapy 30
years earlier, in unknown circumstances, as treatment for vaginal hemorrhage.
Three years before presentation, she had severe macroscopic hematuria.
Sonography showed bladder wall thickening and bilateral pelvicaliceal
dilatation. Serum creatinine level was elevated (221 µmol/L), no malignancy
was found on urinary cytology, and urodynamic studies showed neurogenic
bladder. She was treated with antibiotics and discharged with a bladder
catheter. One month later, she had several episodes of acute pyelonephritis
and gangrenous cystitis, and the catheter was removed. Since then, the patient
had to perform intermittent bladder self-catheterization every 4 hr until 1
month earlier when she became incontinent.
Vesicovaginal fistula was suspected on clinical examination. Cystography
showed early filling of the uterine cavity with contrast material
(Fig. 3). The final diagnosis
was vesicouterine fistula, and the patient had hysterectomy and
cystoplasty.
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Fig. 3. —78-year-old woman with vesicouterine fistula secondary to
radiation therapy (case 3). Cystography image reveals early filling of uterine
cavity with contrast material, opacification of tubes, and peritoneal
smearing.
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Discussion
Most cases of vesicouterine fistulas occur after low cesarean delivery
[2,
3]. They may be associated with
endometriosis [4] as in our
first patient. Other causes include contraceptive device
[2], malignant tumors,
inflammations, and rupture of the uterus and bladder after obstructed labor
[5] as in our second patient,
or radiation therapy and iatrogenic trauma of intermittent bladder
self-catheterization as in our third patient.
Symptoms depend on the level of the fistula and can be explained by the
sphincteric mechanism of the uterine isthmus
[6] and the different pressure
gradients. The shape and the diameter of the isthmus lumen change during the
menstrual cycle. The menstrual blood accumulates in the uterine cavity, and
when the pressure rises above 25–30 mm Hg, the sphincter of the isthmus
relaxes and a bloody discharge occurs
[6,
7].
When a fistula is present above the isthmus, the menstrual blood passes
directly from the uterine cavity into the bladder. No distention of the
uterine cavity takes place, and the sphincter of the uterine isthmus fails to
relax because the pressure in the uterine cavity does not increase. The result
is "Youssef syndrome"
[6]—that is, amenorrhea
with a patent cervical canal, periodic hematuria termed "menouria"
by Youssef [6], and the absence
of urinary leakage through the vagina.
When the fistula is located below the isthmus, the menstrual blood
accumulates normally in the uterine cavity, and when the sphincter of the
isthmus relaxes, the menstrual blood passes as it should through the cervix
into the vagina and not through the fistula into the bladder. Conversely, when
submitted to high pressure in the bladder, urine leaks through the fistula
from the bladder into the uterine cervix and the vagina. The symptoms of
urinary leakage through the vagina are similar to those of the more common
vesicovaginal fistula [6].
In some cases, menouria can be associated with urinary leak through the
vagina [8,
9]. The symptoms can appear
early after surgery or months or even years later
[10].
Diagnosis can be achieved by cystoscopy, vaginoscopy, hysterography
[2,
4,
6,
11], cystography
[4], or excretory urography
[8]. However, findings from
these different techniques can be inconclusive. Results of excretory urography
most often are normal. Cystoscopy— even when repeated—can fail to
confirm the fistula [6,
8]. Methylene blue instilled
into the uterine cavity or through the urethra or through catheterization of a
visible lesion in the bladder wall can confirm the fistula. This test,
however, does not show directly the fistulous tract and its specific location.
Moreover, this test can be negative in patients with a long and tortuous tract
[6,
8].
In our first two patients, transvaginal sonography revealed an abnormal
hypoechoic line connecting the endometrial cavity in the first patient and the
endocervix in the second patient with the bladder wall that appeared encased
in the uterus and focally disrupted. On color Doppler sonography, the area
surrounding this line appeared more vascularized than the adjacent myometrium
and cervical stroma. The sonographic pattern in these two patients and in two
other patients [12,
13] reported in the literature
is difficult to differentiate from the different patterns of a noncomplicated
cesarean scar [14].
Although MRI showed a focal hypointense area in the uterus with an
interruption of the uterine wall, no definite diagnosis could be made. In
addition to the role of MRI in confirming or ruling out the presence of
bladder endometriosis, which can be associated with a vesicouterine fistula
[4], some authors have
identified the fistulous tract on heavily T2-weighted MR sequences
[15].
In fact, injection of contrast medium in the uterus or the bladder is
necessary to show the fistula and to visualize the fistulous tract. Whether to
opacify the uterus or the bladder depends on the level of the
fistula—that is, the clinical symptoms. When patients with menouria are
examined, hysterography, as in our first patient, usually reveals the fistula
by showing leakage of contrast medium into the bladder. However, the fistulous
tract can be difficult to visualize, and helical CT with sagittal reformation
performed after hysterography can be helpful. When the fistula is complicated
with vaginal leakage of urine, opacification of the bladder is the clue to the
diagnosis. Helical CT using IV contrast material to opacify the bladder can
depict the fistula clearly, but a high pressure in the opacified organ can be
necessary as in our second patient. Excretory urography can be falsely normal.
On the other hand, when the fistulous tract is wide as in our third patient,
it can be diagnosed easily on cystography.
In conclusion, helical CT appears as a valuable tool in depicting a
vesicouterine fistula. When a low vesicouterine fistula is present, CT after
IV contrast injection is a good method to show the fistula, but a high
pressure in the bladder may be necessary. When a high vesicouterine fistula is
suspected, it is best shown on hysterography. However, helical CT with
sagittal reformation, performed after hysterography, gives more information to
the surgeon about the precise topography of the fistulous tract. MRI,
gray-scale sonography, and color Doppler sonography can show abnormalities,
but results form these examinations are not conclusive.
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Abstract
Introduction
