Urological reconstructive surgery · KIMS Secunderabad
Bladder Fistula — When the Bladder Develops an Abnormal Connection to a Neighbouring Organ
A bladder fistula is an abnormal communication — a hole or channel — between the bladder wall and an adjacent organ or the skin surface. The most common types are vesicovaginal fistula (between bladder and vagina — the most devastating, causing continuous urinary leakage), colovesical fistula (between bladder and colon — causing faeces or gas in the urine — pneumaturia), and vesicouterine fistula (between bladder and uterus — causing cyclical haematuria around menstruation). Each type has a characteristic symptom pattern, a specific set of causes, and a surgical approach to repair.
Bladder fistulas cause significant physical and social morbidity — particularly vesicovaginal fistulas in women, which cause continuous urinary incontinence, perineal skin damage, and profound social isolation. In India, vesicovaginal fistulas most commonly arise from obstetric complications (prolonged obstructed labour — the presenting foetal part compresses and necroses the vesicovaginal wall, creating a fistula after delivery), prior pelvic surgery (hysterectomy — particularly if the bladder was inadvertently damaged during dissection), radiotherapy, and advanced pelvic malignancy.
Types and causes
| Type · Common causes in India | Characteristic symptom |
|---|---|
Vesicovaginal fistula (VVF) — most common Obstetric trauma (obstructed labour — most common in India) · Hysterectomy complication · Radiation · Advanced cervical cancer | Continuous leakage of urine through the vagina — day and night, regardless of position. Distinguished from stress incontinence by the continuity and the absence of any reservoir function (the woman still feels an urge and may void normally — but the vaginal leakage is constant). |
Colovesical fistula (CVF) Diverticular disease of the sigmoid colon (most common in India in patients above 50) · Crohn's disease · Colorectal cancer · Prior pelvic radiation | Pneumaturia — air or gas in the urine, creating bubbly or frothing urine. Faecaluria — faecal matter in the urine, causing recurrent polymicrobial UTIs with mixed Gram-positive and Gram-negative organisms. Persistent, treatment-resistant UTIs with mixed organisms should always prompt cystoscopy. |
Vesicouterine fistula (VUF) Lower uterine segment Caesarean section (most common — the uterine incision inadvertently involves the posterior bladder wall) · Uterine rupture | Cyclical haematuria (Youssef syndrome) — blood in the urine coinciding with menstruation, from menstrual blood passing through the fistula into the bladder. Amenorrhoea (the menstrual flow is diverted into the bladder rather than exiting the vagina). |
Vesicoskin fistula (enterovesical) Pelvic abscess draining to skin · Advanced bladder cancer · Post-radiation necrosis | Urine draining from the skin surface — usually in the perineum, lower abdomen, or anterior thigh. |
Diagnosis at KIMS
Cystoscopy
The essential investigation. Direct visualisation of the bladder mucosa identifies the fistula opening, its position, size, and the surrounding tissue quality (normal vs radiation-damaged vs tumour-infiltrated). Cystoscopy also assesses the proximity of the fistula to the ureteric orifices — critical for surgical planning (fistulas close to the ureteric orifices require ureteric reimplantation at the time of repair).
CT cystogram
The bladder is filled with contrast through a catheter and CT is performed. Contrast leaking outside the bladder through the fistula track confirms the diagnosis and its location. CT also identifies associated pathology (diverticular disease, pelvic tumour, radiation changes).
Colonoscopy
For colovesical fistula: identifies diverticular disease, Crohn's disease, or colorectal cancer as the underlying bowel cause.
Three-swab test (for VVF)
Three separately labelled swabs are placed in the vagina, the bladder is filled with methylene blue dye through a catheter, and the patient stands and walks for 15 to 20 minutes. Blue staining of the vaginal swab nearest the cervix (upper vaginal swab) indicates VVF; blue staining of the lower swab indicates urethrovaginal fistula; no blue staining but wet swabs indicates a ureterovaginal fistula.
MRI pelvis
For complex fistulas, particularly those associated with radiation or malignancy — provides excellent soft tissue detail for surgical planning.
Treatment at KIMS
Vesicovaginal fistula — transabdominal or transvaginal repair
Small, simple VVFs detected early (within 3 to 4 weeks of the causative event) in non-irradiated tissue may be repaired through the vaginal approach (Latzko technique — colpocleisis). Larger or complex VVFs, or those in irradiated tissue, require transabdominal repair with omental interposition (the omentum — a pedicle of peritoneal fat — is placed between the repaired bladder and vaginal walls to provide additional blood supply and a tissue barrier, reducing fistula recurrence). At KIMS, repair is performed after a minimum of 3 months from the fistula formation — allowing the surrounding inflammation to resolve and maximising tissue quality at repair.
Colovesical fistula — bowel resection and fistula closure
The involved segment of colon (typically the sigmoid in diverticular disease, or the affected bowel segment in Crohn's or colorectal cancer) is resected, the bladder opening is closed, and bowel continuity is restored (primary anastomosis or temporary stoma). The management is primarily colorectal surgical — the KIMS urology team manages the bladder component. Laparoscopic or robotic colectomy with bladder repair.
Vesicouterine fistula — conservative or surgical
In Youssef syndrome from Caesarean section: hormonal suppression (norethindrone or GnRH analogues) induces amenorrhoea and allows the fistula to close spontaneously in approximately 50% of cases. Persistent fistulas require surgical repair — transabdominal closure of both the bladder and uterine defects.
Book a Bladder Fistula Consultation at KIMS. Call 040-4488-5000
Frequently Asked Questions — Bladder Fistula
Continuous urinary leakage through the vagina — day and night, regardless of position, not related to coughing or sneezing, in a woman who also urinates normally — is a vesicovaginal fistula until proven otherwise. The most common cause in India is obstetric trauma from prolonged obstructed labour — the baby's presenting part compresses the vesicovaginal wall against the pubic symphysis, causing ischaemic necrosis. The necrotic tissue sloughs off 5 to 7 days post-delivery, creating a hole between the bladder and vagina. Other causes: inadvertent bladder injury during hysterectomy (typically apparent within the first 1 to 2 weeks post-surgery), radiation for cervical cancer, and advanced pelvic malignancy.
Air or gas in the urine — called pneumaturia — is the most specific symptom of a colovesical fistula (an abnormal communication between the colon and the bladder). The gas produced by intestinal bacteria passes from the colon into the bladder through the fistula, creating bubbly or foaming urine. Pneumaturia is pathognomonic of enterovesical fistula — it is essentially never caused by anything else. The most common cause in adults above 50 in India is diverticular disease of the sigmoid colon — inflamed diverticula may perforate into the adjacent bladder wall. Any patient reporting bubbly or gas-containing urine should have cystoscopy and CT cystogram at KIMS to confirm and characterise the fistula.
Small vesicouterine fistulas following Caesarean section may close spontaneously with hormonal suppression in approximately 50% of cases. Very small vesicovaginal fistulas (below 3 to 5mm) detected within the first week of the causative event may occasionally close with prolonged catheter drainage (6 to 8 weeks of continuous bladder drainage with Foley catheter). Larger or established fistulas in irradiated or malignant tissue do not close without surgery. Colovesical fistulas never close spontaneously — the bowel keeps supplying contents that prevent healing. The general rule: any significant bladder fistula that has not closed within 6 to 8 weeks of catheter drainage alone requires surgical repair.
The 3-month waiting period before VVF repair is based on the principle that surgical repair in inflamed, oedematous tissue has a much higher failure rate than repair in well-vascularised, mature tissue. In the first weeks after obstetric trauma or surgical injury, the tissue around the fistula is oedematous, inflamed, and friable — sutures placed in inflamed tissue do not hold. By 3 months, the inflammation has resolved, the tissue planes are clear, the fistula margins are well-defined, and the surrounding tissue has adequate blood supply for healing. An early repair in inflamed tissue fails in up to 30 to 40% of cases — requiring a second repair. A repair at 3 months in properly prepared tissue succeeds in 85 to 95% of first-time repairs.
KIMS Secunderabad — Dr. K. V. R. Prasad (Chief Urologist, 28+ years), cystoscopy, CT cystogram, three-swab test for VVF, transabdominal VVF repair with omental interposition, transvaginal repair for simple VVFs, laparoscopic colovesical fistula repair with colorectal surgery coordination, vesicouterine fistula repair with gynaecology coordination. NABH and NABL accredited. Call 040-4488-5000.