CASE REPORT
Urethrovaginal Fistula: A Rare Complication of Transurethral Catheterization Lateefa O. AL Dakhil, MD
Abstract: In the developed world, urethrovaginal fistulas are most often observed after urethral diverticulum repair attempts, anterior repairs, or sling procedures. Obstetrical causes are exceptionally rare. In this case of urethrovaginal fistula, the cause was urethral trauma during routine transurethral catheterization, which was most likely caused by the inappropriate placement or displacement of a Foley catheter balloon during normal delivery. We discuss the presentation, diagnosis, and surgical management. Key Words: urethrovaginal fistula, Foley catheter, incontinence (Female Pelvic Med Reconstr Surg 2014;20: 293Y294)
0.5-cm UVF located in the midurethra, approximately 2 cm from the urethrovesical junction (Fig. 1) Successful primary repair was achieved by performing a transvaginal closure of the fistula by wide mobilization into the lateral periurethral spaces and using a vertically placed, layered closure in a tension-free manner with a Martius labial-rotation flap. Postoperatively, the bladder catheterization continued for 2 weeks, along with prophylactic antibiotics and anticholinergic medication. After 2 years of follow-up, the patient remained asymptomatic with no urinary leakage. Patient consent was acquired for this publication.
DISCUSSION Case Report A 28-year-old woman, 4 months after spontaneous abdominal delivery, was referred to the urogynecology department complaining of intermittent urinary leakage, especially when changing positions and with intercourse. The patient had no abnormal urinary symptoms before her delivery. During her abdominal delivery, she received an epidural for labor pain control during the active phase of labor. The patient underwent a transurethral catheterization without any obvious complications. She had a prolonged second stage of labor that lasted for more than 3 hours. During that time, a Foley catheter tip was seen inside the vagina coming from the urethra. The Foley catheter was removed and spontaneous abdominal delivery occurred after a mediolateral episiotomy with no extensions. After delivery, the patient was evaluated by performing a thorough vaginal examination. A proximal urethral tear was identified, and because of perianal and vaginal edemas after abdominal delivery, a decision was made to delay the repair. A 14F Foley catheter was inserted, and a prophylactic antibiotic was administered. Upon examination after 6 weeks, no urethral tears were observed through vaginal examination, and the Foley catheter was removed. The patient experienced incontinence and urinary leakage, which occurred during position changes and during intercourse. The patient was referred to our urogynecology center. During the initial examination, no obvious urethrovaginal fistulas (UVFs) were seen, and she did not leak with the Valsalva maneuver. There was obvious leaking upon pressing of the anterior vaginal wall. A cystourethroscopy confirmed the presence of a
From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Reprints: Lateefa O. AL Dakhil, MD, Urogynecology Division, Department of Obstetrics and Gynecology, King Khalid University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000054
Female Pelvic Medicine & Reconstructive Surgery
&
The Foley catheter is the most frequently used device in hospitals. Catheter-associated urinary tract infection is the most common complication.1 Female urethral injury secondary to trauma is rare and is mostly associated with pelvic fractures. Urethral injuries secondary to catheterization are uncommon. These injuries can occur if the balloon inflates in the urethra instead of the bladder. Injury can also occur when the catheter is pulled on or removed without deflating the balloon. These types of injuries typically occur when a patient is rotated in the bed without first securing the catheter or when a confused patient forgets about the catheter and tries to walk while the catheter remains attached to the bed. Another common urethral injury situation is when a confused patient pulls the catheter out of his/her body.2,3
FIGURE 1. Lacrimal probe size 4/0 inserted into the urethra showing a fistula in the midurethra.
Volume 20, Number 5, September/October 2014
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
AL Dakhil
In this case, it is possible that the Foley balloon was not completely inflated and that during patient movement, it was pulled through the urethra. Another possibility is that the initial inflation was in the urethra instead of the bladder; because the patient had an epidural, she may not have felt it, thus leading to urethral injury and the development of UVF. A third possibility is that the presence of a small, preexisting urethral diverticulum caused injury during routine urethral catheterization. A MEDLINE literature search was conducted, and we found 2 reports of similar situations: one in a patient with preexisting urethral diverticulum and the second in a patient during preparation for elective cesarean section. In the first case, the initial repair was performed 18 weeks after injury and was successful. In the second case, the initial repair was performed immediately but failed; the patient required another repair with an autologous facial sling.4,5
CONCLUSIONS Although traumatic complications from transurethral catheterization are uncommon, debilitating complications, such as that observed in this case, are a possibility.
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Volume 20, Number 5, September/October 2014
A Foley catheter insertion should not be taken for granted as a procedure without risks. Great effort should be exercised to select a well-fitting catheter of an appropriate material and to practice good technique to minimize urethral trauma. Delayed versus immediate repair under these circumstances remains to be determined. REFERENCES 1. Schumm K, Lam TB. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev. 2008;2:CD004013. 2. Perry MO, Hussmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol. 1992;147:139Y143. 3. Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int. 1999;83:626Y630. 4. Cameron AP, Atiemo HO. Unusual presentation of an obstetrical urethrovaginal fistula secondary to improper catheter placement. Can Urol Assoc J. 2009;3:E21YE22. 5. Thrumurthy SG, Hill SR, Islam S. Iatrogenic urethrovaginal fistula from catheterization in labour. Br J Hosp Med (Lond). 2010;71:414.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Urethrovaginal Fistula: A Rare Complication of Transurethral Catheterization Lateefa O. AL Dakhil, MD
Abstract: In the developed world, urethrovaginal fistulas are most often observed after urethral diverticulum repair attempts, anterior repairs, or sling procedures. Obstetrical causes are exceptionally rare. In this case of urethrovaginal fistula, the cause was urethral trauma during routine transurethral catheterization, which was most likely caused by the inappropriate placement or displacement of a Foley catheter balloon during normal delivery. We discuss the presentation, diagnosis, and surgical management. Key Words: urethrovaginal fistula, Foley catheter, incontinence (Female Pelvic Med Reconstr Surg 2014;20: 293Y294)
0.5-cm UVF located in the midurethra, approximately 2 cm from the urethrovesical junction (Fig. 1) Successful primary repair was achieved by performing a transvaginal closure of the fistula by wide mobilization into the lateral periurethral spaces and using a vertically placed, layered closure in a tension-free manner with a Martius labial-rotation flap. Postoperatively, the bladder catheterization continued for 2 weeks, along with prophylactic antibiotics and anticholinergic medication. After 2 years of follow-up, the patient remained asymptomatic with no urinary leakage. Patient consent was acquired for this publication.
DISCUSSION Case Report A 28-year-old woman, 4 months after spontaneous abdominal delivery, was referred to the urogynecology department complaining of intermittent urinary leakage, especially when changing positions and with intercourse. The patient had no abnormal urinary symptoms before her delivery. During her abdominal delivery, she received an epidural for labor pain control during the active phase of labor. The patient underwent a transurethral catheterization without any obvious complications. She had a prolonged second stage of labor that lasted for more than 3 hours. During that time, a Foley catheter tip was seen inside the vagina coming from the urethra. The Foley catheter was removed and spontaneous abdominal delivery occurred after a mediolateral episiotomy with no extensions. After delivery, the patient was evaluated by performing a thorough vaginal examination. A proximal urethral tear was identified, and because of perianal and vaginal edemas after abdominal delivery, a decision was made to delay the repair. A 14F Foley catheter was inserted, and a prophylactic antibiotic was administered. Upon examination after 6 weeks, no urethral tears were observed through vaginal examination, and the Foley catheter was removed. The patient experienced incontinence and urinary leakage, which occurred during position changes and during intercourse. The patient was referred to our urogynecology center. During the initial examination, no obvious urethrovaginal fistulas (UVFs) were seen, and she did not leak with the Valsalva maneuver. There was obvious leaking upon pressing of the anterior vaginal wall. A cystourethroscopy confirmed the presence of a
From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Reprints: Lateefa O. AL Dakhil, MD, Urogynecology Division, Department of Obstetrics and Gynecology, King Khalid University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000054
Female Pelvic Medicine & Reconstructive Surgery
&
The Foley catheter is the most frequently used device in hospitals. Catheter-associated urinary tract infection is the most common complication.1 Female urethral injury secondary to trauma is rare and is mostly associated with pelvic fractures. Urethral injuries secondary to catheterization are uncommon. These injuries can occur if the balloon inflates in the urethra instead of the bladder. Injury can also occur when the catheter is pulled on or removed without deflating the balloon. These types of injuries typically occur when a patient is rotated in the bed without first securing the catheter or when a confused patient forgets about the catheter and tries to walk while the catheter remains attached to the bed. Another common urethral injury situation is when a confused patient pulls the catheter out of his/her body.2,3
FIGURE 1. Lacrimal probe size 4/0 inserted into the urethra showing a fistula in the midurethra.
Volume 20, Number 5, September/October 2014
www.fpmrs.net
293
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
AL Dakhil
In this case, it is possible that the Foley balloon was not completely inflated and that during patient movement, it was pulled through the urethra. Another possibility is that the initial inflation was in the urethra instead of the bladder; because the patient had an epidural, she may not have felt it, thus leading to urethral injury and the development of UVF. A third possibility is that the presence of a small, preexisting urethral diverticulum caused injury during routine urethral catheterization. A MEDLINE literature search was conducted, and we found 2 reports of similar situations: one in a patient with preexisting urethral diverticulum and the second in a patient during preparation for elective cesarean section. In the first case, the initial repair was performed 18 weeks after injury and was successful. In the second case, the initial repair was performed immediately but failed; the patient required another repair with an autologous facial sling.4,5
CONCLUSIONS Although traumatic complications from transurethral catheterization are uncommon, debilitating complications, such as that observed in this case, are a possibility.
294
www.fpmrs.net
&
Volume 20, Number 5, September/October 2014
A Foley catheter insertion should not be taken for granted as a procedure without risks. Great effort should be exercised to select a well-fitting catheter of an appropriate material and to practice good technique to minimize urethral trauma. Delayed versus immediate repair under these circumstances remains to be determined. REFERENCES 1. Schumm K, Lam TB. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev. 2008;2:CD004013. 2. Perry MO, Hussmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol. 1992;147:139Y143. 3. Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int. 1999;83:626Y630. 4. Cameron AP, Atiemo HO. Unusual presentation of an obstetrical urethrovaginal fistula secondary to improper catheter placement. Can Urol Assoc J. 2009;3:E21YE22. 5. Thrumurthy SG, Hill SR, Islam S. Iatrogenic urethrovaginal fistula from catheterization in labour. Br J Hosp Med (Lond). 2010;71:414.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
