Uterovesical Fistula

UTEROVESICAL FISTULA
(Youssef’s syndrome)
Dr.K.Malleswar Rao, MD,

DGO
Civil Surgeon Specialist
Dept. of Obstetrics &
Gynecology
ESI Hospital, Sanathnagar,
Hyderabad.
kasinamrao@gmail.com 1
CASE REPORT

Presenting complaints:
4. Bleeding while passing urine since 6years. (Menourea)
5. Pain in the lower abdomen since 6months.
6. Irregular bleeding per vagina since 3months. (Uterine

bleeding)
Previous history:
8. No h/o urinary incontinence. Nothing particular.
CASE REPORT
Obstetric history: Para 2, Live 2, both deliveries by
C-sections, one in Delhi and another at Bihar state. The
delivery records are unavailable. She underwent
tubectomy.
Menstrual history: Previous: 4-5days/30days, regular
flow. H/o passing blood in urine at the time of menstrual
flow (so called Cyclic Menourea) since 6years.
Present: Irregular excessive
menstrual flow since 3months associated hematuria
since 3months.
General Exam: Patient is anemic, P.R. 80/min, BP
110/70mmHg,
CVS/RS: NAD, P/A: NAD.
Gynaec. Exam: Bimanual vaginal examination: Uterus
AV, bulky, mobile, FF, non-tender.
CASE REPORT
INVESTIGATIONS: ROUTINE (BASIC) WORKUP: -
1.CUE on 7-4-04:WNL except haematuria.
2.IVU on 3-3-04:Both are kidneys normal, no evidence of
obstruction and dilatation of Pelvicalyceal system.
3.Urine for C/S on 3-3-04: E. coli grown in culture and sensitive
to 1.Furadantine, 2.Amikacin.
4. Hb% on 8-3-04: 6gm%.
5. RBS: 103mg%, Blood Urea: 15mg%.
6. “B” Rh-positive, HIV & Hbs Ag: non-reactive.
7. LFT: S. Bilirubin: 0.72mg%, SGPT: 2 IU/L, Alk. Phos: 4KA.
8. X-Ray Chest PA view: Normal.
9. X-KUB on 8-3-04: No ROD seen.
CASE REPORT
Specific WORK-UP: -
1. U/S scan total abdomen done in a

private center on 6-1-04: GB stone 19mm in
size, and evidence of “UTEROVESICAL FISTULA”
seen, other findings normal.
CASE REPORT
2. U/S scan repeated on 8-3-04 in ESI

Hospital, Sanathnagar: GB calculus of
13mm size seen, endometrial polyp/ sub-
mucous fibroid with cervix hypertrophied
and uterine endometrial cavity is in
continuity with the bladder, Right Ovary
3/3cm, Left Ovary 3/3cm.
CASE REPORT
3. Double dye test (oral pyridium +

Intravesical instillation of Methyline blue
dye) done on 3-3-04 revealed no evidence
of VVF or UVF.
CASE REPORT
4. CYSTOSCOPIC Exam. Done in OGH

on 25-03-04: Ureter and both
Ureteric orifices and Bladder wall
are normal; Blood clot present in
bladder and it is evacuated.
CASE REPORT
5. Endovaginal sonogram + Saline

infusion sonohysterogram (SIS) had
been done with the assistance of
equipment company, (as we have
no access to the U/S machine with
TV probe).
CASE REPORT
CLINICAL MANAGEMENT: Preoperatively on

pint of blood transfused on 6-04-04 to
correct anemia and Hb% improve to
10gm% before surgery.
Urinary Tract Infection had been treated
by Inj. Amikacin 15mg/kg /day X 10days.
Later, Urine became Sterile on Culture.

On 15-04-2004: Laparotomy done and total
abdominal Hysterectomy with Repair of the
uterovesical fistula performed.
Per-operative findings:
1. Bladder was adherent up to the fundus of the

uterus.
2. Uterus was larger than normal size.
3. Sub mucous fibroid polyp found at fundus region.
4. Large fistulous track was found between base of
the bladder and anterior wall of the body of the
uterus, which was approx. 1.5 inches in size, and
in fact bladder wall is in continuity with the
uterus as appropriately mentioned in U/S scan.
POST-OPERATIVE MANAGEMENT:
Patient was kept on continuous
bladder drainage for 14days for
proper healing of the bladder wall.
Skin sutures were removed on 7th
POD. Uneventful P.O. course and
went home.
FOLLOW-UP:
She was referred to UROLOGIST for

Urodynamic exam., as frequency of
urine developed post-operatively.
She didn't have any significant

urological dysfunction such as
Vesicourethral anomalies or
dysfunction.
CLINICAL PRESENTATION
Typically, Cyclic Hematuria (Menouria, Vesical
menstruation)
Lochiauria (Urethral passage of Lochia)
In some reported cases, Urinary Incontinence (vaginal
leakage of urine) when fistula involves isthmus region
(VESICOCERVICAL FISTULA)
Herniation of the Amniotic sac through Uterovesical
fistula
Infertility, Amenorrhea
Bladder endometriosis
POSSIBLE CAUSES
Commonly, following Caesarian Section
Previous traumatic (difficult) forceps delivery
Migration of (Perforated) Intrauterine Contraceptive20
kasinamrao@gmail.com
DIAGNOSIS
Cystoscopy, Cystogram, Hysterosalpingogram
Transabdominal/Transvaginal Sonogram
Exclusion of other Genitourinary fistula like
Vesico Vaginal Fistula or Uretero Vaginal
Fistula by DOUBLE DYE TEST (i.e., intravesical
instillation of Methylene Blue+Oral adm. Of
Pyridium)
SALINE INFUSION SONOHYSTEROGRAM (SIS) +
ENDOVAGINAL SONOGRAM
Sonographic Diagnosis of a
Uterovesical Fistula
•Abdominal and endovaginal sonography showed a
large defect in the anterior myometrium in the lower
body of the uterus.
•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.
Sonohysterography:-
It 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 kasinamrao@gmail.com
myometrium, confirming the23
MANAGEMENT
Conservative approach:i) Cystoscopic
fulguration, ii) Cyclic combine hormonal
therapy with continuous
catheterization,iii) Spontaneous
resolution by continuous catheterization
Surgical approach:i) Transabdominal
transperitoneal repair of fistula
with/without Hysterectomy, ii) Fistula
repair with Omental interposition or
Myouterine flap, iii) Vaginal repair in
cases of previous subtotal hysterectomy
INTERNATIONAL CLASSIFICATION OF DISEASES
619 Fistula involving female genital tract
Excludes: vesicorectal and intestinovesical fistula(596.-)
619.0 Urinary-genital tract fistula, female
Fistula:
cervicovesical
ureterovaginal
urethrovaginal
uteroureteric
uterovesical
vesicovaginal
ICD Version 2007 (
http://www.who.int/classifications/apps/icd/icd10online/ind
)
Youssef’s syndrome
The typical triad of Youssef's
syndrome i.e. cyclic hematuria and
amenorrhea without vaginal
leakage of urine.
First case of menouria was reported in the
literature by Machado in 1935. Into about 92
cases were reported since 1908 (on the date
of surgery) and it is rare accounting about 4%
of all Genitourinary fistulas.
Today, 141 articles are reported in Pubmed
data.
Vesicouterine fistula is a rare complication of
gynecologic surgery, which is usually treated
by abdominal hysterectomy and bladder
repair.
We present a case showing the etiology of
vesicouterine fistula and contemporary
reconstructive techniques.
SUMMARY
A 40 yr old rural woman presented with
Menouria (Vesical menstruation) tolerating
the symptom in silence since 6 yrs, came to
the hospital with intolerable “MENORRHAGIA
+ MENOURIA” (due to the growth of
submucous fibroid) since 3 months.
We had managed the case by “TOTAL
HYSTERECTOMY ALONG WITH REPAIR OF
FISTULA”.
Though woman developed transient
frequency and urgency of urine in
postoperative period, she is now totally
asymptomatic and relieved of distressing
symptoms.
Unusual case of post-cesarean
vesicouterine fistula (Youssef's
syndrome).
Therefore, it is pertinent to have periodic
training courses (Update of C-section
workshops) not only for qualified ObGyn
specialists but also for Basic Medical
Practitioners in rural areas, since Cesarian
delivery is the commonest surgical
procedure performed throughout the World
today. kasinamrao@gmail.com 29
Review of literature in
Pubmed database
(Medline)
1) Unusual case of post-cesarean
vesicouterine fistula (Youssef's
syndrome).
Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H.
Department of Urology, Baskent University, 01250 Adana, Turkey.
ferhatkilinc@hotmail.com
http://www.ncbi.nlm.nih.gov/pubmed/12657106?or
2) An unusual case of Youssef's syndrome
(vesicouterine fistula) and
its relationship with placenta percreta.
Majeed SM, Subhani SS.
Department of Surgery, KRL General Hospital,
Islamabad, Pakistan.
http://www.ncbi.nlm.nih.gov/pubmed/17374305?ordinalpos=1&itool=
3) Vesicouterine fistulas following cesarean
section: report on a case, review and update of the
literature.
Porcaro AB, Zicari M, Zecchini Antoniolli S,
Pianon R, Monaco C, Migliorini F, Longo M, Comunale L.
Urologic Operating Unit, Civil Major Hospital, Verona, Italy.
drporcaro@yahoo.com
Spontaneous healing is reported in 5% of cases. Conservative
management by bladder catheterization for at least 4-8 weeks is
indicated when the fistula is discovered just after delivery since
there is good chance for spontaneous closure of the fistulous
track. Hormonal management should be tried in women
presenting with Youssef's syndrome. Surgery is the mainstay and
definitive treatment of vesicouterine fistulas after cesarean
section.
http://www.ncbi.nlm.nih.gov/pubmed/12899224?ordinalpos=1&itoo
4) Youssef's syndrome:
an appraisal of hormonal treatment.
Hemal AK, Wadhwa SN, Kriplani A, Hemal U.
Department of Urology, AIIMS, New Delhi.
Two cases of vesicouterine fistula, caused by LSCS, are presented.

Both cases had classical symptoms of Youssef's syndrome,
i.e. cyclic hematuria, absence of vaginal bleeding and
complete urinary continence.
These patients were treated by the continuous administration of
an estrogen-progestogen combination for 6 months.
However, it failed in 1 case requiring
transabdominal transperitoneal closure of the fistula
with an interposition of omentum.
We feel that hormonal treatment may be tried as first modality
in the treatment of Youssef's syndrome, before resorting to surgery.
http://www.ncbi.nlm.nih.gov/pubmed/8140684?ordinalpos=
1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_
ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_
Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed
5) Vesico-uterine fistula
secondary to cesarean section.
Michielsen DP, Wyndaele JJ, Batchvarov YA.
Department of Urology, University of Antwerp, Belgium.
A vesico-uterine fistula with vaginal urinary incontinence

secondary to cesarean section is reported.
Diagnosis was made clinically, radiologically and endoscopically.
Conservative management failed. Surgical repair was successful.
Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
6) 'Menouria'—
a presentation of vesicouterine fistula.
Bhutta SZ.
Department of Obstetrics and Gynaecology,
Jinnah Postgraduate Medical Centre, Karachi.
1&itool=EntrezSystem2.PEntrez.
Pubmed.Pubmed_ResultsPanel.Pubmed_
DiscoveryPanel.Pubmed_Discovery_
RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
7) Management of vesicouterine fistula
following cesarean section.
Pawar HN.
Department of Pathology, Faculty of Medicine, Kuwait University.
Contrary to belief, urinary incontinence in vesicouterine fistulas

following cesarean section
is as common as cyclic hematuria with apparent amenorrhea.
Review of the English literature revealed 21 cases and
herein is added a new case.
8) Treatment of vesicouterine fistula
by fulguration.
Molina LR, Lynne CM, Politano VA.
Department of Urology,
University of Miami School of Medicine, Florida.
A 29-year-old woman suffered a vesicouterine fistula

following cesarean section.
The fistula was treated successfully after cystoscopic identification
and fulguration of the tract.
Although various surgical approaches
to this problem have been described,
and a number of cases of spontaneous resolution are reported,
to date there have been no reports of treatment of this problem
via cystoscopic fulguration.
We advocate this simple technique
as a primary approach to vesicouterine fistulas.
http://www.ncbi.nlm.nih.gov/pubmed/2724440?ordinalpos=1&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_
9) Vesicocervical fistula—
a rare complication secondary
to caesarean section.
Mahomoud S, Arunkalaivanan AS, Devarajan R, Kaur H.
Department of Obstetrics and Gynaecology, City Hospital,
Dudley Road, Birmingham, B18 7QH, UK.
Conservative management with indwelling catheterisation

for 3 weeks failed.
Hence the fistula was repaired surgically by an abdominal approach.
http://www.ncbi.nlm.nih.gov/pubmed/
15309282?ordinalpos=1&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_
10) A case report on vesico-uterine fistula:
a very rare complication of the
lower caesarean section.
Abu J, Wong MY, Foo KT, Yu SL.
Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore.
http://www.ncbi.nlm.nih.gov/pubmed/
11284616?ordinalpos=1&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_
DiscoveryPanel.Pubmed_Discovery_
RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
Vesicouterine fistula – Imaging
http://www.gfmer.ch/selected_images_v2/detail_
list.php?cat1=17&cat2=103&cat3=721&cat4=1&stype=n
THANKING YOU ALL!!

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UTEROVESICAL FISTULA

Dr.K.Malleswar Rao, MD,

6. Irregular bleeding per vagina since 3months. (Uterine

1. U/S scan total abdomen done in a

2. U/S scan repeated on 8-3-04 in ESI

3. Double dye test (oral pyridium +

4. CYSTOSCOPIC Exam. Done in OGH

5. Endovaginal sonogram + Saline

CLINICAL MANAGEMENT: Preoperatively on

1. Bladder was adherent up to the fundus of the

She was referred to UROLOGIST for

She didn't have any significant

Two cases of vesicouterine fistula, caused by LSCS, are presented.

A vesico-uterine fistula with vaginal urinary incontinence

Contrary to belief, urinary incontinence in vesicouterine fistulas

A 29-year-old woman suffered a vesicouterine fistula

Conservative management with indwelling catheterisation

THANKING YOU ALL!!

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