The clinical manifestation of a significant UVF is quite evident with severe and continuous incontinence being present. Patients with smaller fistula distal to the urinary sphincter complex may present with milder symptoms such as spraying of urinary stream or leakage of unexplained origin. Most often the diagnosis is made on clinical grounds with a thorough pelvic exam. Confirmation with a voiding cystourethrogram (VCUG) and cystourethroscopy is standard (Fig. 16.2a, b). For smaller fistula, bladder distension with methylene blue dye mixed with saline can assist in the diagnosis. Urodynamics are usually not necessary unless significant irritative voiding symptoms are present.

The repair of UVF, although in principle similar to that of a vesico-vaginal fistula, has a few unique considerations that need to be taken into account. The anatomical closure depends on good tissue quality and tissue interposition, a step which is not always easy given the restricted space for reconstruction. Vaginal scarring arising from previous surgeries and the presence of an incompletely removed synthetic material like in this case can make for a difficult tension-free closure. Recurrent SUI can complicate matters when the urinary sphincter complex is involved. For these reasons, outcomes of UVF cannot be extrapolated from repairs of vesico-vaginal fistula (VVF). Even though the mechanism of injury may be the same, the outcomes can be vastly different. From a technical standpoint, we approached the repair vaginally as this is the most minimally invasive irrespective of the size and location of the fistula. It is important that a wide based U-shaped vaginal flap be raised for 2 reasons: (1) it allows for maximal sling excision in the case of MUS and (2) it allows for sufficient room to accommodate any tissue interposition that may be required in the reconstruction.

Some of the relevant repair issues include:

Given the scarcity of UVF cases, there is no consensus on management. Hence treatment success is purported by experts in this field in various case-series reports. The main risks of: (i) fistula recurrence, (ii) recurrent stress urinary incontinence, (iii) voiding dysfunction (urethral lumen narrowing, or over-tightened sling when used) (iv) vaginal pain, and (v) dyspareunia precluding return of sexual function needs to be discussed thoroughly as part of the informed consent although data on functional outcomes is lacking in this regard.

Given the potential complexity of UVF cases, the operative approach is quite variable. A general outline is provided below.

It is our practice to recommend both a suprapubic and an indwelling urethral catheter for optimal bladder drainage. Intravenous antibiotics are continued for 24 h post surgery and transitioned to oral daily prophylaxis antibiotic coverage for the duration of the catheter time. Anti-cholinergic medications are supplemented to reduce and/or prevent bladder spasms. A postoperative voiding cysto-urethrogram (VCUG) is performed at 4 weeks to confirm urethral integrity and fistula closure before suprapubic catheter removal. If urinary leakage is present or suspected (vaginal voiding can sometimes confuse the read), the suprapubic catheter is changed and retained on drainage for a further 2–4 weeks, with or without replacing the urethral catheter.

Urethro-vaginal fistula (UVF) is fortunately a rare event in developed countries but still poses a significant challenge to pelvic reconstructive surgeons. The paucity of reported outcomes from surgical management presents a distinct disadvantage as there is no consensus with regards to management to guide both treating physicians and patients. Much of the current treatment and outcome is based on small case series. In contrast to developing countries, obstetric complications are rare and the majority is iatrogenic from vaginal surgery or radiation. In the last decade, there has been an increase in cases related to the use of synthetic mid urethral sling (MUS) [9–17]. This trend is not surprising given the increase in MUS procedures and their complications. The estimated risk for sling erosion from MUS in the general literature varies from 0.07 to 1.5 %. Various attributable factors have been proposed including tissue factors with vaginal atrophy and estrogen deficiency, although technical factors may also be involved such as submucosal placement and excessive sling tension. Some authors suggest that fibrosis resulting from the rejection process around the prosthetic material is a factor in the occurrence of urethral erosion [17]. During MUS removal, a urethral injury can occur and may not be recognized, leading to secondary incontinence from a UVF. This diagnosis is not always easily recognized unless the clinician has a high index of suspicion. Lateral view voiding urethro-cystogram and urethroscopy are both very useful to confirm the UVF diagnosis.