Int Urogynecol J DOI 10.1007/s00192-014-2328-7
CASE REPORT
Ureterovaginal fistula linked to a retained pessary Fridman Dmitry & Sleemi Ambereen
Received: 19 September 2013 / Accepted: 4 January 2014 # The International Urogynecological Association 2014
Abstract The vaginal pessary is a safe and effective method for the correction of uterovaginal prolapse. Complications are uncommon, but include fistula formation. We report a case of fistulous communication between the ureter and vagina that developed in a patient who had had a pessary for more than 8 years. She initially presented with urinary retention secondary to complete procidentia and declined surgical intervention. The patient was not compliant with follow-up. Eventually, she was scheduled for a vaginal hysterectomy and pelvic floor reconstruction, during which the communicating tract was discovered between the ureter and vagina. Ultimate treatment involved stenting of the ureter and interval ureteroneocystostomy. Fistulae can develop between the ureter and the vagina in the case of procidentia and a retained pessary. Keywords Ureterovaginal fistula . Pessary . Complications
Introduction The use of a vaginal pessary as a means of pelvic prolapse correction is a valid and safe option for either temporizing until definite surgery can be performed or as long-term therapy for women declining surgery. Common complications include bleeding, extrusion, vaginal discharge, pain, and constipation [1]. We report a case of ureterovaginal fistula secondary to a neglected pessary.
F. Dmitry (*) Department of Obstetrics and Gynecology, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467, USA e-mail: [email protected] S. Ambereen Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Floor Reconstruction, Maimonides Medical Center, Brooklyn, NY, USA e-mail: [email protected]
Case report In 2007 a 66-year-old multiparous woman with BMI 31 presented for a follow-up after a visit to an emergency room where she was evaluated for urinary retention secondary to complete procidentia. She reported a prolonged history of complete uterine prolapse complicated by frequent episodes of urinary tract infections (UTIs) and retention. The patient was otherwise healthy with no comorbidities, had no prior vaginal or abdominal surgeries, and did not smoke. On physical examination, uterine procidentia was evident. The current episode of retention was managed with placement of a urinary catheter, and a concurrent UTI was treated with antibiotics. The patient was counseled regarding her condition; management options, including surgical correction of her procidentia and pessary placement, were discussed with the patient. She was concerned about the surgical option, and therefore a Gellhorn pessary (3¼ in [83 mm]; Cooper Surgical, Trumbull, CT, USA) was placed, which successfully alleviated the prolapse and arrangements were made for follow-up. However, the patient did not adhere to the follow-up plan. Over the course of the following years, the patient regularly missed appointments, and developed several episodes of pessary erosion—each successfully treated by short-term pessary removal and topical estrogen therapy. After each episode a pessary was reinserted after confirming complete healing of the erosion, occasionally maintenance topical estrogen was prescribed. The patient also reported that with the pessary in place she was experiencing urinary incontinence upon abdominal stress and was continuously using sanitary pads. On a physical examination, urethral urinary leakage was demonstrated during valsalva after reducing the prolapse, and stress urinary incontinence was confirmed on urodynamics. Otherwise, a scarred area was visualized in the vaginal fornix, but continuous leakage was neither reported nor demonstrated. When the patient was counseled about the risks of longterm pessary use and had the pessary removed she would
Int Urogynecol J
present to ER within a few weeks with urinary retention and UTI. Several times the patient was booked for the surgical intervention to correct the prolapse, but she had never followed through, once cancelling the procedure on the day of the surgery. In March 2012 (almost 5 years after her initial presentation), the patient did come to the hospital for a vaginal hysterectomy and anterior and posterior vaginal wall repair (she declined a sling placement). During the surgical intervention there was no difficulty removing a pessary. Examination under anesthesia confirmed complete procidentia and a longstanding area of granulation tissue and scarring was appreciated in the right vaginal fornix. Vaginal hysterectomy, anterior colporrhaphy, and high uterosacral colposuspension were performed. During cystourethroscopy a brisk efflux of indigo carmine-stained urine was noted from the left ureter, but none was noted from the right. Standard maneuvers were performed to assess for patency, including transection of the right uterosacral suspension sutures. Repeat cystoscopy did not reveal ureteric flow. An unsuccessful attempt was made to pass a double J ureteric stent. Careful inspection of the highly scarred left vaginal epithelium revealed no leakage of urine; however, a pinpoint area of blue tinted epithelium was noted. This epithelium was carefully unroofed and the fistula was now fully appreciated with a flow of blue-tinged urine. The ureteric stent was now easily passed through the opening and placement was further confirmed with intraoperative fluoroscopy, confirming a ureterovaginal fistula at the site of the highly scarred and contracted vaginal epithelium. The vaginal stent was sutured to the epithelium and left in situ. A right nephrostomy tube was placed. Postoperatively, a CT scan demonstrated a narrow fistulous tract (Fig. 1) as well as hydroureter and hydronephrosis. At follow-up the patient had minimal vaginal leakage of urine with the majority of urine collecting in the nephrostomy tube. In July 2012, the patient underwent a robotically assisted right ureteroneocystostomy. Subsequently, the stent was removed and the patient recovered, with no alteration in kidney function.
Discussion Generally, pessary use is a safe option for the management of pelvic floor prolapse, although common complications include vaginal erosion, discharge, pain, constipation, and pessary extrusion. Most early complications associated with pessary use (erosion, discharge) are treated with the local application of estrogen preparations, occasionally requiring antibacterial treatment. In the case of recurrent erosion a change in the type of pessary can be recommended to avoid pressure points. Most patients using pessaries are elderly and sometimes, unfortunately, suffer dementia or are institutionalized.
Fig. 1 CT demonstrating fistulous communication (arrow) between the ureter (U) and the vagina (V)
Accordingly, it is critical that a proper system should be in place for assuring regular follow-up. When there is neglect, prolonged pressure from pessaries can cause serious complications. The most common fistulas associated with pessaries are vesicovaginal [2] and rectovaginal fistula [3] since these structures are directly adjacent to the vagina. A national sample review of Medicare beneficiaries based on ICD-9 codes reported a 3 % rate of vesicovaginal and rectovaginal fistula during 9 years of follow-up [4], although no specific information is provided on the methods of correction (conservative, office procedure, operative intervention). Based on a review of case reports published in the peer-reviewed journals [5], most cases of fistula are associated with neglect and require surgical intervention, although occasionally fistulae develop in elderly patients with appropriate follow-up. The latter review probably reflects a publication bias, since a larger number of fistulae are underreported and are probably treated conservatively or during the office procedure. Vesicovaginal and rectovaginal fistulae result from the pressure from an impacted pessary. In our case, we postulate that the prolapsed uterus brought the ureters into close proximity of the pressure points of the pessary. This situation was further aggravated by chronic inflammation and scarring from the erosion, which eventually contributed to fistula formation. The only case we have found in the literature describing the ureterovaginal fistula [6] also describes a fistula developing in a setting of chronic inflammation in the vaginal fornix, although in that case the pessary had been in place for 13 years and the woman presented complaining of the continuous leakage of urine (she stated that she did not even know that the pessary had been inserted). In our case the fistula was narrow and did not contribute to clinically significant urinary leakage, but scarring and narrowing of the lumen of the ureter contributed to the hydroureter and hydronephrosis.
Int Urogynecol J Conflicts of interest None. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
References 1. Sarma S, Ying T, Moore KH (2009) Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG 116(13):1715–1721
2. Goldstein I, Gilbert JW, Tancer ML (1990) A vesicovaginal fistula and intravesical foreign body. Am J Obstet Gynecol 163(2):589–591 3. Russel JK (1961) The dangerous vaginal pessary. Br Med J 2:1595–1597 4. Alperin M, Khan A, Dubina E, Tarnay C, Wu N, Pashos CL, Anger JT (2013) Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg 19(3):142–147 5. Arias BE, Ridgeway B, Barber MD (2008) Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 19(8):1173–1178 6. Molitor K (1961) [Ureterovaginal fistula caused by a forgotten pessary]. Dtsch Gesundheitsw 16:1980–1983
CASE REPORT
Ureterovaginal fistula linked to a retained pessary Fridman Dmitry & Sleemi Ambereen
Received: 19 September 2013 / Accepted: 4 January 2014 # The International Urogynecological Association 2014
Abstract The vaginal pessary is a safe and effective method for the correction of uterovaginal prolapse. Complications are uncommon, but include fistula formation. We report a case of fistulous communication between the ureter and vagina that developed in a patient who had had a pessary for more than 8 years. She initially presented with urinary retention secondary to complete procidentia and declined surgical intervention. The patient was not compliant with follow-up. Eventually, she was scheduled for a vaginal hysterectomy and pelvic floor reconstruction, during which the communicating tract was discovered between the ureter and vagina. Ultimate treatment involved stenting of the ureter and interval ureteroneocystostomy. Fistulae can develop between the ureter and the vagina in the case of procidentia and a retained pessary. Keywords Ureterovaginal fistula . Pessary . Complications
Introduction The use of a vaginal pessary as a means of pelvic prolapse correction is a valid and safe option for either temporizing until definite surgery can be performed or as long-term therapy for women declining surgery. Common complications include bleeding, extrusion, vaginal discharge, pain, and constipation [1]. We report a case of ureterovaginal fistula secondary to a neglected pessary.
F. Dmitry (*) Department of Obstetrics and Gynecology, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467, USA e-mail: [email protected] S. Ambereen Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Floor Reconstruction, Maimonides Medical Center, Brooklyn, NY, USA e-mail: [email protected]
Case report In 2007 a 66-year-old multiparous woman with BMI 31 presented for a follow-up after a visit to an emergency room where she was evaluated for urinary retention secondary to complete procidentia. She reported a prolonged history of complete uterine prolapse complicated by frequent episodes of urinary tract infections (UTIs) and retention. The patient was otherwise healthy with no comorbidities, had no prior vaginal or abdominal surgeries, and did not smoke. On physical examination, uterine procidentia was evident. The current episode of retention was managed with placement of a urinary catheter, and a concurrent UTI was treated with antibiotics. The patient was counseled regarding her condition; management options, including surgical correction of her procidentia and pessary placement, were discussed with the patient. She was concerned about the surgical option, and therefore a Gellhorn pessary (3¼ in [83 mm]; Cooper Surgical, Trumbull, CT, USA) was placed, which successfully alleviated the prolapse and arrangements were made for follow-up. However, the patient did not adhere to the follow-up plan. Over the course of the following years, the patient regularly missed appointments, and developed several episodes of pessary erosion—each successfully treated by short-term pessary removal and topical estrogen therapy. After each episode a pessary was reinserted after confirming complete healing of the erosion, occasionally maintenance topical estrogen was prescribed. The patient also reported that with the pessary in place she was experiencing urinary incontinence upon abdominal stress and was continuously using sanitary pads. On a physical examination, urethral urinary leakage was demonstrated during valsalva after reducing the prolapse, and stress urinary incontinence was confirmed on urodynamics. Otherwise, a scarred area was visualized in the vaginal fornix, but continuous leakage was neither reported nor demonstrated. When the patient was counseled about the risks of longterm pessary use and had the pessary removed she would
Int Urogynecol J
present to ER within a few weeks with urinary retention and UTI. Several times the patient was booked for the surgical intervention to correct the prolapse, but she had never followed through, once cancelling the procedure on the day of the surgery. In March 2012 (almost 5 years after her initial presentation), the patient did come to the hospital for a vaginal hysterectomy and anterior and posterior vaginal wall repair (she declined a sling placement). During the surgical intervention there was no difficulty removing a pessary. Examination under anesthesia confirmed complete procidentia and a longstanding area of granulation tissue and scarring was appreciated in the right vaginal fornix. Vaginal hysterectomy, anterior colporrhaphy, and high uterosacral colposuspension were performed. During cystourethroscopy a brisk efflux of indigo carmine-stained urine was noted from the left ureter, but none was noted from the right. Standard maneuvers were performed to assess for patency, including transection of the right uterosacral suspension sutures. Repeat cystoscopy did not reveal ureteric flow. An unsuccessful attempt was made to pass a double J ureteric stent. Careful inspection of the highly scarred left vaginal epithelium revealed no leakage of urine; however, a pinpoint area of blue tinted epithelium was noted. This epithelium was carefully unroofed and the fistula was now fully appreciated with a flow of blue-tinged urine. The ureteric stent was now easily passed through the opening and placement was further confirmed with intraoperative fluoroscopy, confirming a ureterovaginal fistula at the site of the highly scarred and contracted vaginal epithelium. The vaginal stent was sutured to the epithelium and left in situ. A right nephrostomy tube was placed. Postoperatively, a CT scan demonstrated a narrow fistulous tract (Fig. 1) as well as hydroureter and hydronephrosis. At follow-up the patient had minimal vaginal leakage of urine with the majority of urine collecting in the nephrostomy tube. In July 2012, the patient underwent a robotically assisted right ureteroneocystostomy. Subsequently, the stent was removed and the patient recovered, with no alteration in kidney function.
Discussion Generally, pessary use is a safe option for the management of pelvic floor prolapse, although common complications include vaginal erosion, discharge, pain, constipation, and pessary extrusion. Most early complications associated with pessary use (erosion, discharge) are treated with the local application of estrogen preparations, occasionally requiring antibacterial treatment. In the case of recurrent erosion a change in the type of pessary can be recommended to avoid pressure points. Most patients using pessaries are elderly and sometimes, unfortunately, suffer dementia or are institutionalized.
Fig. 1 CT demonstrating fistulous communication (arrow) between the ureter (U) and the vagina (V)
Accordingly, it is critical that a proper system should be in place for assuring regular follow-up. When there is neglect, prolonged pressure from pessaries can cause serious complications. The most common fistulas associated with pessaries are vesicovaginal [2] and rectovaginal fistula [3] since these structures are directly adjacent to the vagina. A national sample review of Medicare beneficiaries based on ICD-9 codes reported a 3 % rate of vesicovaginal and rectovaginal fistula during 9 years of follow-up [4], although no specific information is provided on the methods of correction (conservative, office procedure, operative intervention). Based on a review of case reports published in the peer-reviewed journals [5], most cases of fistula are associated with neglect and require surgical intervention, although occasionally fistulae develop in elderly patients with appropriate follow-up. The latter review probably reflects a publication bias, since a larger number of fistulae are underreported and are probably treated conservatively or during the office procedure. Vesicovaginal and rectovaginal fistulae result from the pressure from an impacted pessary. In our case, we postulate that the prolapsed uterus brought the ureters into close proximity of the pressure points of the pessary. This situation was further aggravated by chronic inflammation and scarring from the erosion, which eventually contributed to fistula formation. The only case we have found in the literature describing the ureterovaginal fistula [6] also describes a fistula developing in a setting of chronic inflammation in the vaginal fornix, although in that case the pessary had been in place for 13 years and the woman presented complaining of the continuous leakage of urine (she stated that she did not even know that the pessary had been inserted). In our case the fistula was narrow and did not contribute to clinically significant urinary leakage, but scarring and narrowing of the lumen of the ureter contributed to the hydroureter and hydronephrosis.
Int Urogynecol J Conflicts of interest None. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
References 1. Sarma S, Ying T, Moore KH (2009) Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG 116(13):1715–1721
2. Goldstein I, Gilbert JW, Tancer ML (1990) A vesicovaginal fistula and intravesical foreign body. Am J Obstet Gynecol 163(2):589–591 3. Russel JK (1961) The dangerous vaginal pessary. Br Med J 2:1595–1597 4. Alperin M, Khan A, Dubina E, Tarnay C, Wu N, Pashos CL, Anger JT (2013) Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg 19(3):142–147 5. Arias BE, Ridgeway B, Barber MD (2008) Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 19(8):1173–1178 6. Molitor K (1961) [Ureterovaginal fistula caused by a forgotten pessary]. Dtsch Gesundheitsw 16:1980–1983
