Genital tract fistula refers to an abnormal passage between a part of the genital tract and the urinary tract or intestines, with the former called urinary fistula and the latter called fecal fistula. **Urinary Fistula** In rural areas of China, especially remote mountainous regions, obstetric trauma is the most common cause of urinary fistula. Obstetric fistulas are mostly caused by difficult deliveries, such as cephalopelvic disproportion or prolonged labor, where the anterior vaginal wall, urethra, bladder, and other soft tissues are compressed between the fetal head and the maternal pubic symphysis for an extended period, leading to ischemia, hypoxia, necrosis, and eventually the formation of a fistula. Symptoms typically appear 7–10 days postpartum as fistula-induced urinary leakage. Another cause is surgical injury. Urinary fistulas may result from obstetric vaginal-assisted deliveries, cesarean sections, or gynecological abdominal or vaginal hysterectomies that inadvertently damage the urinary tract, often due to improper handling or technique. The timing of symptom onset depends on the injury site. Additionally, advanced cervical cancer or vaginal cancer eroding the bladder or urethra can form fistulas. Prolonged or oversized vaginal pessaries may also cause urinary or fecal fistulas. Trauma, radiation therapy, or other injuries to the urethra or bladder can similarly lead to fistulas. Urinary fistulas can be classified into the following types: (1) Vesicovaginal fistula, (2) Vesicourethrovaginal fistula, (3) Vesicocervical fistula, (4) Urethrovaginal fistula, (5) Ureterovaginal fistula, (6) Vesicouterine fistula.

1. Medical history Fistula disease The main symptom is urine leakage, where urine continuously flows out from the vagina and cannot be controlled voluntarily. The manifestations vary slightly depending on the location and size of the fistula. Some patients experience continuous urine leakage day and night, some leak urine when lying flat or on their side, some leak urine when standing, and some, in addition to being able to urinate voluntarily, also have urine involuntarily and intermittently leaking from the vagina. Symptoms may differ based on the size and location of the fistula: (1) In cases of vesicovaginal fistula or vesicocervicovaginal fistula with a large fistula opening, the patient completely loses the ability to control urination. (2) In cases of ureterovaginal fistula, if it occurs on one side, since urine from the healthy side can still enter the bladder, the patient may experience both fistula-related urine leakage and controlled urination. (3) In cases of urethrovaginal fistula, if the fistula opening is below the internal urethral orifice and the urethral sphincter functions well, the urine leakage is milder, and the patient may still urinate voluntarily. Due to prolonged exposure to urine, the skin of the vulva, inner thighs, and buttocks may become irritated, leading to vulvar cutaneous pruritus and burning pain. If bacterial infection ascends, complications such as cystitis and pyelitis may occur. Generally, the onset of the disease has a clear cause. Congenital urinary tract malformations are indicated if urine leakage is present from birth. For young, unmarried or childless women presenting with urine leakage, a history of subcutaneous nodules should be inquired about.
2. Physical examination Diagnosis can be confirmed by visualizing the fistula opening on the anterior vaginal wall during speculum examination or digital vaginal examination. For small fistulas that are difficult to locate, a probe or metal catheter can be inserted into the urethra to explore the fistula in conjunction with a finger inside the vagina. The patient can also be examined in the knee-chest position after urination.
3. Auxiliary examinations 1. Methylene blue test: Inject 100–200 ml of diluted, sterilized methylene blue solution into the bladder via a urethral catheter, then clamp the catheter and inspect the vagina. Blue fluid leaking from a small opening on the anterior vaginal wall indicates a vesicovaginal fistula; leakage from the cervical os suggests a vesicocervical or vesicouterine fistula; clear urine leakage indicates a ureterovaginal fistula. 2. Indigo carmine test: Intravenously inject 5 ml of indigo carmine, place dry gauze in the vagina, and observe. Blue fluid leaking from the fistula opening can typically be seen within 5–7 minutes. This test is used for patients with negative methylene blue test results to further determine the location of the fistula. 3. Cystoscopy: Helps determine the number, location, and size of fistulas, as well as their relationship to the ureteral orifices and internal urethral orifice.

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bubble_chart Treatment Measures

1. Non-surgical treatment: For bladder-vaginal fistulas occurring after childbirth or surgery, insert a thicker indwelling catheter through the urethra. Open drainage for 4–6 weeks may allow small fistulas to heal, while larger ones may reduce in size. Concurrent use of antibiotics is recommended to prevent infection. For ureter-vaginal fistulas, a ureteral catheter can be left in place for two weeks, positioned above the fistula. 2. Surgical treatment: (1) Fresh fistulas should be repaired immediately. (2) For older or larger fistulas that cannot heal naturally, repair surgery should be performed 3–6 months after the fistula forms.

bubble_chart Prevention

1. Properly manage the childbirth process, and standardize surgical procedures. 2. If urinary tract injury is discovered during surgery, repair it promptly and correctly. If bladder injury is suspected, insert a urinary catheter early to ensure smooth urine flow and keep the bladder empty, promoting the healing of injured tissues and preventing fistula formation. Fecal fistula.