Vesicovaginal Fistula Visualized in Multiple Modalities

Author(s)

Ryan J, Moriarty H, Geoghegan T.

Ireland; Email:jamesryannchd@gmail.com

Patient

female, 43 year(s)

Clinical History

We present a 43-year-old female with a history of cervical cancer (stage IIIb squamous cell) who presented one-year post radiotherapy with urinary discharge and intermittent bleeding per vaginum. Subsequently she was diagnosed with a local recurrence of malignancy. Of note she had a history of Bechet’s Disease.

Imaging Findings

Contrast CT Urogram (Urographic phase): The distal portion of the right-sided nephroureteric stent can be seen in the posterior aspect of the bladder. Part of the stent extends from the bladder to the vault of the vagina. Contrast is seen within the bladder and within the vagina due to the communicating fistula. There is air in the bladder anteriorly (fig 1).

Pelvic MRI (PV gel contrast) T2 weighted sagittal image: Gel can be visualized extending from the vaginal vault to the posterior aspect of a decompressed bladder indicating the presence of a large VVF (fig 2).

PET: Fluorodeoxyglucose (FDG) avidity can be seen in the bladder and delineating the vaginal vault (fig 3). An axial fused PET/CT image again shows FDG accumulation in the vagina (fig 4).

Anterograde Ureteric Stent Placement: The distal part of the guide wire can be seen passing into the vagina. (fig 5).

Discussion

This patient has a number of risk factors that predispose to urogenital fistula formation; exposure to pelvic radiotherapy, urogenital malignancy and vasculitic disease [1–3]. Radiotherapy and vasculitis damage the small vessels supplying the pelvic mucosal surfaces. Subsequent intimal proliferation can lead to a pathological narrowing and occlusion of these blood vessels. This process is known as endarteritis obliterans and can cause mucosal necrosis and fistula formation [4].

In patients with gynaecological malignancy VVF and enterovaginal fistulas are most commonly encountered [4]. VVF is associated with significant morbidity. Incontinance, pain and bleeding are known complications [4, 5]. However, fistula formation is relatively rare in women with cervical cancer. One study retrospectively reviewed 2096 women that were treated for cervical cancer over a ten-year period. It found that 1.8% of the cohort developed a urogenital fistula [6].

In patients who develop a fistula during treatment for a gynaecologic malignancy it is crucial to determine whether or not the fistula is secondary to tumour recurrence or due to treatment effects (i.e. surgery or radiotherapy). Imaging plays a key role in this differentiation and is a crucial aspect in determining the correct therapeutic avenue to take in order to optimize patient outcomes [4].
VVF can be diagnosed by direct examination where urine is visualized leaking in to the vagina; intra-vesicular dye may be used to aid in this process [5]. A number of radiological investigations can be performed in order to delineate the location, complexity and precise course of the fistula. Often a number of modalities must be used to achieve an accurate diagnosis and to assist in management decisions i.e. pre-surgical planning [4].

MRI is the modality of choice for staging and monitoring local gynaecological malignancies [4, 7]. It provides detailed soft tissue images and can aid in the detection of a number of complications i.e. fistula formation, fibrosis post radiotherapy and tumor recurrence [4]. The use of gadolinium enhanced MRI increases sensitivity with regards to fistula detection [1]. One study involving 15 patients found that MRI correctly identified 91% of vaginal fistulas prior to clinical diagnosis [8].

VVF is a complex clinical entity requiring multi-modal team care. Cross sectional imaging and IR plays a central role in patient management.

Final Diagnosis

Differential Diagnosis List

References

[1]

Yu NC, Raman SS, Patel M, Barbaric Z. (2004) Fistulas of the genitourinary tract: a radiologic review.. Radiographics. Radiological Society of North America 2004 Jan 1;24(5):1331–52.
[2]

Chung HJ, Goo BC, Lee JH, Bang D, Lee KH, Lee E-S, et al. (2005) Behçet’s Disease Combined with Various Types of Fistula. Yonsei Med J. Oct 31;46(5):625.
[3]

Moore KN, Gold MA, McMeekin DS, Zorn KK. (2007) Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma. Gynecol Oncol. Sep;106(3):498–501.
[4]

Narayanan P, Nobbenhuis M, Reynolds KM, Sahdev A, Reznek RH, Rockall AG. (2009) Fistulas in malignant gynecologic disease: etiology, imaging, and management. Radiographics. Radiological Society of North America Jan 1;29(4):1073–83.
[5]

Garthwaite M, Harris N. (2010) Vesicovaginal fistulae. Indian J Urol Apr;26(2):253–6.
[6]

Emmert C, Köhler U. (1996) Management of genital fistulas in patients with cervical cancer. Arch Gynecol Obstet. Jan;259(1):19–24
[7]

Abou-El-Ghar ME, El-Assmy AM, Refaie HF, El-Diasty TA (2012) Radiological diagnosis of vesicouterine fistula: role of magnetic resonance imaging. Magn Reson Imaging Aug;36(2):438–42
[8]

Healy JC, Phillips RR, Reznek RH, Crawford RA, Armstrong P, Shepherd JH (1996) The MR appearance of vaginal fistulas. AJR Am J Roentgenol Dec;167(6):1487–9

Citation

Ryan J, Moriarty H, Geoghegan T. (2016, Jan 31).

Vesicovaginal Fistula Visualized in Multiple Modalities, {Online}.

URL: http://www.eurorad.org/case.php?id=12891

DOI: 10.1594/EURORAD/CASE.12891

ISSN: 1563-4086

Public License

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

To top