CASE 6808 Published on 08.07.2008

Unusual Urinary Incontinence

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Ian Barros D'Sa, Zubair Ali Khan
Queen Elizabeth Hospital, Birmingham, UK

Patient

26 years, female

Clinical History
A young woman had a 4 month of urinary incontinence, occuring randomly with some urgency, but with no stress symptoms. Only significant history was a previous caesarian section in the last year. Urological imaging demonstrated a clear cause.
Imaging Findings
A 26 year old woman had 4 months of urinary incontinence at random times causing occasional urgency. She had no stress symptoms. No previous history of urine infections or other significant medical problems. She had a Caesarian section about 1 year previously. She was treated with an indwelling urinary catheter, however this did not help her symptoms. She underwent an IVU and a cystogram to look for a possible vesico-vaginal fistula.
The IVU demonstrated normal kidney excretion and upper tracts. An abnormal appearance of the uterine cavity was demonstrated on the post release film. It was not viewed well on the post-micturition film. A subsequent cystogram confirmed the uterine cavity appearances posterior to the bladder. On sagittal imaging, a communication from the posterior bladder to the uterine fundus was clearly demonstrated. This confirmed the presence of a vesicouterine fistula.
Discussion
Vesicouterine fistula (VUF) presents usually with urinary incontinence. Other symptoms can also include vaginal discharge and haematuria. Aetiology can be mainly obstetric causes (eg; after caesarian section or rarely, uterine rupture during labour), inflammatory bowel disease or after radiotherapy for malignancy. Colovesicouterine fistulae may present with acute watery vaginal discharge or faecaluria. (1)
VUF can be diagnosed by cystoscopy and hysterography. Sometimes, VUF has been diagnosed on ultrasound, and hysterography has not been required. Ultrasound has previosusly shown defects in the posterior bladder and anterior uterine walls. (2) MRI has been used to show high signal on heavily T2 weighted imaging indicating fluid in the fistula. (3) CT has demonstrated leakage of contrast between bladder and uterus after cystography or hysterography, depending on the pressure gradient obtained and the fistula location relative to the uterine isthmus.(4)
Conservative treatment of VUF has been described by using hormonal manipulation to induce amenorrhoea. One study demonstrated success after six months of treatment with luteinizing hormone releasing hormone analogue. Surgical treatment at laparotomy has been the usual definitive treatment. Treatment of any infection is required and the fistula is excised with subsequent closure of the bladder and uterus.(5)(6)
In our case, this rare cause of incontinence occurred probably after the patient's caesarian section and was demonstrated initally on an IVU.
Differential Diagnosis List
Vesico-uterine fistula
Final Diagnosis
Vesico-uterine fistula
Case information
URL: https://www.eurorad.org/case/6808
DOI: 10.1594/EURORAD/CASE.6808
ISSN: 1563-4086