Transperineal ultrasonographic diagnosis of vesicovaginal fistula

Transperineal Ultrasonographic Diagnosis of Vesicovaginal Fistula Ovadia Abulafia, MD, Harris L. Cohen, MD, Daniel L. Zinn, MD, Kevin Holcomb, MD, David M. Sherer, MD

Vesicovaginal fistula is a known postoperative complication of gynecologic and obstetric abdominal and vaginal procedures.1,2 Infrequently, vesicovaginal fistulas may result from bladder invasion by pelvic organ malignant processes.2 We present an unusual case in which a patient with advanced vaginal squamous cell carcinoma had presenting features of urinary incontinence, vaginal bleeding, and pain. A vesicovaginal fistula was depicted by transperineal ultrasonography. CASE REPORT A 44 year old para 1 woman was referred because of complaints of constant urinary incontinence, vaginal pain, and bleeding of 6 months’ duration. Her past medical history consisted of benign thyroid goiter, current cocaine abuse, and cigarette smoking of 10 years’ duration. Physical examination on admission revealed a cachectic female in Received November 18, 1997, from the Division of Gynecologic Oncology, Departments of Obstetrics and Gynecology (O.A.), and Radiology, Kings County Hospital, State University of New York, Health Science Center at Brooklyn, Brooklyn, New York; and Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Revised manuscript accepted for publication January 25, 1998. Address correspondence and reprint requests to Ovadia Abulafia, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, State University of New York, Health Science Center at Brooklyn, 450 Clarkson Avenue, Box 24, Brooklyn, NY 11203.

no acute distress, weighing 85 lb, with normal vital signs. Pertinent physical findings included a soft, nontender abdomen with no palpable masses. Pelvic examination disclosed a normal introitus and a 3 to 4 cm fungating mass replacing the lower anterior vaginal wall, encasing the urethra, with a palpable indentation suggestive of a possible urinary fistula. The uterine cervix was normal in appearance, size, and palpation. A normal-sized uterus and adnexa were palpated. Biopsy of the vaginal mass revealed squamous cell carcinoma. Cervical Papanicolaou smear was indicative of high-grade squamous epithelial lesion, for which the patient underwent a loop electroexcision procedure, which was negative for invasion. Owing to the lower location of the tumor, the constant urinary incontinence, and the concern about a possible vesicovaginal fistula, transperineal ultrasonography was performed. A 5 MHz transvaginal probe attached to an ATL Ultramark 9 HDI machine (Advanced Technology Laboratories, Bothell, WA) was placed transperineally and axial, sagittal, and parasagittal views were obtained. Varying degrees of angulation were used for the axial views. This procedure allowed the imaging of a vesicovaginal fistula (Figs. 1, 2). After extensive counseling the patient underwent examination under anesthesia and proctoscopy. Cystoscopy, although planned, was not attempted owing to the tumor’s obstruction of the urethra. Exploratory laparotomy was performed, and multiple positive bilateral pelvic lymph nodes were encountered. Because of advanced metastatic disease, pelvic exenteration was not attempted. However, a diverting transverse colon conduit was performed. The patient’s postoperative course was complicated by febrile morbidity of unknown cause. She was discharged after an otherwise uneventful postoperative course.

 1998 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 17:333–335, 1998 • 0278-4297/98/$3.50

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VESICOVAGINAL FISTULA

J Ultrasound Med 17:333–335, 1998

A B Figure 1 Transperineal ultrasonography of vesicovaginal fistula. A, Axial plane. The periurethral soft tissue (u) is greater in thickness than normal. This is consistent with tumor involvement. A mass impression is evident at the base of the fluid-filled bladder (bl). B, Sagittal plane. Fluid is seen in the urethra (u) and in the bladder (bl). Thick vaginal (vag) soft tissue is again noted. Fluid from the bladder is seen to cross over into the area of the vagina (arrows). This does not yet confirm the presence of a fistula.

DISCUSSION Imaging diagnosis of urogenital fistulas has traditionally included intravenous pyelography, cystography, cystoscopy, and instillation of contrast material (either intravenously or by Foley catheter into the bladder), which will allow identification of a fistula with vaginal involvement if the contrast material gains access to the vagina.3 Recently, imaging diagnosis of vesicovaginal and uterovesical fistulas has been reported with transvaginal

ultrasonography.4,5 Our case demonstrates that in the presence of low vesicovaginal fistula the entire fistula tract may be delineated by noninvasive transperineal ultrasonography. This case suggests that in cases of tumor in the lower vagina with symptoms suggestive of urogenital fistula, transperineal ultrasonography should be considered a potential diagnostic tool.

Figure 2 Transperineal ultrasonography of vesicovaginal fistula. A, Sagittal plane. Image was obtained 1 min later than that in Figure 1B and shows a narrower bladder (bl) periphery with fluid present within the vagina (vag). B, Sagittal plane. Fluid is seen in the bladder (bl), within the fistula (arrows), and in the vagina (vag). Again noted are thick vaginal and urethral walls, consistent with tumor involvement. This proves the presence of the vesicovaginal fistula. A

B

J Ultrasound Med 17:333–335, 1998

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Menefee SA, Elkins T: Urinary fistula. Curr Opinion Obstet Gynecol 8:380, 1997

2.

Bladou F, Houvenaeghel G, Delpero JR, et al: Incidence of management of major urinary complications after pelvic exenteration for gynecological malignancies. J Surg Oncol 58:91, 1995

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Mishell DR, Stenchever MA, Droegemueller W, et al: Postoperative counselling and management. In Comprehensive Gynecology. St. Louis, CV Mosby, 1997, p 740

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Yang JM, Su TH, Wang KG: Transvaginal sonographic findings in vesicovaginal fistula. J Clin Ultrasound 22:201, 1994

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Huang SC, Yao BL, Chou CY: Transvaginal ultrasonographic findings in vesico-uterine fistula. J Clin Ultrasound 24:209, 1996

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