Fistulas
A genitourinary fistula is an abnormal communication between the urinary tract and another viscus, body cavity, or the skin. Most acquired GU fistulas in the developed world are iatrogenic — the consequence of pelvic surgery, radiation, or obstetric injury; management may involve drainage, reconstruction or diversion according to the cause and tissue condition. This section organizes fistulas by the patient population in which they occur, because the anatomic relationships, surgical approaches, and interposition options differ substantially between men and women.
For the operative origins of these injuries, see Procedures Causing GU Injury and Intraoperative Consultation.
Fistulas in Females
- Vesicovaginal FistulaThe most common acquired GU fistula in the developed world — iatrogenic after gynecologic surgery; obstetric in low-resource settings.
- Vesicouterine FistulaBladder-to-uterus communication — classically Youssef syndrome after cesarean delivery; menouria, amenorrhea, and preserved urinary continence.
- Ureterovaginal FistulaUreter–vagina communication after pelvic surgery; presents like VVF but requires a distinct diagnostic workup and upper-tract management.
- Rectovaginal FistulaRectum-to-vagina communication — obstetric, inflammatory bowel disease, radiation, or surgical injury; often encountered alongside urinary fistulas in complex multi-compartment cases.
- Obstetric FistulaProlonged-obstructed-labor fistula — the global paradigm of obstetric GU injury; distinctive geography, staged repair, and integrated rehabilitation.
Fistulas in Males
- Rectovesical FistulaBladder-to-rectum communication — post-prostatectomy (rare), radiation, pelvic malignancy, or traumatic.
- Rectourethral FistulaAlmost exclusively in men — post-prostate-cancer treatment (radical prostatectomy, radiation, cryotherapy, HIFU); demands coordinated urologic and colorectal reconstruction.
- Urethropubic FistulaUrethra-to-pubic-bone communication after pelvic fracture urethral injury or radical prostatectomy with osteitis pubis; often requires combined reconstruction with pubectomy.
- Urethrocutaneous FistulaThe most common cutaneous GU fistula — complication of hypospadias repair, urethroplasty dehiscence, perineal trauma, or Fournier's gangrene.
- Urethroperineal FistulaUrethra-to-perineum communication — Fournier's sequela, complex urethroplasty failure, or perineal trauma.
Fistulas (All Patients)
- Pyeloenteric FistulaAbnormal communication between the renal pelvis / collecting system and bowel — most commonly duodenum, colon, or jejunum; usually secondary to infection, calculus disease, or penetrating trauma.
- Nephropleural FistulaCommunication between the collecting system and pleural space — most often after PCNL in a supracostal puncture or following thoracoabdominal trauma.
- Ureterocolonic FistulaUreter–colon communication from diverticular disease, Crohn's, radiation, malignancy, or iatrogenic colorectal injury.
- Colovesical & Small Bowel FistulasEnterovesical fistulas from diverticulitis (most common), Crohn's disease, colorectal malignancy, radiation, and surgical injury — pneumaturia and fecaluria are characteristic clues requiring confirmation.
- Vesicocutaneous FistulaBladder-to-skin communication — post-operative, radiation-associated, chronic catheterization, or malignant erosion.
- Urinary Fistula After Kidney TransplantUreteroneocystostomy leak, ureteral necrosis from distal-ureter ischemia, and graft-to-bladder disruption — the principal early urologic complication of renal transplantation.
- Vascular-Urinary FistulaArterioureteral fistulas can cause life-threatening hemorrhage; the page also covers renal arteriovenous fistulas, including post-biopsy lesions.
Complex Fistula Principles
Certain principles cut across every fistula type and every compartment. Any repair undertaken in the following setting is considered complex, and the operative plan is different from a primary, uncomplicated fistula:
- Multiplicity — two or more fistulous tracts
- Prior failed repair(s) — at least one previous attempt
- Hostile tissue — radiation, ischemia, infection, or inflammatory bowel disease
- Large defect — significant tissue loss precluding primary closure
- Multi-organ involvement — urinary + enteric + vaginal / cutaneous
- Associated malignancy or recurrent cancer
Staging
Complex fistulas may need staged care. Timing depends on anatomy, tissue quality, infection and the need for diversion; a universal waiting interval is not supported.[1]
- Damage control — urinary and/or fecal diversion; drainage of abscess or urinoma; nutritional optimization
- Tissue preparation — address edema, inflammation, necrosis and infection before definitive repair; individualize timing rather than requiring 3–6 months for every fistula
- Definitive reconstruction — single-stage if possible; may require multiple procedures
Tissue Interposition — The Complexity Step
Vascularized tissue interposition is not routine for every simple primary fistula, but it becomes a central planning step when the field is complex — radiation, recurrent failure, tissue loss, infection, inflammatory disease, mesh, or overlapping urinary-enteric compartments:
| Tissue | Best Use |
|---|---|
| Martius flap (labial fat pad) | Vaginal / perineal fistulas; women; reliable, straightforward |
| Gracilis muscle flap | Perineal / rectourethral; irradiated pelvis; excellent bulk |
| Omental pedicle | Abdominal approach; radiation; fills dead space |
| Peritoneal flap | Laparoscopic / robotic VVF repair; limited bulk |
| Fasciocutaneous flap | Large cutaneous defects; perineal reconstruction |
Multi-Compartment Fistulas
- Simultaneous involvement of bladder, vagina, and rectum (cloacal-type) requires coordinated urologic, gynecologic, and colorectal reconstruction.
- Often requires fecal + urinary diversion, staged repair, and gracilis or omental flap.
- Urinary diversion (continent or incontinent) may be the most reliable long-term solution when the bladder is unsalvageable.
Radiation Fistulas
- Tissue quality is the rate-limiting factor.
- Plan vascularized tissue interposition when attempting repair of a radiation-associated urinary fistula; this is an EAU recommendation based on limited evidence.[1]
- Recurrence rates are higher; patient counseling about realistic expectations is essential.
- Permanent urinary and/or fecal diversion should be presented as a valid and dignified option.
Key Operative Principles
- Address urinary obstruction before or with fistula repair to protect the reconstruction.
- Vascularized tissue is the common denominator in all complex repair.
- Diversion is not failure — for radiation or multiply recurrent fistulas, it may be the best quality-of-life decision.
- Multidisciplinary planning (urology, colorectal, plastics, gynecology) is essential for multi-compartment cases.
- Document each prior repair attempt, technique, and tissue used — this drives the next-step strategy.
References
1. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: urinary fistula. 2026. Section 4.8; the disease-specific pages address other fistula populations.