Skip to main content

Vesicocutaneous Fistula

A vesicocutaneous fistula (VCF) is a rare abnormal communication between the urinary bladder and the skin surface.[1] Among the least common urinary fistulae, it is most frequently encountered as a consequence of pelvic trauma, prior surgery, radiation therapy, neurogenic-bladder complications, or chronic infection.[2][3][4][5][6]

For operative selection, see the Fistula Repair (All Patients) database.

See also: The Bladder, Fistulas landing page.

Definition and Classification​

A vesicocutaneous fistula is a persistent, epithelialized or granulation-lined tract connecting the bladder lumen to the cutaneous surface.[1] Useful classifications include:

  • Cutaneous opening: suprapubic (most common), inguinoscrotal, perineal, or thigh[2][3][4][7]
  • Etiology: traumatic, iatrogenic, radiation-induced, infectious, or neurogenic-bladder–related
  • Complexity: simple (short, direct tract) vs. complex (long, tortuous, often with associated tissue loss or abscess cavity)

VCF is distinct from other bladder fistulae such as vesicovaginal, vesicouterine, and colovesical fistulae, although the general principles of fistula management overlap.[8][9]

Etiology​

MechanismNotes
Pelvic-fracture bladder injuryMost frequently described mechanism. Extraperitoneal rupture occurs in 60–90% of pelvic fractures with bladder injury; complex extraperitoneal injuries can drive urine extravasation along tissue planes to skin, with a VCF reported seven years after injury. The separately cited thigh-abscess case demonstrated a posterior urethral, rather than bladder, communication on contrast imaging.[2][4][10][11]
Lower abdominal / pelvic penetrating traumaLoss of skin, fascia, and muscle leaves bladder exposed; closure is difficult without overlying tissue coverage.[3]
Iatrogenic — post-surgicalAfter bladder augmentation, pelvic surgery, or hernia repair. A pediatric VCF after augmentation cystoplasty closed with vacuum-assisted closure (VAC) alone.[1]
Iatrogenic — suprapubic catheter complicationsCatheter displacement, traction on the Foley balloon, or chronic tract issues sustain a fistula around the cystostomy. Long-term indwelling catheters significantly raise the risk of urethral and cutaneous fistulae.[12][13]
Inguinal hernia repairBladder herniation into the inguinal canal (1–4% of inguinal hernias); incarceration with abscess formation can produce VCF presenting as a scrotal abscess.[7]
Radiation therapyPelvic RT for cervical, vulvar, rectal, or prostate cancer; latent period 3 months to 30 years. Endarteritis obliterans → hypoxia → fibrosis → necrosis → fistula. Risk factors: high dose, concurrent chemotherapy, prior surgery, diabetes, and post-radiation biopsy was associated with fistula in one cervical-cancer cohort; this is not a VCF-specific causal estimate.[5][14][15][16] A chronic radiation-induced VCF after liposarcoma RT required bipedicled latissimus + serratus anterior free-flap reconstruction.[17]
Neurogenic bladderUnderrecognized cause. In a selected series of 21 patients with neurogenic-bladder urinary-cutaneous fistulas (not exclusively VCF), drivers were decubitus ulcers (33%), wound infection / abscess (24%), condom-catheter complications (19%), traumatic catheterization (19%), and pelvic trauma (5%). Median follow-up 67 months; 17/21 required permanent surgical or suprapubic-tube urinary diversion; this selected cohort is not a universal VCF prognosis.[6]
Infection / inflammatoryPerinephric or pelvic abscess eroding to skin; a remarkable case described a post-infectious intravesical femoral head from septic hip producing VCF as a labial sinus.[18]
MalignancyLocally advanced bladder, colorectal, or other pelvic tumors; a sunitinib-treated unresectable GIST with bladder invasion developed VCF that closed when the anti-angiogenic was discontinued.[19]

Pathogenesis​

Factors that may impede spontaneous closure include:[20]

  1. Distal obstruction maintaining flow through the tract
  2. Foreign body or calculus physically blocking closure
  3. Granulomatous tissue or malignancy in the tract
  4. Epithelialization of the tract — the fistula develops its own lining

A fifth, particularly relevant to VCF, is radiation-induced ischemia — irradiated tissue has poor vascularity and limited healing capacity.[14][17]

Clinical Presentation​

Presentation is dictated by location and tract size:

  • Continuous or intermittent leakage of urine from the skin — hallmark; clear urine if uninfected, turbid or purulent if infected
  • Skin excoriation and maceration from chronic urine exposure
  • Recurrent perifistular cellulitis or abscess
  • Unusual presentations:
    • Thigh abscess from extravasation tracking along fascial planes years after pelvic trauma[2][4]
    • Scrotal abscess from inguinoscrotal bladder herniation[7]
    • Labial sinus from infected hip joint eroding into bladder[18]
  • Systemic symptoms — fever, malaise, sepsis in complicated cases

Evaluation​

Clinical assessment​

A focused history (prior pelvic trauma, surgery, RT, neurogenic bladder, malignancy) and exam to identify the cutaneous opening and characterize the drainage anchor the workup.

Confirmatory tests​

TestRole
Fluid creatinine / bladder dye testFluid creatinine above serum supports urine leakage; retrograde bladder filling with dilute dye may confirm communication. IV dye has also been described, but is not required.[2][19]
CT abdomen / pelvis with delayed urographic phase (5–20 min)Primary imaging modality; demonstrates contrast extravasation through the tract and identifies abscess, calculi, malignancy, or bladder deformation.[2][9]
Cystography (retrograde or CT cystography)Retrograde CT or plain-film cystography evaluates bladder integrity; both have comparable sensitivity when adequately performed. Passive excreted contrast alone does not reliably exclude a leak.[28][11]
CystoscopyDirect visualization of the intravesical opening and assessment of mucosa for malignancy, radiation change, or foreign body
FistulographyContrast injection at the skin opening delineates tract anatomy
MRIUseful for complex / radiation / malignant cases for soft-tissue detail
IVPLargely supplanted by CT urography but can show bladder deformation and the fistula origin.[2]

Management​

General principles​

The same six principles that govern complex enterocutaneous and entero-urinary fistula management apply:[21][22][23][24]

  1. Control of sepsis (drainage of abscess, broad-spectrum antibiotics)
  2. Urinary diversion / decompression to divert urine away from the tract
  3. Skin care and wound management to protect perifistular skin
  4. Nutritional optimization, particularly in complex or post-radiation cases
  5. Treatment of the underlying cause — remove foreign bodies, relieve obstruction, treat malignancy
  6. Definitive surgical repair once the patient is optimized and conservative therapy has failed

Conservative management​

Appropriate for small, uncomplicated fistulae without distal obstruction, foreign body, or malignancy:

  • Continuous bladder drainage, with catheter size and duration tailored to drainage, clot burden, tissue quality and healing. The ACS recommendation for ≥18 Fr drainage for at least seven days concerns acute uncomplicated extraperitoneal bladder injury, not a validated regimen for every chronic VCF. Confirm closure when indicated before removing drainage.[11]
  • Vacuum-assisted closure (VAC) removes excess fluid, reduces edema, promotes granulation, and approximates wound edges. A pediatric VCF after augmentation closed with VAC alone, and VAC has been used as a preoperative bridge before definitive flap reconstruction.[1][25]

Surgical management​

Required for most complex, chronic, or refractory VCF.

  • Tract excision and bladder closure — selected according to tissue viability and the underlying cause. Achieve a tension-free, watertight repair; the cited case does not establish one mandatory closure protocol for every VCF.[2]
  • Partial cystectomy — when the bladder wall around the fistula is extensively damaged or diseased.[2]
  • Tissue interposition — central principle for complex or recurrent fistulae:
    • Omental flap — most commonly used interposition tissue for abdominopelvic fistulae
    • Muscle flaps — rectus abdominis, gracilis, or rectus femoris musculocutaneous flaps for large defects[25]
    • Free tissue transfer — for the most complex radiation-induced VCF with extensive tissue loss; bipedicled latissimus dorsi + serratus anterior free flap successfully reconstructed both bladder and abdominal wall with no recurrence at 4 months.[17]
  • Closure with overlying tissue reconstruction — Bockrath's two extensive traumatic defects required coverage after previous simple closures had failed; this does not mean every small VCF requires a muscle flap.[3]
  • Transurethral suture cystorrhaphy — minimally invasive endoscopic technique reported for selected vesical fistulae, with cystoscopically assisted suture closure of both vesicovaginal and vesicocutaneous fistulae without open surgery.[26]

Neurogenic bladder with urinary-cutaneous fistula​

Bladder pressure, emptying, catheter trauma, pressure ulcers and infection must all be assessed; high pressure should not be assumed in every patient. The following selected 21-patient series included urinary-cutaneous fistulas at different sites:[6]

  • Surgical repair was attempted in 13 of 21 patients, but 69% (9/13) eventually required permanent urinary diversion despite repair attempts
  • 8 patients underwent primary urinary diversion at presentation
  • Overall, 17/21 (81%) required permanent surgical or suprapubic-tube urinary diversion. The article describes a conduit catheter, not a condom catheter; external condom collection is not equivalent to surgical diversion.

Outcomes underscore the need to address the actual storage, emptying, outlet and wound problems before or alongside fistula repair; high bladder pressure is not universal.

Radiation-induced VCF​

Radiation injury can impair healing; assess bladder function, viable tissue, recurrent malignancy and the patient's goals. Vascularized coverage or urinary diversion may be necessary for extensive damage. Lau reported short-term healing after debridement, bladder closure and omental coverage in a patient with a reasonable-capacity bladder and no evident tumor recurrence who wished to avoid a stoma. Ludolph described free-flap reconstruction for a large combined bladder/abdominal-wall deficit.[5][17]

These case reports do not provide a reliable VCF-specific failure percentage. General pelvic-radiation and vaginal-fistula literature can inform planning, but must not be treated as a VCF outcomes cohort.[15][27]

Prevention​

  • Prompt recognition and repair of bladder injuries — particularly with pelvic fractures; cystography when bladder injury is suspected.[11]
  • Secure anchoring of suprapubic catheters to prevent traction, displacement, and balloon extrusion.[12]
  • Avoid unnecessary biopsy trauma in irradiated fields, but obtain indicated tissue diagnosis when recurrence or another malignancy is suspected; the reported biopsy association does not justify missing cancer.[16]
  • Individualized neurogenic-bladder care — address unsafe storage pressure when present, inadequate emptying, catheter trauma and pressure wounds, with a sustainable drainage and surveillance plan.[6][13]

Outcomes​

  • Post-traumatic VCF — outcomes scale with extent of tissue loss; simple defects close with layered repair and overlying tissue coverage, while extensive defects may require staged reconstruction.[3]
  • Post-surgical VCF — generally favorable when diagnosed early and managed with diversion ± VAC; spontaneous closure is achievable with adequate decompression.[1]
  • Radiation-associated VCF — prognosis depends on tissue loss, bladder function and reconstructive feasibility; the available case reports do not establish a pooled closure or failure rate.[5][17]
  • Neurogenic bladder with urinary-cutaneous fistula — 17/21 in one selected cohort eventually required surgical or suprapubic-tube diversion; this does not establish an 81% requirement for all neurogenic VCF.[6]

See Also​

References​

1. Elizondo RA, Au JK, Gargollo PC, Tu DT. "Vacuum-Assisted Closure of a Vesicocutaneous Fistula in a Pediatric Patient After Bladder Cystoplasty." Urology. 2016;95:190–191. doi:10.1016/j.urology.2016.04.001

2. Kosaka T, Asano T, Azuma R, et al. "A Case of Vesicocutaneous Fistula to the Thigh." Urology. 2009;73(4):929.e7–8. doi:10.1016/j.urology.2008.04.063

3. Bockrath JM, Nanninga JB, Lewis VL, Grayhack JT. "Extensive Suprapubic Vesicocutaneous Fistula Following Trauma." J Urol. 1981;125(2):246–248. doi:10.1016/s0022-5347(17)54989-7

4. Banihani MN, Al-Azab RS, Waqfi NR, Kharashgah MN, Al Manasra AR. "Vesicocutaneous Fistula Presenting as a Thigh Abscess." Singapore Med J. 2009;50(9):e336–e337.

5. Lau KO, Cheng C. "A Case Report — Delayed Vesicocutaneous Fistula After Radiation Therapy for Advanced Vulvar Cancer." Ann Acad Med Singap. 1998;27(5):705–706.

6. Raup VT, Eswara JR, Weese JR, Potretzke AM, Brandes SB. "Urinary-Cutaneous Fistulae in Patients With Neurogenic Bladder." Urology. 2015;86(6):1222–1226. doi:10.1016/j.urology.2015.07.057

7. Manikandan R, Burke Y, Srirangam SJ, Collins GN. "Vesicocutaneous Fistula: An Unusual Complication of Inguinoscrotal Hernia." Int J Urol. 2003;10(12):667–668. doi:10.1046/j.1442-2042.2003.00715.x

8. Rogers RG, Jeppson PC. "Current Diagnosis and Management of Pelvic Fistulae in Women." Obstet Gynecol. 2016;128(3):635–650. doi:10.1097/AOG.0000000000001519

9. Moon SG, Kim SH, Lee HJ, Moon MH, Myung JS. "Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings." Korean J Radiol. 2001;2(2):97–104. doi:10.3348/kjr.2001.2.2.97

10. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and Uro-Trauma: WSES-AAST Guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

11. American College of Surgeons. Best Practices Guidelines: Management of Genitourinary Injuries. 2025. Full guideline.

12. Vaidyanathan S, Hughes PL, Soni BM. "Unusual Complication of Suprapubic Cystostomy in a Male Patient With Tetraplegia: Traction on Foley Catheter Leading to Extrusion of Foley Balloon From Urinary Bladder and Suprapubic Urinary Fistula." ScientificWorldJournal. 2007;7:1575–1578. doi:10.1100/tsw.2007.253

13. Utomo E, Groen J, Blok BF. "Surgical Management of Functional Bladder Outlet Obstruction in Adults With Neurogenic Bladder Dysfunction." Cochrane Database Syst Rev. 2014;(5):CD004927. doi:10.1002/14651858.CD004927.pub4

14. Denton AS, Clarke NW, Maher EJ. "Non-Surgical Interventions for Late Radiation Cystitis in Patients Who Have Received Radical Radiotherapy to the Pelvis." Cochrane Database Syst Rev. 2002;(3):CD001773. doi:10.1002/14651858.CD001773

15. Turina M, Mulhall AM, Mahid SS, Yashar C, Galandiuk S. "Frequency and Surgical Management of Chronic Complications Related to Pelvic Radiation." Arch Surg. 2008;143(1):46–52; discussion 52. doi:10.1001/archsurg.2007.7

16. Feddock J, Randall M, Kudrimoti M, et al. "Impact of Post-Radiation Biopsies on Development of Fistulae in Patients With Cervical Cancer." Gynecol Oncol. 2014;133(2):263–267. doi:10.1016/j.ygyno.2014.02.005

17. Ludolph I, Apel H, Horch RE, Beier JP. "Treatment of a Chronic Vesicocutaneous Fistula and Abdominal Wall Defect After Resection of a Soft Tissue Sarcoma Using a Bipedicled Latissimus Dorsi and Serratus Anterior Free Flap." Int J Urol. 2014;21(11):1178–1180. doi:10.1111/iju.12545

18. Jain V, Sen B, Jain P, et al. "Postinfection Intravesical Femoral Head Resulting in a Vesicocutaneous Fistula: A Bizarre Presentation and Outcome." Pediatr Infect Dis J. 2006;25(10):954–955. doi:10.1097/01.inf.0000237923.61105.1a

19. Watanabe K, Otsu S, Morinaga R, et al. "Vesicocutaneous Fistula Formation During Treatment With Sunitinib Malate: Case Report." BMC Gastroenterol. 2010;10:128. doi:10.1186/1471-230X-10-128

20. Jones J, Aboumarzouk OM. "Fistulae and Sinuses." Chapter 24.

21. Pepe G, Chiarello MM, Bianchi V, et al. "Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights Into Management Using Negative Pressure Wound Therapy." J Clin Med. 2024;13(5):1279. doi:10.3390/jcm13051279

22. Shackley DC, Brew CJ, Bryden AA, et al. "The Staged Management of Complex Entero-Urinary Fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

23. Gill HS. "Diagnosis and Surgical Management of Uroenteric Fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

24. Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI, et al. "ASPEN-FELANPE Clinical Guidelines." JPEN J Parenter Enteral Nutr. 2017;41(1):104–112. doi:10.1177/0148607116680792

25. Katsuragi Y, Ueda K, Kajikawa A, Tateshita T, Okochi H. "Repair of a Huge Vesicocutaneous Fistula With the Rectus Femoris Musculocutaneous Flap and VAC." J Wound Care. 2010;19(4):157–159. doi:10.12968/jowc.2010.19.4.157

26. McKay HA. "Vesicovaginal and Vesicocutaneous Fistulas: Transurethral Suture Cystorrhaphy as a New Closure Technique." J Urol. 1997;158(4):1513–1516. doi:10.1016/s0022-5347(01)64256-3

27. Angioli R, Penalver M, Muzii L, et al. "Guidelines of How to Manage Vesicovaginal Fistula." Crit Rev Oncol Hematol. 2003;48(3):295–304. doi:10.1016/s1040-8428(03)00123-9

28. European Association of Urology. Urological Trauma Guidelines. 2026. Guideline.