Vesicouterine Fistula
A vesicouterine fistula (VUF) is an epithelialized communication between the bladder and the uterine cavity. It is the rarest urogenital fistula — roughly 1–4% of all GU fistulas — but its incidence is rising globally in parallel with cesarean delivery rates, and cesarean section accounts for 83–93% of cases.[1][2][3] VUF is unique in two ways the reconstructive surgeon must respect: the intact cervix often acts as a one-way valve, so the classic presentation is menouria with preserved urinary continence rather than vaginal urine leakage; and because patients are almost always of reproductive age, the operation is judged not just on closure but on uterine preservation and fertility.
For the operation that produces nearly every VUF, see Cesarean Section. For the broader fistula framework, see the Fistulas landing page.
Epidemiology
- VUF accounts for 1–4% of all urogenital fistulas — the least common type.[2][5]
- Historically rare before 1947 when low-segment cesarean replaced the classical incision; recognition has risen with cesarean rates.[2]
- Mean age at presentation 27–31 years — reproductive-age population.[6][7][8]
Etiology and Pathogenesis
| Cause | Notes |
|---|---|
| Cesarean section | 83–93% of all VUF; risk rises with each repeat cesarean — 78.6% of patients had >1 prior cesarean in the largest systematic review[1][2][3] |
| Uterine rupture / VBAC | Less common; presents acutely[5][6] |
| Placenta accreta spectrum | Manual removal of morbidly adherent placenta during cesarean[7] |
| IUD erosion | Rare; perforation through uterine wall into bladder[8] |
| Pelvic trauma, uterine curettage, radiation | Rare[2][4] |
Mechanism after cesarean:[3]
- Inadequate reflection of bladder peritoneum from the lower uterine segment
- Unrecognized cystotomy at hysterotomy or closure
- Bladder wall caught in the uterine closure suture
- ~10% of patients had recognized intraoperative bladder injury or uterine rupture
- The supratrigonal bladder is involved in 92.5% of cases
Classification
Youssef syndrome (1957)
Classic triad when the fistula sits above the internal cervical os and the cervix functions as a competent valve:[7][14][15]
- Menouria — cyclic hematuria with menstruation
- Amenorrhea — no vaginal menstrual flow
- Preserved urinary continence — no leakage per vagina
Józwik classification (2000)
Operationally the most useful — based on the route of menstrual flow, which predicts presentation and treatability with hormonal therapy:[16]
| Type | Menstrual route | Typical presentation |
|---|---|---|
| I | Bladder only | Classic Youssef syndrome — menouria, amenorrhea, continent |
| II | Bladder + vagina | Menouria plus partial vaginal menses; mixed urinary leakage |
| III | Vagina only | No menouria; urinary leakage per vagina dominates |
Type I is the best candidate for hormonal management; Types II and III usually need surgery.[16]
Clinical Presentation
The intact cervix changes the symptom profile fundamentally compared with VVF.[6][7][17]
- Menouria — present in 41–58% of patients; the most characteristic feature
- Urinary leakage per vagina — present in ~65% of series; more common when the fistula sits at or below the internal os
- Amenorrhea — when all menstrual flow diverts through the bladder
- Recurrent UTI
- Secondary infertility — diversion of menstrual flow and altered uterine environment
- First-trimester miscarriage — reported[18]
Timing:
- Early (days–weeks post-cesarean) — vaginal urine leakage
- Delayed (months–years, occasionally decades) — menouria and amenorrhea; one case report 26 years after the inciting cesarean[19]
Extraordinary presentation: at least four reported cases of fetus implanted in the bladder through the fistula tract.[18]
Diagnostic Evaluation
The diagnostic challenge is the one-way valve physiology — intrauterine pressure during menses or HSG exceeds intravesical pressure, so contrast must often be instilled from the uterine side to demonstrate the tract.[20][21]
| Modality | Role | Notes |
|---|---|---|
| Hysterosalpingography (HSG) | First-line in many series | Contrast injected through the uterus opacifies the bladder[2] |
| Cystography | Often false-negative | When positive, classic "flower on top of the bladder" appearance[21] |
| Cystoscopy | Maps fistula location, relationship to ureteral orifices, presence of endometrial / granulation tissue at the site[9][10] | |
| Hysteroscopy | Visualizes the fistula from the uterine side; methylene-blue confirmation[1] | |
| MRI pelvis | Tissue planes, fibrosis, fistula tract for surgical planning[20] | |
| Contrast-enhanced ultrasound (CEUS) | Intravesical or intrauterine SonoVue; intrauterine route is essential when flow is unidirectional uterus → bladder[4][20] | |
| CT urogram | Rules out concurrent ureteral injury |
Management
VUF is the one urogenital fistula in which conservative management has a real role, because the tract is often lined by hormone-responsive endometrial tissue.[22][23]
Conservative — bladder drainage
- Indwelling Foley for 4–8 weeks
- Effective for small, early-recognized fistulas in the absence of significant fibrosis[24][13][5]
- Suprapubic drainage is an alternative
- If no resolution at 2 months, move to surgical repair[24]
Conservative — induced amenorrhea
The fistula tract contains endometrial-like tissue with estrogen and progesterone receptors; suppressing menses promotes atrophy and fibrotic closure.[22][23]
- GnRH agonists (e.g., leuprolide) for ~6 months — most commonly reported regimen[22]
- Continuous combined oral contraceptive as an alternative[13]
- Best candidates: Type I (Józwik) fistulas, small size, no significant surrounding fibrosis
- Combined approach (drainage + amenorrhea) is reported[13]
Surgical repair — timing and approach
Timing: Most series favor delayed repair (≥ 3 months) to allow inflammation to settle — 88.8% of patients in the systematic review underwent delayed repair.[3]
Approach selection:
| Approach | Best fit | Notes |
|---|---|---|
| Transabdominal (open O'Conor) | The default for most VUF — fistula sits high on the bladder, juxta-cervical | Most commonly performed (~89% of series); midline / Pfannenstiel; sagittal cystotomy down to the tract[3][6][8] |
| Robotic-assisted | Modern standard at experienced centers | Mirrors open technique; magnified visualization for the dense vesicouterine adhesion plane; LOS ~ 2 days; uterine-sparing[9][19][25] |
| Laparoscopic | Same indications as robotic | Demonstrated in case reports / small series[10][12] |
| Transvaginal | Selected low fistulas in surgeons experienced with vaginal repair | 3 of 17 patients in one series successfully repaired vaginally; prone-jackknife position useful[6][11][26] |
Operative principles (every approach)
- Adhesiolysis of the vesicouterine plane — adhesions at the cesarean scar are routinely dense
- Excision of the fistula tract with debridement of fibrotic edges
- Separation of bladder from uterus to allow non-overlapping suture lines
- Double-layer bladder closure + single-layer uterine closure is the most-reported pattern in the systematic review[3]
- Tissue interposition — omental flap is the standard; peritoneal flap when omentum is unavailable. Repairs without interposition had higher recurrence (1 of 5 vs 0 of 9 with flap in one series)[3][8]
- Bilateral ureteral stents for identification and protection in any complex case[9]
- Prolonged catheter drainage with cystogram before removal in selected cases
Hysterectomy vs uterine conservation
- Uterine conservation is preferred in any reproductive-age woman — feasible in ~59% of cases (10 of 17) in one series, with all 3 patients desiring pregnancy conceiving spontaneously after repair.[6][19][25]
- Hysterectomy is reserved for completed childbearing, extensive uterine destruction, or concurrent uterine pathology.[2]
Outcomes
The systematic review of 284 patients reported 100% success on first attempt across all combinations of approach and technique when the operative principles above were respected.[3] Individual series report similarly excellent results regardless of approach.[6][8] The single relapse in the systematic review followed a transvesical repair performed without tissue interposition.[3]
Fertility after repair
Fertility outcomes are the metric that matters most to these patients:[3][6][8][27]
- 8 of 14 patients in one series became pregnant after repair and delivered by elective cesarean.[8]
- 3 of 3 patients desiring pregnancy conceived spontaneously in another.[6]
- Pooled long-term pregnancy rates of 25–31%, substantially above the historical ~10%.[27]
- 23 documented live births in the systematic-review cohort.[3]
- All subsequent pregnancies should be delivered by elective cesarean because of uterine-rupture risk at the repair site.[6][8]
- Secondary infertility may itself be the presenting complaint and frequently resolves after repair.[17]
Prevention
Prevention is operative-technique driven at the index cesarean:[3]
- Adequate sharp reflection of the bladder peritoneum from the lower uterine segment, especially in repeat cesarean
- Avoid deep suture bites at hysterotomy closure that may incorporate the bladder wall
- Confirm the bladder dome is clear before placement of every closure suture
- Recognize and immediately repair any cystotomy on the table — delayed recognition is the principal driver of fistula formation
- Counsel about cumulative risk in patients with multiple prior cesareans
VUF vs VVF — quick comparison
| Feature | VUF | VVF |
|---|---|---|
| Frequency | 1–4% of GU fistulas | Most common acquired GU fistula in women |
| Primary etiology | Cesarean section | Hysterectomy (HIC); obstructed labor (LMIC) |
| Hallmark symptom | Menouria; often continent | Continuous urine leakage per vagina |
| Conservative management | Hormonal amenorrhea + drainage often effective | Drainage rarely closes fistula |
| Fertility implications | Central — uterine sparing prioritized | Not applicable |
| First-attempt closure | ~100% with principles respected[3] | 80–95% (simple); lower for complex / radiated |
References
1. Caraman R, Toma A, Balescu I, et al. "Vesico-uterine fistula following C-section — a case report and literature review." In Vivo. 2022;36(1):528–532. doi:10.21873/invivo.12734
2. Tancer ML. "Vesicouterine fistula — a review." Obstet Gynecol Surv. 1986;41(12):743–753. doi:10.1097/00006254-198612000-00001
3. Bonavina G, Busnelli A, Acerboni S, et al. "Surgical repair of post-cesarean vesicouterine fistula: a systematic review and a plea for prevention." Int J Gynaecol Obstet. 2024;165(3):894–915. doi:10.1002/ijgo.15256
4. Sun F, Cui L, Zhang L, et al. "Intravesical contrast-enhanced ultrasound (CEUS) for the diagnosis of vesicouterine fistula (VUF): a case report." Medicine (Baltimore). 2018;97(17):e0478. doi:10.1097/MD.0000000000010478
5. Buckspan MB, Simha S, Klotz PG. "Vesicouterine fistula: a rare complication of cesarean section." Obstet Gynecol. 1983;62(3 Suppl):64s–66s.
6. Rajamaheswari N, Chhikara AB. "Vesicouterine fistulae: our experience of 17 cases and literature review." Int Urogynecol J. 2013;24(2):275–279. doi:10.1007/s00192-012-1798-8
7. Rao MP, Dwivedi US, Datta B, et al. "Post caesarean vesicouterine fistulae — Youssef syndrome: our experience and review of published work." ANZ J Surg. 2006;76(4):243–245. doi:10.1111/j.1445-2197.2006.03591.x
8. Hadzi-Djokic JB, Pejcic TP, Colovic VC. "Vesico-uterine fistula: report of 14 cases." BJU Int. 2007;100(6):1361–1363. doi:10.1111/j.1464-410X.2007.07067.x
9. Perveen K, Gupta R, Al-Badr A, Hemal AK. "Robot-assisted laparoscopic repair of rare post-cesarean section vesicocervical and vesicouterine fistula: a case series of a novel technique." Urology. 2012;80(2):477–482. doi:10.1016/j.urology.2012.04.027
10. Melon J, Chao F, Chan W, Rosamilia A. "Video of the laparoscopic repair of a vesico-uterine fistula." Int Urogynecol J. 2018;29(4):599–600. doi:10.1007/s00192-018-3566-x
11. Milani R, Cola A, Frigerio M, Manodoro S. "Repair of a vesicouterine fistula following cesarean section." Int Urogynecol J. 2018;29(2):309–311. doi:10.1007/s00192-017-3506-1
12. Ravi B, Schiavello H, Abayev D, Kazimir M. "Conservative management of vesicouterine fistula: a report of 2 cases." J Reprod Med. 2003;48(12):989–991.
13. Kumar A, Vaidyanathan S, Sharma SK, Sharma AK, Goswami AK. "Management of vesico-uterine fistulae: a report of six cases." Int J Gynaecol Obstet. 1988;26(3):453–457. doi:10.1016/0020-7292(88)90344-x
14. Al-Shaikh G, Marwa B. "A cervix penetrating the posterior bladder wall: case report." Int Urogynecol J. 2013;24(4):697–699. doi:10.1007/s00192-012-1849-1
15. Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H. "Unusual case of post-cesarean vesicouterine fistula (Youssef's syndrome)." Int J Urol. 2003;10(4):236–238. doi:10.1046/j.0919-8172.2003.00599.x
16. Józwik M, Józwik M. "Clinical classification of vesicouterine fistula." Int J Gynaecol Obstet. 2000;70(3):353–357. doi:10.1016/s0020-7292(00)00247-2
17. Lenkovsky Z, Pode D, Shapiro A, Caine M. "Vesicouterine fistula: a rare complication of cesarean section." J Urol. 1988;139(1):123–125. doi:10.1016/s0022-5347(17)42315-9
18. Armstrong H, Thistle P. "Vesicouterine fistula and fetus in bladder: a case report." J Obstet Gynaecol Can. 2020;42(5):634–636. doi:10.1016/j.jogc.2019.06.010
19. Romito F, Achtari C. "Robot-assisted uterus-sparing repair of a vesicouterine fistula 26 years after cesarean section: a case report and review of surgical techniques." Int Urogynecol J. 2025. doi:10.1007/s00192-025-06304-w
20. Gan L, Xie L, Li H. "Intrauterine contrast-enhanced ultrasound (CEUS) can be an effective approach for the diagnosis of vesicouterine fistula (VUF), especially for patients with fistulas flowing unidirectionally from the uterine cavity." Heliyon. 2023;9(2):e13268. doi:10.1016/j.heliyon.2023.e13268
21. Goel A, Goel S, Singh BP, Sankhwar SN. "Cystographic images of Youssef syndrome: flower on top of the bladder." Urology. 2012;79(5):e69–e70. doi:10.1016/j.urology.2012.01.032
22. Yokoyama M, Arisawa C, Ando M. "Successful management of vesicouterine fistula by luteinizing hormone-releasing hormone analog." Int J Urol. 2006;13(4):457–459. doi:10.1111/j.1442-2042.2006.01325.x
23. Jozwik M, Jozwik M, Sulkowska M, Musiatowicz B, Sulkowski S. "The presence of sex hormone receptors in the vesicouterine fistula." Gynecol Endocrinol. 2004;18(1):37–40. doi:10.1080/09513590310001651768
24. He Z, Cui L, Wang J, Gong F, Jia G. "Conservative treatment of patients with bladder genital tract fistula: three case reports." Medicine (Baltimore). 2020;99(31):e21430. doi:10.1097/MD.0000000000021430
25. Baker MV, Kisby CK, Occhino JA. "Vesicouterine fistula: a robotic approach." Int Urogynecol J. 2022;33(6):1685–1687. doi:10.1007/s00192-021-04940-6
26. Cao M, Zhang J, Chen Y, Liang Y. "Transvaginal repair of vesicouterine fistulae: our experience of three cases." Int Urogynecol J. 2022;33(3):737–740. doi:10.1007/s00192-021-04973-x
27. Lotocki W, Jóźwik M, Jóźwik M. "Prognosis of fertility after surgical closure of vesicouterine fistula." Eur J Obstet Gynecol Reprod Biol. 1996;64(1):87–90. doi:10.1016/0301-2115(95)02251-1