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Vesicovaginal Fistula

A vesicovaginal fistula (VVF) is an epithelialized communication between the bladder and vagina that produces continuous, painless urinary leakage per vaginum. In high-income countries it is overwhelmingly iatrogenic — most commonly after benign gynecologic surgery — while in low-resource settings it is dominated by prolonged obstructed labor and remains a global public-health problem.[1][2][3] VVF is the prototype reconstructive fistula: the principles refined here (anatomic definition, tension-free watertight multilayer closure with non-overlapping suture lines, selective fistula-edge management, selective vascularized tissue interposition, and prolonged drainage) generalize across the entire fistula chapter.[20][27][28]

For the operative settings that produce VVF, see Cesarean Section and Intraoperative Consultation. Cross-compartment and complex-fistula principles are kept on the Fistulas section landing. For operative selection across all repair routes, see the Female Fistula Repair database.

Epidemiology and Etiology​

VVF is the most common acquired GU fistula in women.[1][4]

EtiologySettingNotes
Benign gynecologic surgeryHysterectomy is the dominant cause in high-income countriesEstimated incidence ~0.1–0.2% after benign hysterectomy; laparoscopic / robotic routes carry higher VVF risk than open or vaginal hysterectomy[2][5]
Cesarean deliveryUterine incision into the bladder, bladder-flap injury, placenta accreta spectrumOften vesicouterine rather than vesicovaginal; see Vesicouterine Fistula
Obstetric — prolonged obstructed laborDominant cause in sub-Saharan Africa and South AsiaPressure necrosis of the anterior vaginal wall and bladder against the symphysis; addressed in detail in Obstetric Fistula
Pelvic radiationCervical, endometrial, vaginal, rectal cancer treatmentLate presentation (months to years); poor tissue quality; high recurrence; strongly favors vascularized tissue interposition or diversion discussion[6]
Pelvic malignancyDirect invasion or post-treatment necrosisWorkup must rule out recurrence before reconstruction
Mesh erosionSynthetic midurethral sling or transvaginal mesh erosion through bladderMesh excision concurrent with repair
TraumaPenetrating, foreign body, sexual violenceRare in high-income settings

Pathophysiology​

Three injury mechanisms drive VVF formation, and they predict tissue quality at the time of repair:[1][2]

  1. Direct surgical injury — unrecognized cystotomy at the time of hysterectomy or cesarean, or a suture placed through bladder wall during cuff closure. Tissue is otherwise healthy; fistula declares itself 1–3 weeks postoperatively as the suture line breaks down.
  2. Ischemic — devascularization of the bladder base from electrothermal injury, hemostatic suture, or compressive packing. Presents at 2–6 weeks; surrounding tissue may be inflamed but generally heals well after excision.
  3. Pressure necrosis — sustained compression of the vesicovaginal septum between the fetal head and the symphysis pubis (obstetric) or by retained foreign body. Tissue loss is broader than the visible defect; calcification, fibrosis, and field damage extend well beyond the fistula edge.

Radiation VVF is a fourth category — endarteritis obliterans produces progressive ischemia, the tissue bed is hostile and worsens with time, and recurrence is the rule without vascularized tissue interposition.[6]

Classification​

Simple vs complex (operative phenotype)​

The single most important categorization at the bedside:[7][8]

FeatureSimpleComplex
NumberSingleMultiple
Size< 2.5 cm≥ 2.5 cm
LocationSupratrigonal, away from ureteral orificesTrigonal / juxta-ureteral, involving bladder neck
EtiologyIatrogenic (post-hysterectomy), non-irradiatedObstetric, post-radiation, malignancy-related, mesh
Prior repairNoneOne or more failed
TissueHealthyScarred, ischemic, irradiated

Goh classification (most widely used global system)​

Goh's system grades fistulas on three axes — distance from external urethral meatus, fistula size, and degree of fibrosis / vaginal length — and predicts continence outcome after closure.[9]

AxisGrades
Distance from meatusI > 3.5 cm; II 2.5–3.5 cm; III 1.5–2.5 cm; IV < 1.5 cm
Fistula size (largest diameter)a < 1.5 cm; b 1.5–3 cm; c > 3 cm
Special considerationsi normal vagina, no fibrosis; ii moderate fibrosis or shortened vagina; iii severe fibrosis, circumferential, or prior failed repair

Waaldijk classification (obstetric-fistula-focused)​

Distinguishes Type I (no urethral involvement), Type II (urethral involvement, with subtypes for sphincter and circumferential defects), and Type III (ureteral or other special variants). Used primarily in obstetric-fistula practice and surgical-outcome reporting in low-resource settings.[10]

Clinical Presentation​

  • Continuous, painless urinary leakage per vaginum beginning 1–3 weeks postoperatively (iatrogenic) or after a difficult delivery (obstetric)
  • Leakage may be positional — worse supine, sometimes provoked by bladder filling
  • Reduced or absent voiding per urethra when the fistula is large
  • Recurrent UTI, vaginal candidiasis, vulvar excoriation
  • Psychosocial morbidity — particularly in obstetric fistula, where social isolation and depression are part of the syndrome[3]

A surgeon called to evaluate "post-hysterectomy incontinence" must rule out VVF before attributing leakage to detrusor overactivity, sphincter injury, or ureterovaginal fistula.

Diagnostic Evaluation​

The workup answers four questions: Is it VVF? Where is it relative to the ureters? Is the upper tract involved? Is there cancer recurrence?

Office maneuvers​

  • Speculum exam — pooled urine in the vault, visible fistula tract on the anterior vaginal wall (often after reduction of inflammation)
  • Dye test (single-tampon or three-swab) — instill methylene blue or dilute indigo carmine into the bladder via Foley; a stained proximal tampon confirms VVF, a stained mid tampon suggests ureterovaginal fistula, and a stained distal tampon suggests urethrovaginal leak. The classic double-dye / three-swab test combines oral phenazopyridine (stains urine orange — ureteric source) with intravesical methylene blue (blue — bladder source) to discriminate VVF from ureterovaginal fistula in a single test.[11]
  • Vaginoscopy with a cystoscope — useful when the fistula is small or covered by granulation tissue

Endoscopy and imaging​

  • Cystoscopy is mandatory — defines the fistula location relative to both ureteral orifices, identifies multiple tracts, and rules out mesh, foreign body, or intravesical malignancy[2]
  • CT urogram — assesses for synchronous ureterovaginal fistula or upper-tract obstruction; 10–12% of VVFs have a concurrent ureteral injury[1]
  • Pelvic MRI — preferred for radiation VVF, recurrent fistula, and suspected malignancy recurrence; characterizes tissue quality and defect anatomy
  • Retrograde or antegrade pyelogram — when CT urogram is equivocal for ureteral involvement

Adjuncts​

  • Urine culture before any repair attempt
  • EUA when in-office examination is non-diagnostic — particularly for the small, late-presenting fistula
  • Biopsy of the fistula edge if there is any concern for malignancy or recurrence in the radiated patient

Management​

Conservative — bladder drainage alone​

A small (< 5 mm), early-recognized, non-irradiated VVF may close with continuous catheter drainage, usually assessed after 2–4 weeks and extended selectively to 4–8 weeks if the leak is clearly improving. Reported spontaneous closure rates in selected case series range from 10–20%, with anticholinergics added to suppress detrusor contractions.[12][38] Conservative management is reasonable as a first step in the right patient — but most fistulas require operative closure, and prolonged unsuccessful drainage delays definitive repair without changing outcomes.

Timing of repair​

The classic teaching of 3–6 month delay to allow inflammation to resolve has been challenged by contemporary series and systematic-review planning work. The practical rule is not "early" or "late" by calendar alone; repair when infection is controlled, necrosis has declared itself, exposure is adequate, and the tissue will hold sutures.[8][20][21][22]

TimingIndication
Immediate (intraoperative recognition)Iatrogenic injury identified at the index operation — repair on the table after urologic consult
Brief drainage trial (2–4 wk, extend to 4–8 wk if improving)Small, fresh, non-irradiated VVF with healthy surrounding tissue and no distal obstruction[13]
Early repair (often 2–6 wk)Simple post-hysterectomy or post-cesarean VVF once acute inflammation is quiet and exposure is good; modern iatrogenic series report high success without arbitrary 3–6 mo delay[21][23]
Delayed repair (often ≥ 3 mo)Persistent inflammation, large or multiple fistulas, prior failed repair, complex anatomy, malnutrition, infection, or uncertain tissue viability
Long delay / diversion discussion (6–12 mo or longer)Radiation VVF or malignancy-related field injury — tissue quality dominates, recurrence risk is high, and urinary diversion may be the most durable endpoint[6][22]

Excessive delay is not benign: a 2026 monocentric experience found prolonged delay (12 vs 6 months) predicted failure, while a 2026 transvaginal series found early repair was not inferior to delayed repair in appropriately selected patients.[21][22]

Surgical principles (apply to every approach)​

  1. Cystoscopic mapping — confirm fistula location and rule out ureteral involvement; place ureteral stents if either orifice is within 1 cm of the tract
  2. Wide circumferential mobilization of the fistula edges
  3. Selective fistula-edge / tract management — no randomized evidence proves that routine tract excision is superior to non-excision; tailor trimming, freshening, or excision to approach, fibrosis, tissue viability, and defect size[20][24][26]
  4. Tension-free, multi-layer, non-overlapping closure — bladder mucosa, detrusor / fibromuscular layer, vaginal wall, each in a different orientation
  5. Vascularized tissue interposition when indicated — not routine for simple, non-irradiated primary VVF; strongly favored for radiation, recurrent, large, mesh-associated, or tissue-deficient fistulas[7][18][29][30]
  6. Prolonged urethral catheter drainage — typically 14 days for simple repairs, 21 days or longer for complex/radiated; cystogram before catheter removal in selected cases
  7. Bladder rest — anticholinergics to suppress detrusor activity and avoid suture-line stress

Fistula Tract Excision: Not a Universal Rule​

The evidence on fistula tract excision is mixed, and no high-quality comparative trial has definitively shown that excision improves VVF closure compared with non-excision techniques. The decision is best understood as an approach-specific maneuver, not an independent surgical principle.[20][27]

SettingTypical tract strategyEvidence signal
Latzko partial colpocleisisNo tract excision; vaginal epithelium around the fistula is denuded and the tract is inverted / imbricatedLarge apical-vault series report 98–100% closure in selected non-irradiated VVF, including a 108-patient modified Latzko series with 100% closure.[39][40]
Transvaginal multilayered closureVariable: mobilize bladder and vagina widely; freshen or trim edges only if neededEdge freshening remains debated; trimming can enlarge the defect or weaken an already scarred suture line.[20][26]
Open / laparoscopic / robotic abdominal repairTract excision is commonly performed because exposure permits separation of bladder and vagina around the fistulaRobotic and laparoscopic series using systematic excision report high closure, but they usually combine excision with meticulous mobilization, multilayer closure, drainage, and frequent interposition.[24][25]
Scarred, recurrent, or obstetric tissuePreserve viable tissue; avoid converting a small tract into a large defectA multinational 12-country experience avoided routine edge trimming and emphasized complexity as the dominant determinant of closure: simple 91%, recurrent 79%, complex 68%.[26]

The operative endpoint is therefore not "excised tract" but healthy, mobile, watertight tissue layers under no tension. If excision helps achieve that, it is reasonable; if it enlarges the hole or compromises blood supply, non-excision or minimal freshening is more reconstructive.

Surgical Approach​

The choice of approach depends on fistula location, vaginal access, surgeon expertise, tissue quality, and the need for concurrent ureteral reimplant or augmentation.[8][14][15][27]

ApproachBest fitCaveats
Transvaginal — classic flap repair (Sims-style)Most simple supratrigonal VVFs with good vaginal accessMobilizes bladder and vagina for layered closure; fistula edges may be freshened, but routine wide excision is debated
Transvaginal — Latzko partial colpocleisisSmall, post-hysterectomy, vault-apex fistula in a patient with a deep vaginaInverts the fistula without tract excision; vaginal foreshortening of ~1–2 cm; success rates ~93–100% in selected apical series[15][39]
Transabdominal — open or laparoscopic O'ConorLarge, juxta-ureteral, complex, or recurrent VVF; concurrent need for ureteral reimplant or augmentationSagittal cystotomy carried down to the fistula; tract usually excised; bladder closed in two layers with omental or peritoneal interposition between bladder and vagina[16][25]
Robotic O'Conor / extravesical repairSame indications as open abdominal repair, especially when high or peri-orifice anatomy is hard to expose vaginallyModern series report success rates ~93–100% with median LOS 2–3 days; technique varies between transvesical and extravesical routes[14][17][24]

Transvaginal repair — operative pearls​

  • Position — high lithotomy or prone jackknife (the latter for the difficult-to-expose vault fistula in a foreshortened vagina)
  • Schuchardt incision to widen vaginal access when needed
  • Hold the fistula edge with stay sutures — convert a hole into a slit by tagging at 12 and 6 o'clock to deliver the edges
  • Avoid aggressive tract excision in the small fistula — Latzko-style mucosal denudation and inverting closure preserves bladder and vaginal length
  • Martius flap is the workhorse interposition — labial fat-pad flap mobilized on its inferior pedicle, tunneled subcutaneously to the fistula bed (see Martius flap)
  • Test with retrograde fill of dilute methylene blue before closing the vaginal layer

Transabdominal (O'Conor) repair — operative pearls​

  • Bladder bivalving — sagittal cystotomy from the dome down to (but not through) the fistula
  • Tract excision or controlled edge freshening when it helps create healthy margins; avoid unnecessary enlargement of a small defect
  • Wide bladder–vagina dissection to allow non-overlapping closure
  • Omental pedicle interposition between the closed bladder and vagina is the standard interposition for the abdominal approach; alternatives are peritoneal flap (laparoscopic / robotic) or rectus muscle flap
  • Robotic series favor the transvesical approach with Firlit-style mobilization and a peritoneal interposition flap when omentum is unavailable[14][17]

Tissue interposition​

Vascularized tissue between the closed bladder and vagina is best viewed as an indicated adjunct, not a reflex step. It is most useful when the tissue bed is irradiated, recurrent, mesh-injured, ischemic, large, or difficult to close without tension; it is not required for many simple, primary, non-irradiated VVFs.[6][7][18][29][30]

TissueBest useNotes
Martius flapTransvaginal repair; vaginal/perineal fistulasReliable, low-morbidity, available in any vaginal repair
Omental pedicleTransabdominal / robotic O'Conor; radiation casesExcellent bulk; depends on omental reach
Peritoneal flapRobotic / laparoscopic; when omentum unavailableLimited bulk; reliable for non-radiated repair
Gracilis muscle flapRecurrent, large, or radiated VVF; failed prior interpositionRequires medial-thigh harvest; substantial bulk

The Martius flap deserves a specific caveat in obstetric-fistula practice: Browning's randomized data in a high-volume obstetric-fistula cohort showed no improvement in closure or continence rates with Martius interposition for routine obstetric VVF — reinforcing that interposition is a tool for specific indications (radiation, recurrence, large defect, hostile bed), not a default for every repair.[18]

Emerging adjuncts​

Adjunct materials are most useful when ordinary layered closure lacks a healthy second layer, not as substitutes for exposure, mobilization, drainage, or tissue optimization. For a full flap-and-adjunct selection framework, see Tissue Interposition Flaps.

AdjunctPotential roleEvidence signal
Buccal mucosal graft (BMG)Second layer for scarred, shortened, or tissue-deficient vaginal repairs; robotic interposition when vaginal tissue is inadequateSmall contemporary series and case reports suggest feasibility, including 100% closure in a 10-patient transvaginal series and successful robotic BMG interposition with omentum.[31][32]
Platelet-rich plasma / fibrinBiological adjunct for recurrent or poorly healing tissue; peri-fistula injection and/or interposition after de-epithelializationSmall uncontrolled VVF series report high closure, including 11/12 standalone PRP/PRF cures and recurrent-case neoadjuvant PRP before Latzko repair; evidence remains low quality.[33][34][35]
Small intestinal submucosa (SIS)Off-the-shelf acellular matrix for complicated VVF when local tissue is thin or scarredPilot data in complicated VVF reported 21/23 closures without inflammatory reaction.[36]
Regenerative bioglues / scaffoldsInvestigational sealants or matricesPreclinical bioglue models are promising but not ready to replace vascularized tissue in irradiated or recurrent human VVF.[37]

Outcomes​

Modern series report first-attempt closure rates of 80–95% for simple VVF, with success dropping with each subsequent repair and with adverse fistula characteristics.[2][7][8][19] A large multinational experience illustrates the gradient: anatomic closure was 91% for simple fistulas, 79% for recurrent fistulas, and 68% for complex fistulas, underscoring that tissue compromise and case complexity often matter more than any single technical maneuver.[26]

SettingTypical first-attempt closureNotes
Simple iatrogenic VVF, transvaginal or O'Conor90–95%The benchmark for primary repair[8][14]
Robotic O'Conor (modern multi-institutional)93–100%Median LOS 2–3 days; equivalent to open in experienced hands[14][17]
Latzko (selected vault VVF)93–98%Vaginal foreshortening of 1–2 cm; preserves bladder[15]
Obstetric VVF (high-volume centers)80–95% closure; continence lower (~70–85%)Stress incontinence after closure is the durable challenge[3][19]
Radiation VVF40–70% primary; permanent diversion is a legitimate alternativeTissue quality dominates outcome[6]

Stress urinary incontinence persists in ~10–20% of women after successful anatomic closure of obstetric VVF — particularly when the fistula involved the proximal urethra or sphincter complex; concurrent or staged anti-incontinence surgery may be required.[19]

Special Situations​

Radiation VVF​

Tissue quality is the rate-limiting factor.[6]

  • Wait for tissue stabilization after radiation and complete malignancy workup before attempting repair; many cases require 6–12 months or longer
  • Hyperbaric oxygen (20–40 sessions) may improve tissue oxygenation in selected cases
  • Strongly favor vascularized tissue interposition — omentum, Martius, gracilis, or rectus flap depending on route and defect
  • Counsel realistically about recurrence and about permanent urinary diversion as a dignified, durable alternative when reconstruction is not feasible

Mesh-erosion VVF​

  • Concurrent mesh excision with VVF repair
  • Avoid leaving residual synthetic material at the suture line
  • Tissue interposition recommended even for "simple"-appearing mesh-related VVFs

Recurrent VVF​

  • Always repair through a fresh tissue plane — do not redo the same approach without reconsideration
  • Vascularized interposition or another healthy second layer is usually required
  • Diversion (continent or incontinent) is a valid endpoint after multiple failures; framing this as a quality-of-life decision rather than as failure is part of the conversation

Large or trigonal VVF involving the ureteral orifice​

  • Stent both ureters preoperatively if either is within 1 cm of the tract
  • Consider concurrent ureteral reimplant at the time of repair when the fistula involves the ureteral orifice
  • Plan an abdominal / robotic approach; transvaginal exposure is rarely adequate

See Also​

Videos​

Reconsidering Vesicovaginal Fistula Management
Stanford CME Grand Rounds (2024)

References​

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37. Kim HJ, Turner D, Shi R, et al. "Preclinical evaluation of a regenerative immiscible bioglue for vesico-vaginal fistula." Acta Biomater. 2021;125:183–196. doi:10.1016/j.actbio.2021.02.037

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40. Kieserman-Shmokler C, Sammarco AG, English EM, Swenson CW, DeLancey JO. "The Latzko: a high-value, versatile vesicovaginal fistula repair." Am J Obstet Gynecol. 2019;221(2):160.e1–160.e4. doi:10.1016/j.ajog.2019.05.021