VVF can occur due to several causes, each impacting the quality of life for the affected individual. While obstetric complications remain the leading cause in low-resource countries, other medical conditions and surgeries can also contribute.

1. Obstetric Causes

1. Prolonged or Obstructed Labor:
   The leading cause of VVF in developing countries. The constant pressure of the baby's head against the mother's pelvic region causes ischemia and subsequent necrosis in the vaginal and bladder walls, leading to the formation of a fistula.

   1. Obstetric fistula is often a complication of neglected obstructed labor, where skilled medical intervention, such as a cesarean section, was not available.

2. Instrumental Deliveries:

   1. Forceps or vacuum-assisted deliveries may also lead to trauma in the vaginal or bladder wall, causing fistulas.

3. Perineal Tears:
   Severe perineal tears during childbirth, if improperly repaired, can create pathways for urine to leak from the bladder to the vagina.

2. Iatrogenic Causes (Surgical Causes)

1. Pelvic Surgeries:

   1. Hysterectomy, bladder surgeries, or surgeries to treat pelvic endometriosis can damage the vaginal wall or bladder, leading to VVF.

   2. Cesarean Sections performed incorrectly or with poor technique may increase the risk of fistula formation.

2. Radiation Therapy:

   1. Pelvic radiotherapy for cancers such as cervical or rectal cancer can damage the tissues, leading to fistula formation. This form of fistula is typically referred to as radiation-induced fistula.

3. Infectious and Inflammatory Causes

1. Chronic Infections:

   1. Chronic urinary tract infections (UTIs), pelvic inflammatory disease (PID), or tuberculosis in the pelvic organs can lead to tissue destruction, which may result in a fistula.

   2. HIV/AIDS: Immunocompromised patients have a higher risk of developing infections that weaken tissues and contribute to fistula formation.

4. Traumatic Causes

1. Pelvic Injuries:

   1. Accidents, falls, or physical trauma to the pelvic area can damage the bladder or vagina, creating an abnormal connection between the two.

2. Surgical Complications:

   1. Incorrect procedures during gynecological surgeries or abdominal surgery can lead to unintended fistula formation.

The symptoms of vesicovaginal fistula can vary based on the size, location, and complexity of the fistula. The primary symptom is continuous urinary leakage, which can occur with minimal activity and significantly impact the individual's daily life.

Primary Symptoms:

1. Urinary Incontinence:

   1. Continuous leakage of urine from the vagina, particularly when standing, coughing, or laughing.

   2. Leakage can be moderate to severe, and it may occur regardless of the bladder's fullness.

2. Foul-Smelling Vaginal Discharge:

   1. Due to the continuous presence of urine in the vaginal canal, odor becomes a persistent issue, leading to vaginal irritation and possible skin breakdown.

3. Recurrent Urinary Tract Infections (UTIs):

   1. Chronic leakage increases the risk of UTIs, which may be recurrent and difficult to treat.

Secondary Symptoms:

1. Pain during Intercourse:

   1. Dyspareunia (painful intercourse) occurs as a result of the abnormal opening between the vagina and bladder.

2. Pelvic Pain:

   1. Chronic pelvic discomfort is common in some individuals with VVF, especially if the fistula has been present for a long period.

3. Skin Breakdown:

   1. Constant exposure to urine can cause skin irritation, sores, and ulcers around the vaginal and perineal regions.

Proper diagnosis of VVF is critical to determining the best course of treatment. Various diagnostic methods can be used to identify and assess the fistula.

1. Clinical Evaluation

1. Medical History: A thorough history including obstetric history, surgical interventions, and any previous treatments.

2. Physical Examination: Inspection of the vaginal canal to look for visible signs of urinary leakage and skin irritation.

2. Diagnostic Imaging

1. Dye Test (Cystoscopy or Vaginoscopy):

   1. Methylene blue or indigo carmine is introduced into the bladder to check for leakage into the vagina.

2. Ultrasound:

   1. Transvaginal ultrasound is often the first imaging technique used to detect the location and size of the fistula.

3. CT/MRI:

   1. Pelvic MRI or CT scan may be required for complex fistulas to assess adjacent structures and plan surgery.

4. Cystography:

   1. A contrast X-ray used to assess the bladder's integrity and define the location of the fistula.

The treatment of VVF primarily involves surgical intervention, although some conservative management approaches can be used for minor cases.

1. Conservative Management

For small fistulas or newly diagnosed cases:

1. Urinary Diversion: A catheter may be used to divert urine away from the fistula site and allow healing.

2. Antibiotics: To treat any infections that might complicate the condition.

2. Surgical Repair

Surgical treatment is necessary for larger or more complex fistulas:

1. Transvaginal Repair:

   1. The most common procedure for anterior fistulas. Involves cutting away damaged tissue, closing the fistula, and reinforcing the repair site using tissue from the labia or perineum.

2. Transabdominal Repair:

   1. Used for posterior fistulas (closer to the cervix), this approach involves accessing the pelvic organs through an abdominal incision.

3. Laparoscopic/Robotic-Assisted Surgery:

   1. Minimally invasive techniques that reduce recovery time and post-operative complications, especially for complicated fistulas.

4. Tissue Interposition Flaps:

   1. Techniques like the Martius flap (labial tissue) are used to reinforce the fistula repair.

3. Post-Surgical Care

1. Bladder Drainage: A catheter is placed for 2-3 weeks after surgery to reduce pressure and promote healing.

2. Pain Management: Analgesics and anti-inflammatory medications for post-operative pain.

3. Antibiotics: To reduce the risk of post-operative infection.

Prevention Strategies