Question

A 45 year old female patient underwent hysterectomy. On the 7th post-operative day she complains of continuous dribbling of urine and fever. Micturition was not voluntary. What is the diagnosis?

• A. Vesicovaginal fistula
• B. Ureterovaginal fistula
• C. Vesicouterine fistula
• D. Urethrovaginal fistula

Hint:

The uterus is already removed, so which structure in front of it leaks into the vagina?

Answer 1

The Correct Option is A

Step 1: A patient develops continuous involuntary leakage of urine after hysterectomy. Continuous dribbling with absent voluntary voiding indicates that urine is escaping through an abnormal communication rather than being stored and passed normally, pointing to a urinary fistula.

Step 2: After hysterectomy the uterus has been removed, so a vesicouterine fistula is impossible because the uterus no longer exists to form a tract with the bladder. Therefore option (c) cannot be the correct diagnosis. A fistula injury at hysterectomy classically involves the bladder, which lies just in front of the uterus and is the structure most often damaged during the operation.

Step 3: Continuous total incontinence with no voluntary control, appearing in the early post-operative period after a hysterectomy, is the hallmark of a vesicovaginal fistula. Urine drains constantly from the bladder into the vagina. A ureterovaginal fistula can also cause continuous leakage but the bladder still fills, so some voluntary voiding is usually preserved, which does not fit a complete loss of voluntary micturition as well. A urethrovaginal fistula distal to the sphincter typically causes leakage only during voiding, not continuous dribbling.

Step 4: The clinical picture of continuous involuntary dribbling after hysterectomy is best explained by a vesicovaginal fistula.