Presentation
Hematuria and pelvic abdominal pain after cesarean section 15 hours earlier.
Patient Data
CT C+ administration: arterial portal & renal excretory phase.
Enlarged uterus and vascularization due to pregnancy. Residual gas in the pelvic and endometrial cavity in the context of recent cesarean section.
No contrast leakage suggesting active bleeding is identified in the arterial and venous phases.
However, in the excretory phase, contrast can be observed passing from the bladder into the endometrial cavity and showing communication between these two structures (vesicouterine fistula) due to a bladder dome defect.
Case Discussion
Fistulas of the female urogenital tract are rare complications after obstetric maneuvers, pelvic pathologies or their treatment. Ureterovaginal and vesicovaginal fistulas are the most frequent in different series in the literature. Vesicouterine fistulas are infrequent, however, they have been described with greater frequency in recent years, the main associated risk factor being a history of cesarean section.
The symptoms consist of hematuria that can be cyclical coinciding with menstruation (menouria), apparent amenorrhea as well as intermittent urinary incontinence, signs that correspond to the classic Youssef triad.
Diagnosis can be made by hysterosalpingography, cystography, or cystoscopy. Currently, the CT or MRI is more used to identify the fistulous tract.
As a treatment, some cases of conservative treatment have been described for spontaneous closure in case of small fistulas with few symptoms, using bladder catheterization and contraceptives. However, most cases are subsidiary to surgical treatment, also considering the morbidity and general condition of the patient. In this case, surgical treatment was indicated due to early diagnosis and due to the size of the fistulous tract, with satisfactory subsequent evolution.