Post-traumatic bony impingement into vagina: a rare cause of urethrovaginal fistula

Abstract

A 22-year-old woman met with road traffic accident 6 months back following which she underwent exploratory laparotomy with intraperitoneal bladder rupture repair. She presented with urethrovaginal fistula due to a fragment of fractured pubic bone impinging into the anterior vaginal wall. The findings were confirmed on CT scan and cystoscopy. The patient was managed with removal of the bony spicule and transvaginal repair of urethrovaginal fistula with Martius fat pad interposition.

Background

Female urethral injuries due to pelvic fractures are less common than those in males due to greater mobility, relatively protected location and shorter length of female urethra. Association of such injuries with fistulas to the vagina is rare. These injuries usually present as incontinence, inability to void and blood at introitus. These injuries are best managed with immediate primary repair of urethra and vagina.

Case presentation

A 22-year-old unmarried woman presented with continuous leakage of urine per vaginally for 6 months. She had history of road traffic accident 6 months back, following which she underwent exploratory laparotomy with primary repair for intraperitoneal rupture of urinary bladder (at other hospital). She also had pelvic fracture for which she was prescribed a pelvic binder and bed rest. After the laparotomy she was maintained on supra-pubic catheter and per urethral catheter for 4 weeks, which were subsequently removed. Since then she had continuous leakage of urine per vaginally. She had no difficulty in walking following conservative management of pelvic fracture.

Investigations

A plain X-ray of pelvis clearly showed the pelvic fracture (figure 1). A pelvic examination and cystoscopy were done under anaesthesia. On examination she had a pointed bony chip that was felt per vaginally. Cystoscopy revealed fistula around 1×1 cm on anterior proximal urethra communicating with vagina, which was confirmed by passing guide wire through fistulous tract and findings were confirmed on vaginoscopy. A CT scan of the pelvis showed bilateral superior and inferior pubic rami fracture with displaced bony fragments indenting over the vagina and along the urethral tract (red arrow) along with thin contrast leak seen from bladder into vagina through the anterior vaginal wall. Also seen was the displaced fractured left pubic bone fragment along the urethra (figure 2).

Figure 1.

Pelvic radiograph showing bilateral superior and inferior pubic rami fracture.

Figure 2.

CT scan showing pubic rami fracture with displaced bony fragments indenting over the vagina and along the urethral tract (red arrow).

Treatment

Transvaginal repair of the urethrovaginal fistula was planned, and the patient was posted in the operation theatre. A supra-pubic catheter and per urethral catheter were placed, and the patient was placed in prone jack-knife position for the repair. The bony chip was first removed with a bone nibbler following which the urethrovaginal fistula was closed in two layers. Martius labial fat pad flap was interposed between the urinary bladder and the vaginal wall.

Outcome and follow-up

The catheters were removed sequentially at 4 weeks postoperatively. The patient voided well. At 6 months follow-up, she is asymptomatic and voiding well without any incontinence.

Discussion

Female urethral injuries are uncommon. Most injuries to the female urethra are due to obstetric complications during a vaginal delivery.¹ Non-obstetric urethral injuries in females are very rare; usually associated with severe blunt trauma which has an associated pelvic fracture. Compared with males, incidence of urethral injuries in females is very low. This may be attributed to the flexibility provided to the female urethra by the vaginal wall and its greater elasticity.² The urethral injuries may be complete or partial. Partial injuries like lacerations are overlooked as catheterisation is easily possible in such patients.

Patients with pelvic fracture can have associated bladder injuries, which are almost always evident. In such a scenario, associated vaginal injuries can be misses, which also happened in our case. So, it is prudent that vaginal examination should also be done to rule out any such associated injury.

There are plenty of literature on management of pelvic fracture urethral injuries in males, but literature on management in females is based on experience of surgeons in anecdotal case reports. Primarily three types of management options are mentioned in literature with their pros and cons: immediate primary realignment, immediate primary anastomotic repair and delayed repair.³

Primary repair is associated with high chances of stricture, while delayed repair warrants complex reconstruction due to associated scarring with increased risk of vaginal stenosis. The immediate primary anastomotic repair has the advantage of absence of scarring and repair can be done per vaginally.

In our case, immediate primary repair of urethra and vagina would be better if diagnosed earlier. So, a thorough examination is must in every case of pelvic trauma in females, so that such injuries do not get missed and patient is spared from unnecessary multiple surgeries.

Learning points.

• First examination of patients with pelvic trauma should be thorough and include per vaginal examination to avoid missing of concomitant urethral and vaginal injuries.

• Urethral and vaginal injuries associated with pelvic trauma are usually complex and may require meticulous reconstructive procedures.

• Patient and their relatives should be properly counselled regarding complexity of injury and its further course of management and possible complication.

• Immediate primary repair is most suitable for patient as it avoids future surgical and mental trauma, provided situation permits.