Keywords : acute vesicovaginal fistula, intercourse, trauma
In developing countries obstetric trauma continues to be the major cause of vesicovaginal fistula (VVF) 1,2. Gynecological surgery and irradiation also contribute to the incidence of VVF 3-4. We report an unusual incidence of VVF following sexual intercourse in a postmenopausal woman which is probably the first to be reported.
A 57 year old postmenopausal lady was admitted in the emergency department on 20th July, 1998 with a history of severe vaginal bleeding following intercourse. Physical examination revealed a pale lady with tachycardia and blood pressure of 80/60 mm Hg. After resuscitation with IV fluids, vaginal examination revealed anterior forniceal tear, blood and watery discharge. On catheterization, the tip of the Foley’s catheter was found in the vaginal cavity. On 21st July, 1998 she was posted for an examination under anesthesia and repair of the vaginal tear and the VVF.
Examination under anesthesia revealed a linear tear in the anterior fornix.
The tear also involved the posterior wall of the bladder and the trigone. Both the ureteric orifices were exposed to the vagina (Figure 1).
Both the ureteric orifices were catheterized with 5 F infant feeding tubes and the tear in the bladder was closed in three layers with 4-0 catgut and 3-0 vicryl. The vaginal tear was closed with 2-0 vicryl. The ureteric catheters were removed after seven days and the bladder catheter was removed on the 10th postoperative day. The patient was discharged in good condition on 3rd August 1998. She was assessed at three months and six months after the discharge and was doing well.
VVF following intercourse is rare though it has been reported before 5-6. The trauma is very often reported late and not immediately 5. VVF following intercourse is usually seen in young women 3. This report is the first acute case occurring in a postmenopausal lady. The VVF occurred due to the shallowness and tenting of the postmenopausal vaginal fornix, thin vaginal mucosa, and vigorous intercourse.
Acute traumatic VVF when closed immediately usually heals well. The key to repair is proper identification of the tissues and anatomical closure.
