HOPI - Vesicovaginal Fistula (VVF)

1. Chief Complaint

2. History of Presenting Illness

Onset and Duration

• Ask when the leakage started - this directly points to the cause:
  • Immediately (within 48-72 hours) post-surgery - suggests intraoperative bladder injury
  • 10-14 days post-hysterectomy - classic presentation of post-operative VVF (most common)
  • 1-3 weeks after catheter removal - post-hysterectomy VVF
  • Years after pelvic radiation - post-irradiation VVF (can manifest very late)
  • After prolonged/obstructed labour - obstetric fistula (developing countries)

Character of Leakage

• Continuous, constant leak of urine from the vagina - hallmark symptom
• Occurs irrespective of position, activity, or time of day
• May be intermittent in very small fistulae (must then differentiate from stress or urge urinary incontinence)
• The urine leaks vaginally even when the patient voids normally from the urethra (dual-route leakage)

Precipitating Factors / Predisposing History

• Prior pelvic surgery - particularly total abdominal hysterectomy (most common cause in developed countries; overall VVF rate 0.1-4% post-hysterectomy; abdominal hysterectomy is 3x more likely than vaginal hysterectomy to cause VVF)
• Obstetric history - prolonged or obstructed labour, young age at first marriage, short stature, low socioeconomic status (main causes in developing countries due to ischaemic pressure necrosis of anterior vaginal wall, bladder, urethra)
• History of pelvic radiation (for cervical, uterine, or rectal cancer)
• History of pelvic malignancy (cervical, vaginal, bladder cancer - direct invasion)
• History of diverticular disease, Crohn's disease, TB (inflammatory causes)
• Foreign body erosion

Associated Symptoms

• Vaginal discharge that is watery - may precede frank urinary leakage
• Recurrent urinary tract infections - due to ascending infection via the fistula
• Excoriation/skin maceration of vulva and inner thighs - from constant wetness
• Foul-smelling discharge (infected urine/secondary infection)
• Haematuria - if fistula involves inflamed or malignant tissue
• Absence of normal urethral voiding may still occur (patient may still void normally)
• If pneumaturia or fecaluria are also present - suspect concomitant rectovaginal or vesicoenteric fistula (especially in obstetric fistulae in developing countries or Crohn's disease)

Bowel Symptoms

• Constipation, diarrhea, fecal incontinence - suggests possible associated rectovaginal fistula

Severity and Impact

• Degree of social disability/isolation - constant wetness causes significant psychological distress
• Effect on daily activities, sleep, sexual life
• Use of pads/napkins, frequency of changes

3. Gynaecological History

• Last menstrual period (LMP), menstrual regularity
• Parity and mode of deliveries (especially obstructed labour, forceps, prolonged second stage)
• Previous gynaecological procedures (hysterectomy, anterior colporrhaphy, pelvic floor repair)

4. Past Medical & Surgical History

• History of pelvic malignancy and treatment (surgery, chemotherapy, radiotherapy)
• Tuberculosis or other pelvic inflammatory conditions
• Previous fistula repairs (recurrent fistula - important for planning)

5. Drug and Allergy History

• Current medications

Key Diagnostic Clue in History

• Bailey and Love's Short Practice of Surgery, 28th Ed., pp. 1526-1527 - Clinical features and causes of VVF
• Berek & Novak's Gynecology, p. 1464 - Post-operative VVF presentation and management
• Campbell-Walsh Wein Urology - Evaluation of fistula in context of recurrent UTI