Synopsis
Recognise urinary or bowel fistula and iatrogenic bladder or ureteric injury early, select anatomy-specific investigations, stabilise acute harm and arrange reconstructive specialist care without stigma or avoidable delay.
- Obstetric fistula most often follows prolonged obstructed labour without timely operative birth: sustained pressure causes ischaemic pelvic-tissue necrosis and a delayed opening into bladder, ureter, urethra or rectum.
- In UK practice, gynaecological or obstetric surgery is a major setting for new urinary fistula or ureteric injury; malignancy, radiotherapy, inflammatory disease and trauma are other causes.
- Continuous vaginal urine leakage suggests fistula rather than stress or urgency incontinence; preserved normal urethral voiding alongside continuous leakage particularly suggests ureterovaginal communication.
- Absence of haematuria does not exclude ureteric injury, and thermal or ischaemic injury may present days after an apparently uncomplicated operation.
- For suspected ureteric injury in a stable patient, CT urography including delayed excretory images is the key anatomical study; retrograde or antegrade urography can confirm an equivocal case and permit drainage.
- Suspected postoperative bladder injury is assessed with active retrograde cystography; passive bladder filling during excretory CT is not an adequate cystogram.
- A newly recognised injury may be repaired immediately by an experienced team; delayed ureteric injury commonly needs nephrostomy or JJ-stent diversion before anatomy-specific reconstruction.
- Fistula care includes skin, infection, renal, nutritional, sexual, reproductive and psychological assessment, not closure of a tract alone.
Key red flags
No urine or markedly reduced urine after pelvic or obstetric surgery, especially with flank pain or rising creatinine.
Fever, rigors, hypotension, peritonism, ileus or a painful collection with a suspected urinary leak.
Continuous clear vaginal or drain fluid soon after hysterectomy, caesarean birth or other pelvic surgery.
New hydronephrosis, urinoma, ascites, renal impairment or contrast extravasation after an operation.
Faeces or gas passing through the vagina, severe perineal wound breakdown or concern for bowel injury.
Haematuria, inability to void or a painful distended bladder after difficult pelvic dissection or instrumentation.
Known pelvic malignancy, prior radiotherapy or recurrent inflammatory bowel disease with a new fistula symptom.
Tissue necrosis, offensive discharge, severe skin injury, malnutrition, safeguarding concern or marked psychological distress.
Investigation priorities
Assess infection, inflammation, renal injury and physiological impact before contrast, drainage or repair.
Management branches
Postoperative oliguria, sepsis, peritonism, obstruction, urinoma or high-output urinary drainage is suspected.
- Escalate to senior gynaecology and urology, assess ABC physiology, sepsis, abdomen, urine output, renal function, haemoglobin and operative details.
- Start resuscitation and indicated sepsis treatment, maintain accurate fluid balance and obtain urgent CT urography or active cystography according to the suspected organ.
- Drain the bladder, obstructed upper tract and infected or enlarging collection promptly; do not defer physiological control while the final reconstructive approach is debated.