Etiopathogenesis and Classification of VVF

Classification

Simple fistulas are usually small in size (≤0.5cm) and are present as single non-radiated fistulas.

Complex fistulas include previously failed fistula repairs or large-sized (≥2.5 cm) fistulas, fistulas due to chronic diseases or radiotherapy and fistulas more than 2.5 cm in size.

Causes of Vesico-Vaginal Fistulas

• Traumatic
• Postsurgical - Abdominal or vaginal hysterectomy
• External trauma (e.g., penetrating, pelvic fracture, sexual assault)
• Radiation therapy
• Advanced pelvic malignancy
• Foreign body
• Obstructed labour
• Uterine rupture
• Caesarean section injury to bladder
• Congenital

Classification 

Marion Sims Classification (1852)

1. Urethro-vaginal
2. Bladder neck
3. Body and floor of bladder
4. Utero-vesical

Waaldijk Classification (1995).

Type 1 fistula – not involve closing mechanism

Type 2 – involve closing mechanism

1. 1. without (sub)total urethra involvement

   2. with (sub)total urethra involvement
      1. without circumferential defect
      2. with circumferential defect

Type 3 – ureter and other exceptional fistula

GOH Classification ¹

Type 1: Distal edge of fistula > 3.5 cm from external urinary meatus
Type 2: Distal edge of fistula 2.5–3.5 cm from external urinary meatus
Type 3: Distal edge of fistula 1.5 − < 2.5 cm from external urinary meatus
Type 4: Distal edge of fistula < 1.5 cm from external urinary meatus

1. 1. Size < 1.5 cm, in the largest diameter
   2. Size 1.5–3 cm, in the largest diameter
   3. Size > 3 cm, in the largest diameter
      

i. None or only mild fibrosis (around fistula and/or vagina) and/or vaginal length > 6 cm, normal capacity
ii. Moderate or severe fibrosis (around fistula and/or vagina) and/or reduced vaginal length and/or capacity
iii. Special consideration e.g. postradiation, ureteric involvement, circumferential fistula, previous repair.

Rosenshein (1980) (genito-anorectal classification)

i. Type 1: Total loss of perineal body with no other associated defects
ii. Type 2: Fistula associated with loss of perineal body
iii. Type 3: Fistula in lower third of vagina, intact or attenuated perineal body
iv. Type 4: Fistula in middle third of vagina
v. Type 5: Fistula in upper third of vagina

Presentation

The classical presentation sign is continuous (day and night) incontinence after a recent pelvic operation. If the fistula is small, then watery discharge from the vagina accompanied by normal voiding may be the only symptom. The patient may experience recurrent cystitis or pyelonephritis; unexplained fever; hematuria; flank, vaginal, or suprapubic pain; and abnormal urinary stream. Those with larger fistulas may not void transurethrally and may have total incontinence. Urinary leakage may make the patient a social recluse, disrupt sexual relations, and lead to depression, low self-esteem, and insomnia. The leakage of urine may cause irritation of the vagina and vulvar mucosa, and perineum and usually produces a foul ammonia odor. 

References

1. Goh JT. A new classification for female genital tract fistula. Aust N Z J Obstet Gynaecol. 2004 Dec;44(6):502-4. doi: 10.1111/j.1479-828X.2004.00315.x. PMID: 15598284.