Recurrent Urovaginal Fistula: A Sequel of Missed Ureteral Involvement.

A 44-year-old multipara presented with continuous urinary leakage per vagina of 15 months duration despite abdominal vesicovaginal fistula repair. Intravenous urography revealed normal upper urinary tract. Methylene blue test was positive but no fistula was detected on cystoscopy. Failure to cystoscopically visualize the catheter, which was easily introduced through the vaginal end of fistulous tract warranted a fistulogram that simulated retrograde ureteropyelogram and showed contrast in the bladder confirming ureterovesicovaginal fistula. Patient underwent transvesical ureteroneocystostomy with closure of bladder communication and remains continent at six months follow-up. Recurrence of urovaginal fistulae after vesicovaginal fistula repair may be attributable to undiagnosed ureteral involvement despite normal upper tract imaging. Simple procedures like cystoscopic visualization of catheter along with fistulogram can clinch the diagnosis in such cases.

Multiple Developmental Urogenital Anomalies: A Therapeutic Challenge.

Case report: In cases of atretic lower vagina, drainage of hematocolpos per se is inadequate as recurrent hematocolpos from re-stenosis is common. Surgical reconstruction in these cases should be directed to relieve obstruction and ensure continued vaginal patency. A 14-year-old girl reported with primary amenorrhea and recurrence of cyclical lower abdominal pain due to re-stenosis following a primary intervention for hematocolpos. Evaluation identified an atretic lower vagina and multiple associated urinary tract anomalies like unascended right kidney, malrotated left duplex collection system, ureteric diverticula and bladder diverticulum with left ureter opening into it. Though associated Grade IV vesicoureteral reflux (VUR) posed a management dilemma, drainage of hematocolpos and restoration of vaginal continuity by pull through of the proximal vagina and approximating its edges to fourchette relieved the patient of pain, restored menstruation, resolved the VUR and obviated the need for extensive urinary reconstructive procedures. Conclusion: In case of atretic lower vagina, drainage of hematocolpos per se is inadequate as recurrent hematocolpos from re-stenosis is common and surgical reconstruction should be directed to relieve obstruction and ensure continued vaginal patency. Coexisting developmental urinary tract anomalies may not require immediate surgical intervention.