Editing Functional: Urinary Fistulae (section)

==== Diagnosis and Evaluation ====

===== UrologySchool.com Summary =====

* '''<span style="color:#ff0000">Recommended (4)</span>'''
# '''<span style="color:#ff0000">History and Physical Exam</span>'''
# '''<span style="color:#ff0000">Labs</span>'''
##'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
#'''<span style="color:#ff0000">Imaging:</span>'''
## '''<span style="color:#ff0000">Lower tract imaging (with cystogram and/or voiding cystourethrogram (VCUG))</span>'''
## '''<span style="color:#ff0000">Upper tract imaging (with CT urography)</span>'''
# '''<span style="color:#ff0000">Other</span>'''
## '''<span style="color:#ff0000">Cystoscopy</span>'''

* '''<span style="color:#ff0000">Optional</span>'''
** '''<span style="color:#ff0000">Dye test</span>'''

===== Recommended =====
* '''History and Physical Exam'''
** '''History'''
*** '''<span style="color:#ff0000">Most common complaint is constant urinary drainage per vagina</span>'''
**** The amount of urinary leakage can vary considerably from patient to patient and may be proportional to the size of the fistula tract.
*** '''Pain is uncommon'''
** '''Physical exam'''
*** '''A pelvic examination with a speculum should always be performed'''.
**** '''VVFs after hysterectomy are most commonly located along the anterior vaginal wall at the level of the vaginal cuff'''
*** '''<span style="color:#ff0000">Visual and manual assessment of inflammation surrounding the fistula is necessary,</span>''' because it may affect timing of the repair. 
****Significant inflammation, infection, or induration around the fistula may mitigate against immediate repair.

* '''Laboratory'''
** '''<span style="color:#ff0000">Urinalysis +/- culture, when indicated</span>'''
**Cytology, when indicated

* '''Imaging'''
** '''<span style="color:#ff0000">Lower tract imaging (with cystogram and/or voiding cystourethrogram (VCUG))</span>'''
*** '''A cystogram that fails to demonstrate a suspected VVF but lacks voiding images or postvoid images should be considered non-diagnostic.'''
** '''<span style="color:#ff0000">Upper tract imaging (with CT urography)</span>'''
***'''Up to 12% of postsurgical VVFs have an associated ureteral injury or ureterovaginal fistula'''

* '''Other'''
** '''<span style="color:#ff0000">Cystoscopy</span>'''
*** '''<span style="color:#ff0000">Should be performed in patients for whom a suspicion of VVF is present</span>'''

===== Optional =====
* '''Dye test'''
** '''The presence of a VVF may be confirmed by instilling a colored solution, such as methylene blue or indigo carmine into the bladder per urethra and observing whether vaginal drainage is discolored'''
*** Small or occult fistulae may be identified in this fashion.
*** '''Staining at the introital (distal) end of the packing suggests urinary incontinence or a urethrovaginal fistula, whereas proximal staining suggests a VVF'''
*** '''If the vaginal packing remains dye-free with this maneuver, then the possibility of a ureterovaginal fistula can be investigated''' with the use of clean vaginal packing, '''IV indigo carmine (or other vital dye),''' and a repeat pad test. '''Blue staining at the proximal end of the pad after this maneuver suggests the presence of a ureterovaginal fistula'''
*** '''A double dye''' or tampon '''test''' may confirm the diagnosis of urinary fistula, as well as suggesting the possibility of an associated ureterovaginal or urethrovaginal fistula. In one variation of the double dye test, a tampon is placed per vagina. Oral phenazopyridine is administered, and vital blue dye is instilled into the bladder. If the tampon is discolored 
****Yellow-orange at the top, it is suggestive of a ureterovaginal fistula
****Green (a combination of blue and yellow) discoloration in the midportion of the tampon suggests VVF
****Blue staining at the bottom suggests a urethrovaginal fistula