Question Title: fistula

Dear Doctor,
I had a hysterctomy and bladder sling installed in July of 1997. Before the surgery I had some leaking when sneezing. After the surgery, I had a catheter for over a month, because I could not empty my bladder correctly. I also started having constant urinary infections, and a discharge from my vagina. After about three months, I started to bleed, but the urologist and gynecologist could not determine if I was bleeding from the vagina or urethra. The urologist put me on different antibiotics, but the infections continued. The gynecologist noticed a lesion in my vagina and referred me back to the urologist. The urologist said I had a growth in my vagina that needed to be removed and I had surgery in April of 1999. The bleeding continued, and the urologist referred me back to the gynecolost. By this time I felt really frustrated, so I went to my primary doctor for advice on what to do. She examined me and said I had a fistula that was leaking urine from my urethra to my vagina and she referred me to a different urologist. This urologist examened me and recommended that I have the sling removed, but he said that he didn't thing I had a fistula. I had surgery on July 2nd. The doctor said I indeed had a fistula and he repaired it as best as he could, but that there were no guarantees that the fistula would heal. I have not bled since, and the pain that I was experiencing with the sling is gone, so I am very much relieved. I still have a catheter on, but I am scheduled to have it removed this week. My question is, where do I go from here? I continue to leak more than ever now? Will I need further surgery to correct this? And what hope to give me for the fistula? I am 52 years old.
Thank you for any advice you can give me. Emily

The continued bleeding you have experienced is difficult to comment upon but it sound like the sling eroded through the vagina causing some bleeding and urinary incontinence. The fistula you have refer to can be a difficult complication to treat. The cause of a fistula tract include foreign body i.e.sling, cancer, obstruction, infection. It is important to allow the fistulous tract to heal with catheter drainage and it may take several weeks to months.. If you continue to have leakage soon after the procedure it will not likely improve. The majority of urologist are waiting for about six months before trying a second sling/bladder neck suspension. Autologous rectus fascia appears to have lower erosion rates.

Sincerely,
HFHS M.D.-JS
*Keyword:Fistula

Dear DoctorHFHS M.D.-JS,
Thank you for your response to my inquiry. I have not had any bleeding since the sling way removed and the fistula repaired. The pain I experienced has also significantly subsided. I fear surgery in the future to place another sling because of the pain and complicated I suffered with my first one. My biggest concern right now is making sure that the fistula heals. What are the changes of the fistula not healing? Will my life ever be normal again?

Em

Dear EM,
If you are still leaking after the procedure your urologist performed (I’m not sure from you description)and wish to have a second sling, I think it is reasonable to obtain a second or third opinion. It cannot hurt to get the information about the procedure before making this decision particularly after what happened the first time. It sounds like all you know for sure is that you are unhappy with your current situation. I am not familiar with your history or physical exam but feel that because you are unsatisfied with your current therapy, another (third urologist)opinion from a female urologist, would be helpful and may rest your mind.. You may need to have a urodynamic work-up to obtain a leak point pressure with bladder function studies. These studies are to make sure that your current post operative situation has not changed significantly and that a second sling is the proper procedure for you.. This work-up will give the urologist the ability to classify your incontinence into one of three categories. If you have a problem with the function of the urinary sphincter(type 3) stress urinary incontinence, a sling may be very helpful. Even if you have type 2 stress urinary incontinence a sling may help.
As you know, the sling operation can be done as an out patient or a minimal hospital stay. It is usually very successful with durable and reliable results between 80-90%. Urinary retention after a pubovaginal sling is the most common complication of this procedure. The usual success of this operation is that one third of the patients void by one week and one third within three months. The remaining third need some further type of intervention to relax the sling (your situation). Other options involve reconstructive surgical procedures. In your case, the sling may have been too tight causing you to have urinary stasis allowing the urine to remain in the bladder and cause infection. A fistula could form from erosion of the prosthetic material or problems encountered during surgery.
I’m sure your doctor has entertained the thought of a second sling procedure but you have to be willing to proceed. Usually, as I stated before, this procedure is successful but I have not had the chance to evaluate or examine you. Then again , I don’t have your full history and there may be some reason that this procedure is contraindicated. I would discuss the option of a sling with your urologist. If he doesn’t give you an answer you are satisfied with, I would get a third opinion.
You don’t have to remain incontinent the rest of your life. Talking to a female urologist that specializes in treating patients with complicated conditions as in your situation may be your best option.
This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).

Sincerely,
HFHS M.D.-AK
*keyword:Stress urinary incontinence

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