Hormonal dependence of fistulas communicating with the uterus

Youssef syndrome with a summary of management options

Vesicouterine fistula is one of the rare varieties of urogenital fistula. Type I urogenital fistula or Youssef syndrome is characterised by menouria, amenorrhoea and urinary continence and it mostly follows lower segment caesarean delivery. There are only scattered case reports to help guide diagnostic and therapeutic options for this condition. These patients mostly need a combination of diagnostic modalities to confirm the diagnosis. Here, we present one such case of para 4 live 4 with classical symptoms of Youssef syndrome following a laparotomy for uterine rupture repair. CT urography confirmed the diagnosis and cystoscopy helped localise the exact location. Transabdominal fistula excision and repair was done. The paper also presents a summary of diagnostic and therapeutic options for this condition as reported in previous case reports for easy reference for practising gynaecologists and urologists.

Structural arrangement of vesicouterine fistula revisited: An immunohistochemical study documenting the presence of the endometrium

Previous research has described a woman of reproductive age who presented with a vesicouterine fistula (VUF) of 20 months' duration. The VUF was lined with a metaplastic glandular epithelium containing both estrogen receptors (ER) and progesterone receptors (PR) in abundance. The aim of the present investigation was to evaluate the histology of the VUF canal when exposure to urine of the cellular elements within the fistula was of much shorter duration. A 41-year-old woman who developed a VUF during her third cesarean section was treated with transvesical fistula excision, electrocoagulation, and subsequent attempted hormonal treatment. Later, the patient underwent open surgery fistula repair. Postoperative specimens were subjected to anatomopathological examination together with immunohistochemical staining for ER and PR using monoclonal anti-human antibodies. Herein, we present for the first time detailed microscopic evidence that, at two separate timepoints, the fistulous tract was lined with the endometrium, which covered approximately 80% of the length of the VUF canal. In its intermediate segment, the urothelium formed an additional layer on the surface of the endometrium. At both timepoints, in the columnar epithelial and stromal endometrial cells lining the fistula, both ER and PR were present in abundance. In conclusion, VUF in subjects of reproductive age fulfill criteria for endometriosis. This study provides a rationale for the conservative treatment of VUF consistent with the hormonal treatment of endometriosis.

Medical treatment of uterocutaneous fistula with gonadotropin-releasing hormone agonist administration

BACKGROUND

Uterocutaneous fistula is a rare complication of uterine surgery. All published cases have been surgically treated with hysterectomy and excision of the fistulous tract. We report a case of uterocutaneous fistula that was successfully treated with gonadotropin-releasing hormone agonist administration.

CASE

A 25-year-old woman reported bloody discharge during her periods from a previous Pfannenstiel incision. A fistulous tract leading from the incision scar to the uterus was diagnosed. Leuprolide acetate depot was administered twice subcutaneously at a dose of 11.25 mg. The fistulous tract closed spontaneously, and the patient was symptom free thereafter.

CONCLUSION

Medical treatment with gonadotropin-releasing hormone agonists should be considered before resorting to surgery for treatment of uterocutaneous fistulae.