Unlocking the Challenges of Diagnosing

Fistulas in the Pelvis

Lucy Chow, MD & Simin Bahrami, MD

Department of Radiological Sciences
David Geffen School of Medicine at UCLA
 Goals and Objectives
• Understand the anatomy, clinical presentation,
and causes of fistulas in the pelvis.
• Review the imaging findings of pelvic fistulas in
different imaging modalities, such as CT, MR,
and fluoroscopy
• Discuss potential diagnostic pitfalls and the
management of pelvic.

Disclosure: None of the authors have any financial

conflicts of interest to disclose.
 Introduction
• Fistula formation in the pelvis is a devastating condition
that causes significant morbidity.
• Different pelvic fistulas have different etiologies, vary in
anatomy, and have distinct clinical presentation.
• Causes significant physical and psychological impact on
the patient’s quality of life.
• Imaging is crucial for identification of site and course of
fistulas.
 Anatomy
Fistula: abnormal connection between two or more epithelial surfaces.
Genitourinary
ureter A) Vesicouterine
B) Vesicovaginal
C) Urethrovaginal
colon
D) Ureterovaginal
Intestinogenitourinary
E) Colouterine
F) Colovaginal
G) Colovesical
urethra
H) Rectovaginal
Genitocutanous
I) Perineovaginal
 Clinical Presentations

Colovesical
Enterovesical Rectouterine
Rectovaginal
Vesicouterine •  Pneumaturia Colovaginal
Vesicovaginal •  Fecaluria
Ureterovaginal
Ureterovaginal •  Vaginal discharge
•  Vaginal infection
•  Passage of stool,
•  Incontinence mucus or flatus
•  Vaginal urine leakage through vagina
•  Localized pain Rectum
•  Pruritis vulvae Bladder
•  Perineal skin irritation
•  Genitourinary tract infections
ACQUIRED ETIOLOGIES Malignancy Uterine, Cervical, Vaginal, Bladder, Colorectal, Prostate

Birth Trauma
Gynecological Processes Endometriosis
Fibroids
Retained Foreign Bodies
Infectious Tuberculosis
Chronic Granulomatous Disease Schistosomiasis
Actinomycosis
Diverticulitis
Inflammatory
Inflammatory Bowel Disease
IATROGENIC ETIOLOGIES

Radiation Therapy External Beam

Late Complication Vaginal Vault
1-2 years Post Treatment Brachytherapy
Prostate
Hysterectomy
Instrumented Vaginal
Gynecological Surgery Delivery
Early Complication Birth Trauma
<30 days Post Operative Cesarean Sections
Pelvic Mesh Implants
 Pathophysiology
ACQUIRED
Malignancy
• Fistulas occur in 2.5% of patients
with gynecological malignancy.
• Vesicovaginal and colovaginal are
most common types.
• Causes fistula by direct invasion
to adjacent structures
Birth trauma
• Common in developing countries
• Tissue compression during labor
leads to ischemia, necrosis and
fistula formation
Fetus
Bladder
Rectum
IATROGENIC
Post-surgical
• Common in developed countries
• Bladder injury in hysterectomy
• Forceful blunt dissection results in
bladder wall tear or
devascularization
• Vaginal cuff suture into bladder
causes tissue ischemia and
necrosis leads to fistula
• Surgery involving vaginal wall
Chemoradiation
• Alters the anatomy
• Causes increased fibrosis and
loss of soft tissue planes
• Causes endarteritis obliterans and
ischemic necrosis resulting in
fistula formation
 Common Imaging Findings

Focal wall thickening Fistulous tract

Presence of air or contrast material Loss of soft tissue plane

 Non-Imaging Examinations
Physical examination Cystoscopy
Direct visualization
of the urethra and
bladder through
a cystoscope
Vaginal fluid analysis
Test fluid for urea,
creatinine, and potassium

Pyridium test Methylene blue test

Administer oral Instill methylene blue
phenazopyridine into bladder and
and examine examine vagina
tampon for red for its presence
staining (pyridium)
 Fluoroscopy CT MRI

Types of Studies Types of studies Helpful Sequences

q  Cystogram q  Multiple Phases: q Fistulous tract high-signal
q  Excretory urography Unenhanced, contrast intensity on T2-weighted
enhanced, and or STIR sequences
q  Vaginography delayed excretory
q  Water-soluble enema q  Genitourinary q T1-weighted images after
Fistulas: Use bladder administration of
q  Fistulograms intravenous gadolinium-
or vaginal contrast
q  Enteric Fistulas: Use based contrast
rectal contrast
Benefits/Tips Benefits/Tips Benefits/Tips
ü  Real time imaging ü  Increased sensitivity ü  Excellent soft tissue
ü  Different projections, and accuracy when contrast to delineate
patient positioning compared to tract
and maneuvers can fluoroscopy ü  Multi-planar sequences
provoke fistula ü  Determine presence helpful, particularly
visualization and location of leaks sagittal plane
ü  Oblique and lateral ü  Image reconstruction ü  Delayed sequences for
views useful in multiple planes contrast excretion
Limitations Limitations Limitations
ü Incompletely visualize ü Visualization dependent ü Visualization dependent
associated complications on contrast timing on contrast timing
ü Motion artifact degrade
ü Limited anatomic detail image quality
 Vesicouterine Fistula
70F with fibroids and
pain.
(a) Sagittal CE-CT
* demonstrates calcified
* uterine fibroid (*)
(b, c) One year later,
* repeat CE-CT shows
interval erosion of the
aa b c fibroid (*) into the
bladder with wall
thickening, mucosal
enhancement and foci
of air.
(d-f) T2 and post-
* contrast T1 images
confirm fibroid erosion
into the bladder with a
* fistulous connection
between the uterus
* and bladder dome
(arrow), compatible
d e f with a vesicouterine
fistula. Patient
underwent fibroid
Teaching point: removal,
MR provides superior contrast resolution hysterectomy, and
bladder repair.
Allows better visualization of fistulous tract
 Vesicovaginal Fistula
71F with cervical cancer
s/p hysterectomy and
radiation.
(a) Sagittal CT Cystogram.
Contrast in the vagina (*)
with fistulous connection to
bladder (arrow), compatible
with a vesicovaginal fistula.
(b-c) Oblique and lateral
*
*
Cystogram. Contrast
instilled into the bladder
a b c
with leakage into vagina (*)
through the vaginal cuff.

24F with Crohn’s disease.

(d-f) MR enterography
axial and sagittal delayed
images demonstrates
contrast in the bladder
and vagina (*) suggesting * *
a vesicovaginal fistula.
d e f
 Vesicovaginal Fistula
Pre and Post Repair

a b c d

e f g
65F with cervical cancer s/p radiation with subsequent radiation-induced
vesicovaginal fistula in the region of the bladder base.
(a-d) CT Cystogram shows contrast extending from the bladder into the region of
the vagina and introitus.
After fistula repair, (e) CT shows a clear fat plane between the vagina and bladder.
(f-g) Mild irregular thickening of the posterior bladder (arrow) is compatible with
post surgical changes of vesicovaginal fistula repair.
 Urethrovaginal Fistula
47F s/p retropubic mesh
sling placement
(a) Cystoscopy show
subsequent mesh erosion
into the urethra
b (b-d) Cystogram
a demonstrates eccentric
irregular accumulation of
contrast along the left
posterior aspect of the
bladder neck/proximal
urethra, in the region of
the vagina. On the
magnified images, a thin
sinus tract is identified
(arrow). On the post-void
images, the structure
d retains contrast.
c
 Urethrovaginal Fistula

a b
51F with history of periurethral and
perivaginal mesh excision. (a-b) Axial
and (c) sagittal MR demonstrate thin
tract of hyperintense fluid extending
down the patulous urethra (yellow
arrow). Small collection of T2
hyperintense fluid is seen in the lower
vagina (white arrow). This likely
c indicates a urethrovaginal fistula.
 Ureterovaginal Fistula

a b c d
69F with ovarian cancer status post TAH-BSO and tumor debulking presented with
vaginal fluid leakage. (a-d) Axial, sagittal, and coronal CT Urogram delayed images
show contrast opacifying the bilateral ureters and bladder with leakage into the
vagina. Fistulous tract (yellow arrow) is at the level of the distal left ureter.

(e-f) Nephrostomy tube was

placed. Left nephrostogram
shows contrast opacifying the left
renal pelvis and ureter. The left
distal ureter drains directly to the
vagina (V). No communication
seen between the left distal ureter V
and the bladder. Ureter was
subsequently implanted into the
bladder dome over a stent. e f
 Enterovesical Fistula
66F with rectal cancer
s/p chemoradiation.
Subsequently developed
small bowel obstruction
and enterovesical fistula.
(a-b)) CT Abdomen with
oral contrast
a b demonstrates small
bowel superior and
ventral to the bladder
with surrounding
inflammatory changes.
(c) An air-filled tract
extends from this loop of
bowel to the bladder
(arrow). (d) Air and
c d contrast in the bladder is
enteric in origin.
 Colouterine Fistula
a b
d e
Teaching point:
T2-weighted or STIR sequences are helpful to
evaluate for fistulous tract
61F with pain and
feculent vaginal
drainage.
(a-c) CE-CT. Sigmoid
colonic wall thickening
and soft tissue
stranding consistent
with acute sigmoid
diverticulitis.
Associated abscess
and soft tissue
c contiguity with locules
of gas between the
inflamed sigmoid
colon and uterine
fundus concerning for
a colouterine fistula
(red arrow).
(d-f) MR. Axial and
sagittal T2 images
f show a fistulous tract
between the uterus
and sigmoid colon.
T2-fat saturated
images show a
hyperintense tract
(yellow arrow).
 Colovaginal Fistula
85F with air and
feculent vaginal
discharge.
(a, b) CT with oral
contrast show
posterior sigmoid
b diverticulum
a c tethering the
superior aspect of
the vaginal cuff
(arrows) with trace
extravasation into
the vagina.
(d, e) Contrast
instilled through the
rectum shows
e extravasation
c d
through a fistulous
tract (arrow),
Teaching point: extending from the
Ensure adequate opacification of proximal colon to the vagina.
colon to identify colovaginal fistulas
 Rectovaginal fistula

A B

61F with colon cancer s/p radiation and low anterior resection and subsequent
development of radiation-induced rectovaginal fistula.
A)  Sagittal CE-CT shows direct communication of the anterior lower rectum with
the vaginal canal (yellow arrows) and discontinuity of the intervening fat
plane. Feculent material and air is seen in the vaginal canal.
B)  Gastrograffin enema demonstrates contrast material filling the rectum (R) and
leaking into the vagina (V) through a narrow fistula (red arrow) extending from
the upper rectum near the rectosigmoid junction to the vaginal fornix, findings
consistent with a rectovaginal fistula.
 Colovesical Fistula

a b c

86F with diverticulosis. (a-b) Coronal CT shows a fistulous tract containing fluid and
air (yellow arrow) extending from the bowel into the bladder wall. (c) Axial CT shows
focal bladder wall thickening at the fistula site. The bladder also contains air.

(d-e) Cystogram shows

contrast injection
though the Foley
catheter, opacifying the
bladder and
rectosigmoid colon.
(f) Post drainage image
shows residual colonic
d e f
contrast.
 Multiple Complex Fistulas
50F s/p hysterectomy.
(a) CT Cystogram shows
opacification of the bladder
and rectosigmoid colon,
suggestive of a colovesical
fistula located at the level of
the vaginal apex.
c (b) Contrast extravasation
from the anterior sigmoid
a b colon to the vaginal apex
(yellow arrow), compatible
with a colovaginal fistula.
(c) Residual contrast
identified within the introitus
of the vagina.
(d, e) Large bowel is closely
adherent to the anterior
pelvic wall with adjacent
increased soft tissue
thickening, foci of gas and
contrast in the low anterior
d e pelvic wall. Findings
suggestive of a
colocutaneous fistula (white
arrow). Contrast again seen
in vagina (red arrow).
 Multiple Fistulas
62F with a history of
vaginal wall squamous
cell carcinoma.
Sagittal (a, b) and axial
(c, d) PET-CT images
a c demonstrates intensely
FDG-avid urine within
the bladder, vagina, and
large bowel consistent
with vesicovaginal and
colovaginal fistulas.

d
b

Teaching point:
Ureterovaginal fistulas and vesicovaginal fistulas have a 10%
association. If one type of fistula is visualized, look for other types.
 Interesting Case #1
a b
c d
Teaching point:
Use initial unenhanced CT images to problem solve.
68F with diverticulosis and
occasional fecaluria. CT
Cystogram was obtained.
(a, b) Short colovesical sinus tract
(arrows) extending from a focal
region of tenting at the left
posterior bladder dome extends to
the sigmoid mesenteric fat and
through the sigmoid colon wall
without definite intraluminal
extension.
(c, d) Additional hyperdensities
also seen adjacent to the bladder
(arrowheads) which were identified
as calcified fibroids on the non-
contrast images, and were not
extraluminal contrast.
 Interesting Case #2
60F with history of
cervical cancer and
invasion into the
rectosigmoid. A colonic
stent was placed for large
bowel obstruction.
Sagittal (a, b) and axial (c,
a b b) CT images
demonstrates a moderate
amount of debris and gas
within the vagina. The
rectal stent appears to
have migrated into the
vagina through the known
c d rectovaginal fistula.
 Interesting Case #3

a b

50F with history of vesicovaginal fistula after hysterectomy which was

subsequently repaired. Patient presented with dysuria. (a) Axial CT Abdomen
demonstrated a bladder stone posterior to the bladder adjacent to the left
vaginal cuff. (b) Cystoscopy demonstrated a defect in the bladder wall related
to a sinus tract from the previous vesicovaginal fistula repair. Surgery was later
performed and the stone removed from the bladder sinus tract.
 Pitfalls: Mimics
39F s/p myomectomy with
new fever and abdominal pain.
(a-d) CT Abdomen
demonstrates a large gas and
fluid collection within the
posterior fundus at the site of
the myomectomy. There is an
area of disruption through the
left aspect of the fundus which a b
tracks into a gas and fluid
collection in the left adnexal
region (arrow). The collection
is not contiguous with the
bowel. The abscess may be
mistaken for a colouterine
fistula.

Teaching point:
Carefully identify the site
and examine the full
course of potential d
fistulas c
 CONSERVATIVE MANAGEMENT
Indications
q Simple fistulas
q Small size
q Unrelated to malignancy or XRT
Treatments
•  Antibiotics
•  Sitz bath for symptomatic relief
•  Estrogen therapy to improve tissue
vascularization in post-menopausal
patients
•  Urinary diversion: Transurethral or
suprapubic catheter, nephrostomy
•  Percutaneous drainage, if an
abscess is present
Outcomes
•  Some may resolve spontaneously
•  Proceed to surgery if not improved
OPERATIVE MANAGEMENT
Indications
q  Complex fistulas (>2 tracts)
q  Not amenable to conservative
management
Percutaneous Treatments
• Covered stent placement
• Ureteral occlusion
Surgical Treatments
• Excision of fistulous tract and closure
with sutures
• Surgical debridement of the fistula
edges without full excision
• Covering the fistula by mobilizing
normal tissue (fat pad graft) adjacent to
the fistula causing subsequent scarring
and healing
 Conclusion
• Pelvic fistula is a devastating condition that causes
significant morbidity.
• Evaluation of pelvic fistulas is challenging.
• Imaging can assist in making the correct diagnosis,
describing the course of the fistula, and
demonstrating associated complications.
• This information is important for guiding treatment.
 References
1. Lee JK and Stein SL. Radiographic and Endoscopic Diagnosis and Treatment of
Enterocutaneous Fistulas. Clin Colon Rectal Surg. 2010;23(3):149–160.
2. Addley HC et al. Pelvic Imaging Following Chemotherapy and Radiation Therapy for
Gyne- cologic Malignancies. RadioGraphics. 2010;30:1843–1856.
3. Avritscher R et al. Fistulas of the Lower Urinary Tract: Percutaneous Approaches for
the Management of a Difficult Clinical Entity. RadioGraphics. 2004; 24:S217–S236.
4. Outwater E and Schiebler ML. Pelvic Fistulas: Findings on MR Images. AJR.
1993;160:327-330.
5. Papadopoulou I et al. Post–Radiation Therapy Imaging Appearances in Cervical
Carcinoma. RadioGraphics. 2016; 36:538–553.
6. Paspulati RM and Dalal TA. Imaging of Complications Following Gynecologic
Surgery. RadioGraphics. 2010; 30:625–642.
7. Yu NC et al. Fistulas of the Genitourinary Tract: A Radiologic Review.
RadioGraphics. 2004; 24:1331–1352.
8. Titton RL, et al. Urine leaks and urinomas: diagnosis and imaging-guided
intervention. RadioGraphics. 2003; 23:1133–1147.