SEARCH

SEARCH BY CITATION

Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 32 year old woman was referred to our centre for evaluation of incontinence following delivery of her second child. Her first pregnancy ended with an elective termination performed by dilatation and curettage. Her second pregnancy ended with a dilatation and curettage following a missed abortion diagnosed by ultrasound at 13 weeks of gestation. She then underwent assisted conception on account of secondary infertility. Her third pregnancy was complicated by triplets and positive anticardioplin antibodies. She experienced contractions as early as 16 weeks of gestation, was admitted to the hospital at 19 weeks and was given magnesium sulphate. She developed chorioamnionitis and delivered spontaneously all three infants at 22 weeks. All three infants died.

The woman became pregnant for the fourth time. A prophylactic McDonald suture was placed with Mersilene tape at 14 weeks of gestation. At 27 weeks of gestation, her pregnancy was complicated by torsion of a right ovarian cyst, for which she underwent salpingo-oophorectomy. She then had premature rupture of the membranes at 33 weeks of gestation; the suture was removed and she delivered a little girl weighing 2685 g. The woman had no complaints of urinary incontinence following this delivery.

The woman became pregnant for the fifth time and again prophylactic cerclage was performed at 14 weeks of gestation. The operation notes stated that the anterior cervix was flush with the vagina and therefore the bladder was mobilised anteriorly and a modified McDonald suture with Mersilene tape was placed. An amniocentesis was performed at 37 weeks of gestation and fetal lung maturity was confirmed. The suture was removed under epidural anaesthesia and labour was induced. She delivered a little boy weighing 3575 g by low forceps. Following this delivery, the woman began to complain of urinary incontinence. She was then instructed on Kegel exercises and treated with a brief course of anti-cholinergic therapy by her perinatologist.

When the woman's urinary incontinence persisted beyond the postpartum period despite Kegel exercises and anti-cholinergic therapy, she was referred to the urogynecology unit. Our initial evaluation revealed a well supported pelvic floor and no neurological abnormalities. We presumed she had mixed urinary incontinence. She was instructed in neuromuscular re-education, was started on anti-cholinergic therapy and was asked to attend for multichannel urodynamic investigations. During this procedure, water was noted to be coming from the vagina and cystourethroscopy revealed a vesicocervical fistula, situated in the midline, approximately 1 cm above the interureteric ridge.

It was decided that the fistula was too large and organised to heal with bladder drainage. Having finished childbearing, she decided to have a hysterectomy at the time of the repair. She underwent total abdominal hysterectomy, transabdominal repair of the fistula and interposition of an omental graft. She has recovered without incident, and currently has no complaints of urinary leakage.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

Cervical incompetence has plagued women for more than 350 years. It was described as early as 1658 by Riverius1. The term ‘cervical incompetence’ was first coined by Gream in 18651. The incidence of cervical incompetence has been estimated to be between 0.05% and 1%; cervical incompetence has been implicated as a cause of second trimester loss in 16% to 25% of these cases. Shirodkar2 described his technique in 1955 and McDonald3 described his in 1957. These techniques are the two most widely used and taught procedures for cervical incompetence.

There have been various complications described as a result of cervical cerclage: vesicovaginal fistula, urethrovaginal fistula, ureterovaginal fistula and uterine rupture4,5. Both vesicouterine and vesicocervical fistulae are more commonly seen following caesarean section, traumatic operative vaginal delivery or rupture of the uterus. To our knowledge, this is the second case reported in the literature of a vesicocervical fistula following cervical cerclage.

Golomb et al.6 reported a similar case who had a Shirodkar suture placed at 13 weeks of gestation. The woman in their case report went into labour but ultimately delivered by caesarean section. There is no way to determine if the fistula resulted from the cerclage or the caesarean section. They felt the fistula resulted from the cerclage based on the woman's history and because the fistula appeared well organised on cystourethroscopy, which was done two days post-operatively. The fistula healed spontaneously with continuous bladder drainage at two months. The fact that the fistula healed spontaneously seems to contradict the fact that it was well organised.

These two cases show there is a small but real risk of vesicocervical fistula in women who undergo cervical cerclage, especially when the bladder is mobilised anteriorly. In this operation, every effort must be made to maintain the integrity of the urinary tract. Tying the knot at the six o'clock position and avoiding blunt dissection sometimes used to remove the suture before labour may prevent a fistula. Women who complain of urinary incontinence following cervical cerclage should undergo a thorough evaluation including cystourethroscopy, intravenous pyelography and voiding cystography. Conservative measures may be tried to heal the fistula, but if these fail, surgical repair of the fistula is necessary.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References
  • 1
    Wong GP, Farquharson DF, Dansereau J. Emergency cervical cerclage: a retrospective review of 51 cases. Am J Perinatol 1993;10(5):341347.
  • 2
    Shirodkar VN. A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic 1955;52: 299.
  • 3
    McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Empire 1957;64: 346.
  • 4
    Ulmsten U. Complication of cervical cerclage. Lancet 1977;2: 1035.
  • 5
    Bates JI, Cropley T. Complication of cervical cerclage. Lancet 1977;2: 1350.
  • 6
    Golomb J, Ben-Chaim J, Goldwasser B, Korach J, Mashiach S. Conservative treatment of a vesicocervical fistula resulting from Shirodkar cervical cerclage. J Urol 1993;149: 833834.