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.