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(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
Obstetric history: Para 2, Live 2, both deliveries by
C-sections, one in Delhi and another at Bihar state. The
delivery records are unavailable. She underwent
tubectomy.
Menstrual history: Previous: 4-5days/30days, regular
flow. H/o passing blood in urine at the time of menstrual
flow (so called Cyclic Menourea) since 6years.
Present: Irregular excessive
menstrual flow since 3months associated hematuria
since 3months.
General Exam: Patient is anemic, P.R. 80/min, BP
110/70mmHg,
CVS/RS: NAD, P/A: NAD.
Gynaec. Exam: Bimanual vaginal examination: Uterus
AV, bulky, mobile, FF, non-tender.
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
INVESTIGATIONS: ROUTINE (BASIC) WORKUP: -
1.CUE on 7-4-04:WNL except haematuria.
2.IVU on 3-3-04:Both are kidneys normal, no evidence of
obstruction and dilatation of Pelvicalyceal system.
3.Urine for C/S on 3-3-04: E. coli grown in culture and sensitive
to 1.Furadantine, 2.Amikacin.
4. Hb% on 8-3-04: 6gm%.
5. RBS: 103mg%, Blood Urea: 15mg%.
6. “B” Rh-positive, HIV & Hbs Ag: non-reactive.
7. LFT: S. Bilirubin: 0.72mg%, SGPT: 2 IU/L, Alk. Phos: 4KA.
8. X-Ray Chest PA view: Normal.
9. X-KUB on 8-3-04: No ROD seen.
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
Specific WORK-UP: -
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
CASE REPORT
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
On 15-04-2004: Laparotomy done and total
abdominal Hysterectomy with Repair of the
uterovesical fistula performed.
Per-operative findings:
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
POST-OPERATIVE MANAGEMENT:
Patient was kept on continuous
bladder drainage for 14days for
proper healing of the bladder wall.
Skin sutures were removed on 7th
POD. Uneventful P.O. course and
went home.
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
FOLLOW-UP:
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
Sonographic Diagnosis of a
Uterovesical Fistula
•Abdominal and endovaginal sonography showed a
large defect in the anterior myometrium in the lower
body of the uterus.
•The adjacent wall of the urinary bladder also
appeared deficient without any area of thickening in
the adjacent bladder wall.
•The rest of the endometrium, myometrium, and
urinary bladder wall appeared normal.
•Both kidneys were normal without obstruction.
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UTEROVESICAL FISTULA
Sonohysterography:-
It was performed at the time of menses. The
patient was placed in the lithotomy position,
and the cervix was visualized with the help of a
Sims speculum and an anterior vaginal wall
retractor. The cervix was grasped with
Volsellum forceps. It was cleaned with
povidone-iodine. A Leech-Wilkinson– type
cannula was introduced into the cervical canal
after expelling air from it with saline. The
speculum was removed carefully, and an ATL
C9-5 endovaginal probe (Philips Ultrasound,
Bothell, WA) was introduced into the vagina.
Saline was injected into the cannula, and
simultaneously the uterus was scanned in the
longitudinal plane. The saline freely entered
the urinary bladder in a jet through the
deficiency in the kasinamrao@gmail.com
myometrium, confirming the23
UTEROVESICAL FISTULA
(Youssef’s syndrome)
MANAGEMENT
Conservative approach:i) Cystoscopic
fulguration, ii) Cyclic combine hormonal
therapy with continuous
catheterization,iii) Spontaneous
resolution by continuous catheterization
Surgical approach:i) Transabdominal
transperitoneal repair of fistula
with/without Hysterectomy, ii) Fistula
repair with Omental interposition or
Myouterine flap, iii) Vaginal repair in
cases of previous subtotal hysterectomy
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
INTERNATIONAL CLASSIFICATION OF DISEASES
619 Fistula involving female genital tract
Excludes: vesicorectal and intestinovesical fistula(596.-)
619.0 Urinary-genital tract fistula, female
Fistula:
cervicovesical
ureterovaginal
urethrovaginal
uteroureteric
uterovesical
vesicovaginal
ICD Version 2007 (
http://www.who.int/classifications/apps/icd/icd10online/ind
)
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Youssef’s syndrome
The typical triad of Youssef's
syndrome i.e. cyclic hematuria and
amenorrhea without vaginal
leakage of urine.
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UTEROVESICAL FISTULA
First case of menouria was reported in the
literature by Machado in 1935. Into about 92
cases were reported since 1908 (on the date
of surgery) and it is rare accounting about 4%
of all Genitourinary fistulas.
Today, 141 articles are reported in Pubmed
data.
Vesicouterine fistula is a rare complication of
gynecologic surgery, which is usually treated
by abdominal hysterectomy and bladder
repair.
We present a case showing the etiology of
vesicouterine fistula and contemporary
reconstructive techniques.
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UTEROVESICAL FISTULA
SUMMARY
A 40 yr old rural woman presented with
Menouria (Vesical menstruation) tolerating
the symptom in silence since 6 yrs, came to
the hospital with intolerable “MENORRHAGIA
+ MENOURIA” (due to the growth of
submucous fibroid) since 3 months.
We had managed the case by “TOTAL
HYSTERECTOMY ALONG WITH REPAIR OF
FISTULA”.
Though woman developed transient
frequency and urgency of urine in
postoperative period, she is now totally
asymptomatic and relieved of distressing
symptoms.
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UTEROVESICAL FISTULA
Unusual case of post-cesarean
vesicouterine fistula (Youssef's
syndrome).
Therefore, it is pertinent to have periodic
training courses (Update of C-section
workshops) not only for qualified ObGyn
specialists but also for Basic Medical
Practitioners in rural areas, since Cesarian
delivery is the commonest surgical
procedure performed throughout the World
today. kasinamrao@gmail.com 29
Review of literature in
Pubmed database
(Medline)
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1) Unusual case of post-cesarean
vesicouterine fistula (Youssef's
syndrome).
Kilinc F, Bagis T, Guvel S, Egilmez T, Ozkardes H.
Department of Urology, Baskent University, 01250 Adana, Turkey.
ferhatkilinc@hotmail.com
http://www.ncbi.nlm.nih.gov/pubmed/12657106?or
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2) An unusual case of Youssef's syndrome
(vesicouterine fistula) and
its relationship with placenta percreta.
Majeed SM, Subhani SS.
Department of Surgery, KRL General Hospital,
Islamabad, Pakistan.
http://www.ncbi.nlm.nih.gov/pubmed/17374305?ordinalpos=1&itool=
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3) Vesicouterine fistulas following cesarean
section: report on a case, review and update of the
literature.
Porcaro AB, Zicari M, Zecchini Antoniolli S,
Pianon R, Monaco C, Migliorini F, Longo M, Comunale L.
Urologic Operating Unit, Civil Major Hospital, Verona, Italy.
drporcaro@yahoo.com
Spontaneous healing is reported in 5% of cases. Conservative
management by bladder catheterization for at least 4-8 weeks is
indicated when the fistula is discovered just after delivery since
there is good chance for spontaneous closure of the fistulous
track. Hormonal management should be tried in women
presenting with Youssef's syndrome. Surgery is the mainstay and
definitive treatment of vesicouterine fistulas after cesarean
section.
http://www.ncbi.nlm.nih.gov/pubmed/12899224?ordinalpos=1&itoo
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4) Youssef's syndrome:
an appraisal of hormonal treatment.
Hemal AK, Wadhwa SN, Kriplani A, Hemal U.
Department of Urology, AIIMS, New Delhi.
http://www.ncbi.nlm.nih.gov/pubmed/9864873?ordinalpos=
1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_
ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_
Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
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6) 'Menouria'—
a presentation of vesicouterine fistula.
Bhutta SZ.
Department of Obstetrics and Gynaecology,
Jinnah Postgraduate Medical Centre, Karachi.
http://www.ncbi.nlm.nih.gov/pubmed/8993046?ordinalpos=
1&itool=EntrezSystem2.PEntrez.
Pubmed.Pubmed_ResultsPanel.Pubmed_
DiscoveryPanel.Pubmed_Discovery_
RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
kasinamrao@gmail.com 36
7) Management of vesicouterine fistula
following cesarean section.
Pawar HN.
Department of Pathology, Faculty of Medicine, Kuwait University.
http://www.ncbi.nlm.nih.gov/pubmed/3966287?ordinalpos=
1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_
ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_
Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed
kasinamrao@gmail.com 37
8) Treatment of vesicouterine fistula
by fulguration.
Molina LR, Lynne CM, Politano VA.
Department of Urology,
University of Miami School of Medicine, Florida.
http://www.ncbi.nlm.nih.gov/pubmed/
15309282?ordinalpos=1&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_
ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_
Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed
kasinamrao@gmail.com 39
10) A case report on vesico-uterine fistula:
a very rare complication of the
lower caesarean section.
Abu J, Wong MY, Foo KT, Yu SL.
Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore.
http://www.ncbi.nlm.nih.gov/pubmed/
11284616?ordinalpos=1&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_
DiscoveryPanel.Pubmed_Discovery_
RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
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Vesicouterine fistula – Imaging
http://www.gfmer.ch/selected_images_v2/detail_
list.php?cat1=17&cat2=103&cat3=721&cat4=1&stype=n
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UTEROVESICAL FISTULA
(Youssef’s syndrome)
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