A 40-year-old G3P3 woman with grade 3 cervical intraepithelial neoplasia underwent loop electrosurgical excision procedure complicated by a large vesicovaginal fistula. She was initially managed with an indwelling Foley catheter to allow for fistula maturation. During planned surgical repair it was discovered that the fistula had closed spontaneously.
Loop electrosurgical excision procedure (LEEP) is widely used for the treatment of cervical intraepithelial neoplasia (CIN). The most common LEEP complications include bleeding, infection, and cervical stenosis. In addition, LEEP increases the risk for preterm delivery and premature rupture of membranes. Rectovaginal and vesicovaginal fistulae (VVF) after LEEP are uncommon but have been reported.
The majority of vesicovaginal fistulae in the developed world are iatrogenic, most commonly the result of complications during hysterectomy. Successful conservative management via continuous bladder catheter drainage for small VVF have been described in the medical literature. However, there are currently no widely accepted guidelines on which patients to offer such management. We present in this study a case of a 3 cm LEEP-induced VVF that unexpectedly closed with conservative management alone.
Case Report
An otherwise healthy 40-year-old G3P3 woman underwent LEEP after cervical biopsy showed grade 3 CIN. The procedure note reported abnormal bleeding, which was controlled with electrocautery and Monsel’s solution. On postoperative day 1, the patient reported urinary leakage from the vagina and manual examination confirmed a VVF. A large 26F catheter was placed, which improved, but did not resolve, the leakage. The pathology report from the LEEP specimen revealed chronic cervicitis with nuclear features suggestive of HPV as well as the presence of uroepithelium.
On postoperative day 3, the patient was referred to our tertiary care center where speculum examination was attempted but abandoned because of severe pain. Cystoscopy and cystogram revealed a large 3-cm defect located just superior and posterior to the trigone of the bladder ( Figure 1 ). The defect was measured cystocopically using the bladder trigone as a size reference. Immediate surgical repair was considered, but because of the degree of visible tissue necrosis ( Figure 2 ), it was believed that delayed repair after the tissue had matured might improve the chances of a successful closure. Debridement was not performed out of concern for making the fistula larger.
Out of concern for long-term sequelae of large bore catheterization, the 26F catheter was replaced with a 16F catheter, which remained for the next 7 weeks, during which time the patient reported persistent but improved drainage per vagina. Preoperative cystoscopy at 11 weeks revealed dramatic improvement in the size of the fistula, to approximately 5 mm. Because of patient preference and persistent leakage, definitive surgical repair via vaginal approach was planned. However, at the time of the planned operation, we were unable to cannulate the fistula tract via the cystoscope nor per vagina as had been possible just 1 week prior ( Figure 3 ). In addition, we could demonstrate no vaginal leakage and concluded that the fistula had closed spontaneously. This was confirmed with bladder instillation of methylene blue. Three months later, the patient remains completely dry.
