Complete history and physical examination are essential in evaluation of VVFs. History should include the details of gynecologic and past obstetric history, surgical history, pelvic malignancy, radiotherapy, or pessary usage. Abdominal examination may reveal abdominal or flank tenderness secondary to ureteral obstruction or retroperitoneal urinary extravasation. On pelvic examination, the vagina should be carefully inspected with use of a speculum. If this is difficult to perform in the office, an examination under anesthesia should be performed. In acute fistulas, the mucosa surrounding the fistula tract may appear inflamed and erythematous. For a more mature fistulous tract, a small opening may be visualized in the vaginal wall. Examination of the vaginal vault may reveal a collection of fluid at the apex of the vagina. To confirm urine leakage, the fluid is analyzed for urea and creatinine. Urine levels of urea and creatinine should be several folds higher than of serum. Rectal examination is also required for detection of any mass or tumor. A phenazopyridine test is an excellent test to be performed during pelvic examination to diagnose VVF and to differentiate between it and ureterovaginal fistula (UVF). At our institution, we use the double-dye technique to differentiate between VVF and UVF.9 The patient intakes 400 mg of phenazopyridine hydrochloride (Pyridium). One hundred milliliters of diluted methylene blue solution is instilled into the bladder via a urethral catheter. The catheter is removed and a tampon is inserted vaginally, and the patient is asked to come back in 2 hours. The tampon is inspected. If it is stained blue, it is a VVF. If stained orange, it is a UVF, and further work-up is needed.

Radiographic examination by intravenous urography is useful to rule out UVFs. In patients with VVF, up to 25% will have hydroureteronephrosis with 10% having a concomitant UVF.10 Other radiologic investigations include oblique and lateral cystograms, and vaginograms.

Cystoscopic examination can identify the presence and the size of fistula, and its relation to the trigone and ureteral orifices. Careful cystoscopy is required to identify the presence of other fistulas. Fistulas occurring after hysterectomy are typically found along the anterior vaginal vault and the interureteric ridge. Fistulas after radiation for pelvic cancer are often located in the caudal portion of the trigone, distal to the interureteric ridge. Biopsy is recommended if there is a history of malignancy.

Bilateral retrograde pyelography can confirm the diagnosis of a concomitant UVF. Vaginoscopy is performed simultaneously with cystoscopy to assess the quality of the vaginal aspect of the fistula. Additionally, adjacent tissue is inspected for prospective use as flaps. If intravenous urog-raphy and retrograde pyelograms are inconclusive, then fistulogram may be performed transvaginally.

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