










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.
This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Vesicouterine fistula, Caesarean, bladder, 
uterus, Burkina Faso

None declared. Received on February 13, 2021 
Accepted on May 13, 2021

Soc Int Urol J. 2021;2(4):210–215

DOI: 10.48083/NFMO2987

210 SIUJ  •  Volume 2, Number 4  •  July 2021 SIUJ.ORG

ORIGINAL RESEARCH

Vesicouterine Fistula in Burkina Faso:  
Report of 36 Cases in a Multicentric Study
Boureima Ouedraogo,1 Brahima Kirakoya,2 Moussa Kabore,2 Adama Millogo,2  
Adama Ouattara,3 Fasnewinde Aristide Kaboré2

1Urology Department University Hospital of Tingandogo, Burkina Faso 2Department of Urology and Andrology, University Hospital Yalgado Ouédraogo of Ouagadougou, 
Burkina Faso 3Urology Department University Hospital Souro Sanou of Bobo-Dioulasso, Burkina Faso 

Abstract

Objective To report etiological and therapeutic features of vesicouterine fistulas (VUF) in Burkina Faso.

Patients and Methods We performed a retrospective, descriptive, and multicentric study based on the medical 
records of women treated for VUF from January 2010 to December 2016.

Results VUF accounted for 7.2% (36/497) of urogenital fistulas managed during the study period. The median 
age of the 36 patients was 35 years (interquartile range = 27 to 37.5 years) with values ranging from 16 years to 64 
years old. Among VUF, obstetric fistula accounted for 26 cases (26/36) versus 10 cases (10/36) of iatrogenic fistula. 
Obstetric VUF were consecutive to emergency Caesarean section (n = 16) and vaginal delivery (n = 10) after 
prolonged obstructed labor. The 10 cases of iatrogenic VUF were subsequent to prelabour Caesarean section. The 
main circumstance of VUF occurrence was Caesarean section (26/36). In 10 cases (10/36), VUF was associated with a 
vesicovaginal fistula. Thirty days after the removal of the catheter, the success rate fell from 89% to 80.6%.

Conclusion VUF is rare but its frequency is not negligible in our context. The main circumstance of occurrence 
remains Caesarean section. The best treatment remains prevention

Introduction

Vesicouterine fistula (VUF) is an abnormal communication between the posterior wall of the bladder and the anterior 
wall of the uterus[1,2]. It is an uncommon condition compared with vesicovaginal fistula and mainly affects young 
women in their thirties[1,3]. It is such a rare phenomenon that the literature consists mainly of cases reports and case 
series. VUF accounts for 1% to 4% of all urogenital fistulas, with an increasing trend reported in the literature[1,4,5]. 
In 2014, Kaboré et al. performed a prospective cohort study of 170 patients in Burkina Faso managed for urogenital 
fistula (UGF) and reported a frequency of 8.2% for VUF[6].

VUF usually presents with a classic triad of symptoms described by Youssef: cyclical hematuria, amenorrhea, and 
urinary continence[7], although patients with VUF may sometimes present with a permanent urine leakage through 
the genital tract. Like vesicovaginal fistulas, VUFs have a devastating psychosocial and economic impact on the 
women who experience them.

The most common etiology of VUF is iatrogenic through pelvic surgery. Caesarean section is the most common 

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cause reported in the literature, accounting for 
approximately 83% to 93% of cases of VUF[8]. In Burkina 
Faso, Sombié et al. reported an increase in Caesarean 
section rate from 0.48% in 2000 to 2.1% in 2014[9]. 
This trend of increasing Caesarean section rates will 
likely be accompanied by an increase in the incidence 
of VUF. Treatment of VUF can be conservative or 
surgical. However, conservative treatment has shown a 
low success rate in contrast to surgical treatment which 
provides good results[10].

The aim of the present study was to analyze the 
etiological and therapeutic aspects of VUF in Burkina 
Faso through a multicentric study.

Materials and Methods 
Study design and period
We conducted a multicentric retrospective study over 
a 7-year period (from January 1, 2010, to December 31, 
2016).

Study site and population
Our study popu lation consisted of a l l patients 
managed for urogenital fistula at 7 referral centers 
for the treatment of urogenital fistulas in Burkina 
Faso: University Hospital Yalgado Ouédraogo of 
Ouagadougou, Regional Hospital of Fada N’gourma, 
Regional Hospital of Dori, Saint Camille Hospital 
in Ouagadougou, New PolyClinic of the Center in 
Ouagadougou, Medical Center with Surgical Antenna 
in Boromo, and Medical Center with Surgical Antenna 
of Schipphra in Ouagadougou. We analyzed the medical 
records of all patients managed for VUF.

Definition of variables
The following variables were studied for patients with 
VUF: age, parity, female genital mutilation (Yes or 
No), history of prior fistula repair (Yes or No), duration 
of labor, time between fistula onset and the surgical 
repair, fistula size, Jóźwik's classification, etiological 
factors (obstetric and iatrogenic), duration of bladder 
catheterization, and postoperative results (success or 
failure). Etiological factors were divided into 2 groups: 
iatrogenic fistulas following prelabour Caesarean 
section, and obstetrical fistulas following vaginal 
delivery or emergency Caesarean section performed 
too late. We used the classification of VUF into 3 types 
proposed by Jóźwik[11]: type I presents with amenorrhea 
and cyclic menouria without urinary incontinence; type 

II presents with cyclic menouria, but has regular menses 
and urinary incontinence; and type III presents with 
only urinary incontinence, without menouria and with 
normal menses. Data were collected on an individual 
and anonymous data sheet.

This study was performed in accordance with the 
ethical standards laid down in the Declaration of 
Helsinki.

Analysis and measures
Data were analyzed using the SPSS software, version 
21.0. The categorical variables were analyzed through 
the study of frequencies. The continuous variables were 
analyzed through the study of median and interquartile 
range (IQR), minimum and maximum. We defined a 
successful surgical repair outcome at one month as a 
complete closure of the defect attested by a methylene 
blue test and without urinary incontinence. The 
Shapiro-Wilk test was used to assess the normality for 
continuous variables. The continuous variables do not 
follow a normal distribution in the sample of 36 patients. 
We therefore used the medians.

Results
During the study period, 497 cases of urogenital 

fistula were managed in the 7 centers. VUF accounted 
for 7.2% (36/497) of all urogenital fistulas. The annual 
frequency of VUF was 5.14. The annual distribution of 
VUF is presented in Figure 1. The median age of the 
36 patients was 35 years (IQR = 27 to 37.5 years), with 
values ranging from 16 years to 64 years old.

According to Jóźwik’s classification, 31 cases (31/36) 
were type II. In 10 cases (10/36), VUF was associated 
with a vesicovaginal fistula. Obstetric fistula was noted 
in 26 cases (26/36) versus 10 cases (10/36) for iatrogenic 
fistula. Among patients with obstetric fistulas, 5 
patients (05/26) gave birth at home without medical 
assistance. The main circumstance of VUF occurrence 
was Caesarean section (26/36). The median duration of 
VUF was 125.8 months (IQR = 108 to 136.5), with values 
ranging from 24 months to 144 months. Patient and 
VUF characteristics are summarized in Table 1.

The management of VUF was surgical in all patients. 
The transperitoneal route was used in 30 cases (30/36). A 
vaginal hysterectomy was performed in 6 cases (06/36). 
The 10 cases of associated vesicovaginal fistula were 
repaired during the same surgical procedure. Urine 
drainage was performed by systematic transurethral 
bladder catheterization in all cases after the surgery. 
The median duration of bladder catheterization was 
14 days (IQR = 12 to 15.8), with values ranging from 
10 to 21 days. Four patients (4/36) had postoperative 
complications: urinary tract infection in 3 patients, and 
hematuria in 1 patient. All patients were evaluated on 

Abbreviations 
IQR interquartile range 
UGF urogenital fistula 
VUF vesicouterine fistula 

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the day of bladder catheter removal and 1 month after.

Discussion
VUF is a very rare condition that has been estimated 
to accou nt for 1% to 4% of a l l genitourina r y 
fistulas[1,4,5,12]. However, recent studies have shown 
an increase in the prevalence of VUF. In a study of 272 
women with obstetric fistula, Egziabher et al. reported 
23% had VUF[13]. In 2020, Richter et al., describing 
the characteristics of genitourinary fistulas in Kigali, 
Rwanda, reported 185 (29%) cases of vesicouterine/
vesicocervical fistula[14]. In our series, we report 36 
cases of VUF, accounting for 7.2% of all genitourinary 
fistulas. To our knowledge it is one of the largest case 
series published to date. Indeed, these 7 centers are 
referral centers for the treatment of urogenital fistulas 
in Burkina Faso. Most of the published literature 
consists of cases reports and case series. Benchekroun 
et al. reported 30 cases over a 25-year period[15]. Hadzi-
Djokic et al. reported 14 cases over a 37-year period[16].

Two main factors may explain the increasing trend 
in the prevalence of VUF in low-resource countries: the 
trend of increasing Caesarean section rate (with non-
specialist staff sometimes deciding on the procedure 
without strong medical indication), and the high 
number of unassisted deliveries[5,17]. According to 
Sombié et al., the rate of Caesarean section delivery in 
Burkina Faso increased from 0.48% in 2000 to 2.14% 
in 2014[9]. VUFs most commonly occur following low-
segment Caesarean section[1,2,10,11,18,19]. In a review 
including reports from 1986 to 1997, 83% of VUF were 
associated with Caesarean section[20]. In the present 
study, most VUF (26/36) occurred following Caesarean 
section. The mechanism by which communication 

occurs between bladder and uterus may be a bladder 
injury during incision of the lower segment of the 
uterus, during vesicouterine detachment or by uterine 
rupture affecting the bladder. Excessive intraoperative 
bleeding may also lead to injury from attempts to 
achieve hemostasis[2,5].

VUF has been described following dystocic vaginal 
deliveries. It occurs in patients with a scarred uterus 
or af ter instrumenta l extraction[1,3,21,22]. The 
posterior wall of the bladder becomes progressively 
devitalized due to changes in the vascular network 
at the scar of the first operation. A dehiscence of the 
uterine scar and simultaneous injury of the bladder 
wall at the vesicouterine interface may occur with the 
thinning of the lower segment during labor, leading to 
the fistula[2,5]. In the present study, dystocia was the 
second most common cause of VUF. Drissi et al.[1] and 
Hodonou et al.[3] made the same observation. None of 
the patients in our study had a scarred uterus, and no 
instrumental extraction was noted. Deliveries were 
often unassisted, and 5 patients delivered at home. 
Other causes of VUF reported in the literature are 
gynecological (migration of an intrauterine device, 
degenerated or adherent myoma of the bladder) or 
congenital[1,2,7]. We did not find these causes in our 
study.

The purpose of VUF treatment is to suppress 
communication between uterus and bladder. Two 
therapeutic approaches are possible: conser vative 
management and surgical management. Conservative 
m a n a g e m e n t  c o m b i n e s  i n d w e l l i n g  b l a d d e r 
catheterization with hormonal treatment that suppresses 
menstruation for 3 to 6 months[2,23,24]. Spontaneous 
closure of small fistulas seen at an early stage has 
been reported[2,23], providing some justification 
for conservative management. However, results are 
generally disappointing, with Jóźwik et al. estimating 
the success rate to be about 5%[24]. In our series, no 
patients were conservatively managed. We agree with 
Sylla et al. that large or late-onset VUF should receive 
surgical treatment[25]. DiMarco et al. in a series of  
8 cases of VUF undertook conservative management 
of 2 patients, but this was not successful, and surgical 
intervention was eventually required[10]. This consists of 
the excision of the fistulous pathway and necrotic tissue 
and separate suturing of the bladder and uterus by either 
the extraperitoneal or transperitoneal route[1]. Bladder 
catheterization is maintained for about 2 weeks[5,21]. 
Hysterectomy is an option if no further pregnancy 
is desired. Vaginal hysterectomy was performed in 6 
cases (16.7%) in our series. The laparoscopic approach 
is reported in the literature with similar results to open 
surgery[4,25]. VUF repair was performed by open 
surgery in our study. Our results were similar to those 

0

2

6

8

10

12

4

2016

11

2015

9

2014

6

2013

5

2012

2

2011

1

2010

2

FIGURE 1. 
Annual distribution vesicouterine fistulas (n = 36)

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TABLE 1. 

Patient characteristics and vesicouterine fistula characteristics (n=36) 

Median IQR (Min, Max) Frequency

Age, years 35 27–37.5 (16, 64)

Parity 4.1 2.6–5.6 (1, 11)

Genital mutilation

• No 30

• Yes 06

Etiology

Obstetric

• Vaginal delivery 10

•  Emergency Caesarean section performed too late 16

Iatrogenic (prelabour Caesarean section) 10

Jóźwik’s classification

• Type I 02

• Type II 31

• Type III 03

Duration of fistula, months

<24 3

24–48 1

48–72 2

72–96 1

96–120 4

≥ 120 25

Duration of labor, hours 19.7 17.6–22.6 (01, 24)

Fistula size, cm 02 1.4–2.8 (01, 04)

Prior repair of VUF

• Yes 17

• No 19

reported in the literature, with a successful closure 
rate of 88.9% 1 week after indwelling catheter removal.  
This excellent early result decreased to 80.6% after  
1 month. This finding suggests the need for monitoring of 
patients undergoing VUF or, more generally, urogenital 
fistula surgery. Poor tissue vascularization and fibrosis 
are responsible for poor wound healing after surgery[26].  
In addition, special attention has to be paid to the 
complete excision of perifistular necrotic tissue during 
surgery to allow better healing of tissues already 
weakened by ischemia. The postoperative failure rate 

reflects the difficulty of closing some urogenital fistula, 
sometimes after several re-interventions[11,26]. In the 
present study, 17 patients (17/36) had a prior surgical 
repair of their VUF.

Caesarean section must be medically indicated, 
and more obstetricians and specialized nurses may be 
required to perform this procedure more proficiently. 
Meda et al. showed that in Burkina Faso, only 39.2% of 
Caesarean sections are performed by obstetricians and 
28.7% by nurses specialized in surgery[27]. Every effort 

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must be made to prevent urogenital fistula, in particular 
by ensuring all women have access to prenatal care and 
to skilled medical assistance in delivery.

The limitations of this study lie in its retrospective 
nature, which means that some data were not available. 
Also, the postoperative follow-up of our patients was 
limited to one month. This study did not take into 
account data from all the urogenital fistula centers in 
Burkina Faso.

Conclusion
Globally, VUF is rare, but it presents a significant 
challenge in some areas. It occurs mainly af ter 
Caesarean section. The results of surgical treatment 
are good, but the best treatment remains prevention 
through pregnancy monitoring and delivery in medical 
facilities.

Acknowledgments
The authors thank Mr Boyo Pare for English language 
revision.

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