A fistula after hysterectomy is an abnormal tunnel that forms between the vagina and a neighboring organ, most often the bladder. It occurs because tissue is damaged during surgery, sometimes from a cut or stitch that goes through the wrong layer, but frequently from heat generated by the energy devices used to control bleeding. The connection is uncommon but far from rare enough to be dismissed as a freak event, and it accounts for a large share of all fistulas seen in countries with modern surgical facilities. Understanding how these fistulas develop, what they feel like, and how they are fixed can help anyone facing this complication navigate a frustrating and often emotionally difficult recovery.
What a Post-Hysterectomy Fistula Actually Is
A vaginal fistula is an opening that should not exist between the vagina and either the urinary tract or the digestive tract.1Insights into Imaging. Elucidating vaginal fistulas on CT and MRI When the connection runs from the vagina to the bladder, it is called a vesicovaginal fistula, or VVF. That is by far the most common type after hysterectomy. Less frequently, the tunnel links the vagina to the ureter (the tube draining the kidney to the bladder) or to the rectum. Ureterovaginal fistulas tend to produce different symptoms from VVFs, and rectovaginal fistulas involve stool rather than urine. All of them share the same root cause: tissue was compromised during or after the operation, and the body’s healing process created a channel between two spaces that are normally sealed off from each other.
In well-resourced countries, surgery is the dominant cause of urogenital fistulas. A systematic review found that about 83% of urogenital fistulas in these settings followed some kind of surgical procedure, in contrast to low-resourced countries where roughly 95% of fistulas result from prolonged obstructed labor during childbirth.2PubMed. The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review Within that surgical category, hysterectomy stands out as the leading single procedure.
How the Type of Hysterectomy Affects Risk
Not all hysterectomies carry the same fistula risk, and the differences are bigger than you might expect. A large Danish population study found that laparoscopic hysterectomy had the highest rate of subsequent fistula surgery, while subtotal abdominal hysterectomy (the type that leaves the cervix in place) had the lowest.3Obstetrics & Gynecology. Hysterectomy for Benign Indications and Risk of Pelvic Organ Fistula Disease The gap was wide: roughly 96 fistula surgeries per 100,000 person-years after laparoscopic hysterectomy versus about 14 per 100,000 person-years after the subtotal approach. Total abdominal hysterectomy also appears to be a notable contributor; a separate analysis found that patients who developed a VVF were more likely to have undergone a total abdominal hysterectomy compared with other surgical routes.4PubMed Central. Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications
Why the subtotal approach fares best is fairly intuitive: it leaves the cervix and the lower vaginal cuff alone, which means the surgeon does not need to dissect the bladder off the front of the cervix. That dissection step, required in a total hysterectomy, is where most bladder injuries happen. The laparoscopic route, despite its general reputation for being less invasive, introduces more energy-device use in a tight space, and the two-dimensional camera view can make the tissue planes harder to identify precisely.
Why Fistulas Form Even When Nothing Goes Visibly Wrong
One of the more unsettling aspects of this complication is that most fistulas are not caused by an obvious mistake the surgeon noticed at the time. A Japanese retrospective study of 28 VVF cases found that hysterectomy-related fistulas made up 75% of the total, and no bladder injury was recognized during the original surgery in about two-thirds of those cases.5PubMed Central. Transvaginal vesicovaginal fistula closure: A retrospective study of 28 cases at a single facility in Japan When the researchers reviewed surgical records from the referring hospitals, the bladder dissection was described as straightforward in most cases. Energy devices were used in every patient for whom the surgical device was documented.
That finding points to thermal injury as a major culprit. Both monopolar and bipolar electrosurgical instruments generate heat that can extend beyond the visible tip of the device. The tissue looks fine at the time, but microscopic damage to the vaginal cuff and the adjacent bladder wall has already started a process of tissue death. Over the following days and weeks, the devitalized tissue breaks down, and a hole forms. This delayed mechanism explains why symptoms often appear not during the hospital stay but days or weeks later, catching patients off guard at home.
Who Is at Higher Risk
Beyond the type of hysterectomy chosen, several patient-level and surgical-environment factors make a fistula more likely. Observational evidence points to increasing age, smoking, a history of diverticulitis, and pelvic adhesions from prior surgery or endometriosis as significant risk factors.6PubMed. Risk of pelvic organ fistula in patients undergoing hysterectomy The common thread is tissue quality: older tissue heals more slowly, smoking impairs blood supply, diverticulitis creates chronic inflammation near the surgical field, and adhesions force the surgeon to cut through scar tissue where normal anatomical layers have fused together.
Prior pelvic radiation therapy is another well-known contributor, though it typically applies to patients undergoing hysterectomy for cancer rather than benign conditions. Irradiated tissue is fragile, poorly vascularized, and prone to delayed healing. Even without radiation, patients with large uterine fibroids (myomas) that distort the anatomy can end up at higher risk, because the surgeon has to work around abnormal tissue planes to free the bladder from the uterus.
Recognizing the Symptoms
The hallmark symptom of a vesicovaginal fistula is continuous, involuntary leakage of urine from the vagina. It is different from stress incontinence, which happens in spurts during coughing or lifting. With a VVF, the leakage is constant and does not respond to pelvic floor exercises or changes in position. Many women describe soaking through pads within hours. The urine irritates vaginal and vulvar skin, causing soreness and recurrent infections.
Symptoms usually appear within the first two weeks after surgery but can show up later. One published case report describes a 48-year-old woman whose urine leakage from the vagina began seven days after a hysterectomy performed for uterine fibroids.7Andalas Obstetrics And Gynecology Journal. A Case Report: Vesico Vaginal Fistula The timing varies depending on the mechanism: a direct surgical cut to the bladder can produce symptoms within a day or two, while a thermal injury may not become apparent for a week or more, as the tissue gradually breaks down.
Ureterovaginal fistulas present differently. Because only one ureter is usually involved, the bladder still fills and empties somewhat normally, so a woman may have both normal urination and vaginal leakage. She might also develop flank pain on the affected side if the kidney becomes partially obstructed. Rectovaginal fistulas present with passage of gas or stool from the vagina, often accompanied by foul-smelling discharge and recurrent vaginal infections.
How Fistulas Are Diagnosed
Physical examination can sometimes confirm a fistula, particularly if the opening is visible on speculum exam. But many fistulas are small or positioned where they are hard to see, and imaging studies are usually needed. Fluoroscopic techniques such as voiding cystourethrography (where contrast dye is instilled into the bladder and then watched as the patient voids) remain central for evaluating the lower urinary tract, while intravenous urography or direct ureteral studies are used for suspected upper-tract involvement. Cross-sectional imaging with CT is increasingly used as a first-line test in many hospitals.8PubMed. Fistulas of the genitourinary tract: a radiologic review MRI can also be helpful, particularly for complex or recurrent fistulas, because it provides excellent soft-tissue detail without radiation.
A simple bedside test sometimes used early on is the “double-dye” or tampon test. The patient drinks an oral dye (like phenazopyridine, which turns urine orange) while blue dye is instilled into the bladder via catheter. A tampon placed in the vagina is then checked: blue staining suggests a VVF, orange staining suggests a ureterovaginal fistula, and both colors suggest both. It is not perfectly sensitive, but it is inexpensive, quick, and can help guide which imaging study to order next.
Can a Fistula Heal on Its Own
Doctors sometimes try conservative management first, which in practice means leaving a urinary catheter in place for several weeks to keep the bladder decompressed so that no urine flows through the fistula. The idea is to let the edges of the opening scar over and seal. A systematic review of over 1,400 VVFs following benign gynecologic surgery found that about 16% were initially managed this way, with catheter drainage lasting anywhere from 2 to 12 weeks. Unfortunately, only about 8% of those conservatively managed fistulas actually closed without surgery.9PLoS ONE. Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis The remaining 92% eventually went on to surgical repair.
That low spontaneous closure rate means conservative treatment is really more of a trial period than a treatment plan. If the fistula is very small and was caught early, catheter drainage is a reasonable first step because it costs little and avoids another operation. But if the leakage persists after a few weeks, waiting longer without a clear downward trend in symptoms is unlikely to help and only delays definitive repair.
When to Operate
The traditional teaching was to wait at least three months after the original hysterectomy before attempting fistula repair, allowing inflammation and tissue swelling to resolve.10PubMed Central. Update on vesicovaginal fistula: A systematic review That advice still holds in most cases, and delayed repair generally produces better outcomes than rushing in.11PubMed Central. Vesicovaginal fistula: Review and recent trends There is an exception, however: when the fistula is identified very early, there is no active infection, and the patient has not undergone pelvic radiation, some surgeons advocate for early repair with good results. The shift toward earlier surgery in select patients reflects improving surgical techniques and a recognition that three months of constant urine leakage is profoundly distressing.
Surgical Repair Options
Fistula repair can be performed through the vagina (transvaginal), through the abdomen (transabdominal, usually with an open incision), or with robotic or laparoscopic assistance. A study of 449 women undergoing VVF repair found that transvaginal was the most common approach, used in about 56% of cases, followed by transabdominal at 33% and laparoscopic or robotic at about 11%.12Female Pelvic Medicine and Reconstructive Surgery. Perioperative Outcomes of Vesicovaginal Fistula Repair by Surgical Approach
The abdominal approach was associated with longer hospital stays (a median of three days compared with one day for the other approaches), higher rates of prolonged hospitalization, more major complications, and more blood transfusions. After adjusting for other variables, the abdominal route carried about six times the odds of prolonged hospitalization compared with transvaginal repair and about twelve times the odds compared with the robotic or laparoscopic route. The choice of approach depends on fistula location, size, and complexity: high fistulas near the top of the vagina that sit close to the ureters often need an abdominal approach, while lower and more accessible fistulas do well with vaginal repair.
The overall success rates of surgical repair are encouraging. The same meta-analysis that tracked conservative management reported a surgical cure rate of about 98%.13PLoS ONE. Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis Data from well-resourced countries show median closure rates around 95%.14PubMed. The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review
Tissue Flaps and Complex Repairs
For larger, recurrent, or radiation-damaged fistulas, surgeons often interpose a layer of well-vascularized tissue between the repaired bladder and vagina to reduce the chance of the repair breaking down. When working through the vagina, the most common flap is the Martius flap, a pad of fat harvested from the labium majus and tunneled into the repair site. When working through the abdomen, an omental flap (a tongue of fatty tissue from the abdominal lining) is sometimes brought down to cover the repair.15PubMed Central. Management of vesicovaginal fistulas after gynecologic surgery
Not every fistula needs a flap. When the tissue around the fistula looks healthy and well-supplied with blood, simple excision and closure may be sufficient. One series of 26 fistula repairs using interposition flaps reported cure rates above 95% at first attempt, with no recurrence during a mean follow-up of about 29 months.16PubMed Central. Interposition flaps in vesicovaginal fistula repairs can optimize cure rate Use of an interposition flap has also been identified as a protective factor against recurrence in a systematic review of predictors of VVF failure.17PubMed Central. Predictors of recurrence after vesicovaginal fistula repair: a systematic review of surgical and patient-related factors
What Predicts Recurrence
Even with high overall success rates, some fistulas come back after repair. The same systematic review identified several consistent predictors of recurrence: a fistula diameter larger than about two to three centimeters, severe scarring around the fistula, involvement of the urethra or bladder neck, and the presence of multiple fistulas. Having had a prior failed repair was also a negative predictor. On the protective side, surgery performed at a specialist center and the use of tissue interposition flaps were associated with lower recurrence.18PubMed Central. Predictors of recurrence after vesicovaginal fistula repair: a systematic review of surgical and patient-related factors
The specialist-center finding is worth pausing on. Fistula repair is not a high-volume procedure for most gynecologists or urologists; the surgeon who does it regularly has far more experience with the tissue handling, the judgment calls about when to use a flap, and the postoperative management that prevents recurrence. If you are facing a repair, asking about your surgeon’s fistula-specific volume is a reasonable and important question.
Rectovaginal Fistulas After Hysterectomy
Although vesicovaginal fistulas get most of the attention, hysterectomy can also produce a rectovaginal fistula if the posterior vaginal wall or the anterior rectal wall is injured. These are rarer but create their own set of distressing symptoms: passing gas or stool through the vagina, chronic vaginal discharge, and recurrent infections. A retrospective study of 40 rectovaginal fistula repairs found an overall success rate of about 83%, with local repairs succeeding in about 88% of cases. Transabdominal repairs did less well, succeeding in about half of cases. Prior failed repair and the underlying cause of the fistula were the main negative predictors of healing.19International Journal of Surgery Open. Rectovaginal fistulas, outcomes of various surgical repair and predictive factors of healing success Fecal diversion with a temporary colostomy did not significantly improve healing in that study, a finding that challenges the assumption that resting the bowel guarantees a better result.
Preventing Fistulas During Hysterectomy
Prevention is obviously preferable to repair, and several strategies are used. Careful identification of the bladder edge before dissection, gentle tissue handling, limited use of electrosurgical energy near the bladder, and intraoperative cystoscopy to check for bladder injury before closing have all been advocated. Intraoperative cystoscopy, where a small camera is inserted into the bladder at the end of the procedure, can catch perforations or dye leakage that would otherwise go unnoticed. A review of U.S. malpractice cases involving fistulas after elective hysterectomy noted that cystoscopy could have been beneficial in some of those cases.20PubMed. Review of Malpractice Litigations Involving Vesicovaginal and Rectovaginal Fistulas Following Elective Hysterectomy for Benign Indications in the United States From 1970 to 2020
Prophylactic ureteral stents, where small tubes are threaded into the ureters before surgery to help the surgeon feel or see them during dissection, are sometimes used in high-risk cases. In one series of patients undergoing hysterectomy and other pelvic procedures, none of those who had stents placed beforehand suffered a ureteral injury.21PubMed Central. Protect the ureters However, evidence is mixed. A more recent study focusing specifically on radical hysterectomy for cervical cancer found that prophylactic ureteral stents did not reduce ureteral injuries and actually increased urinary complications and medical costs.22PubMed. Analysis of the use of prophylactic ureteral stents in preventing iatrogenic ureteral injury during radical hysterectomy for cervical Cancer The takeaway is that stents may help in certain scenarios but are not a universal safeguard, and the decision should be individualized.
The Emotional and Sexual Toll
Living with a fistula between surgeries is often described by patients as isolating and humiliating. Constant urine or stool leakage makes it difficult to work, exercise, or socialize. Many women withdraw from intimate relationships. The psychological burden can resemble what patients experience with other chronic incontinence conditions, but the added knowledge that it resulted from a surgical procedure can generate feelings of anger and betrayal toward the healthcare system.
The good news is that repair tends to reverse much of the damage. Research on sexual function after fistula surgery found that repair improves sexual function and quality of life regardless of whether the repair was done vaginally or abdominally.23PubMed. Sexual function after vaginal and abdominal fistula repair That said, some women continue to experience pelvic floor dysfunction, stress incontinence, or vaginal shortening after repair. Pelvic floor physiotherapy before and after surgery can address residual weakness, improve coordination of the pelvic muscles, and help manage any ongoing incontinence through bladder retraining and targeted exercises.24Glob Libr Women’s Med. Physiotherapy in the Context of Fistula Management
Malpractice Litigation and Documentation
Fistulas after elective hysterectomy sometimes lead to lawsuits. A review of U.S. malpractice cases from 1970 to 2020 identified 17 cases involving fistulas after benign hysterectomy. Most involved vesicovaginal fistulas, and the most common allegation was negligence. The majority of verdicts, 14 out of 17, favored the defending surgeon. In the three cases where the patient prevailed, monetary awards ranged from about $250,000 to roughly $750,000 (significantly more when adjusted for inflation). The factors that most often strengthened the surgeon’s defense were thorough operative documentation, clear informed consent, and prompt referral to a specialist once the fistula was recognized.25PubMed. Review of Malpractice Litigations Involving Vesicovaginal and Rectovaginal Fistulas Following Elective Hysterectomy for Benign Indications in the United States From 1970 to 2020
For patients, this has a practical implication: if you suspect a fistula after hysterectomy, request copies of your operative report and any cystoscopy findings early on. Understanding what was documented at the time of surgery helps both your treating team and, if it comes to that, any legal review. More immediately, it ensures continuity of care if you are referred to a specialist at a different institution.
Pelvic Floor Rehabilitation After Repair
Even after a successful surgical closure, the pelvic floor often needs rehabilitation. The muscles, nerves, and connective tissue in the pelvis have been through two surgeries at a minimum, and many women are left with weakened or uncoordinated pelvic muscles. Physiotherapy programs designed for fistula patients typically include pelvic floor muscle exercises to rebuild strength, stretching for hip and pelvic mobility, manual therapy or scar massage to improve tissue flexibility, and patient education on bladder retraining and hydration.26Glob Libr Women’s Med. Physiotherapy in the Context of Fistula Management Some patients also benefit from accommodations like absorbent underwear or assistive devices during the recovery period.
A follow-up study of women who participated in a structured physiotherapy and health education program before and after fistula surgery found that quality-of-life measures and continence were tracked at 3, 6, and 12 months after the procedure, suggesting that meaningful recovery is a months-long process rather than something that resolves once the wound heals.27International Journal of Gynecology & Obstetrics. One‐year follow‐up of women who participated in a physiotherapy and health education program before and after obstetric fistula surgery Pelvic floor rehabilitation is still underutilized after fistula repair in many healthcare settings, and it is worth asking your surgical team for a referral to a specialist physiotherapist even if one is not offered automatically.