A urethrovaginal fistula is an abnormal passage that forms between the urethra and the vagina, allowing urine to leak continuously through the vaginal opening. It is an uncommon condition, but when it develops, its effect on daily life can be severe. Most cases trace back to childbirth injuries or prior vaginal surgery, though pelvic fractures and cancer treatments account for a meaningful share as well. Surgical repair closes the fistula successfully in the vast majority of cases, yet the path from diagnosis to a full return to normal urinary function involves more complexity than the high closure rates might suggest.
What Causes a Urethrovaginal Fistula
The two most common origins are obstetric trauma and vaginal surgery.1PubMed. Management of urethrovaginal fistulas The obstetric pathway is especially well understood. During prolonged or obstructed labor, the baby’s head can compress the soft tissue of the vaginal wall against the pubic bone for hours, cutting off blood supply. The tissue dies, and over the following days or weeks a hole opens between the urethra and vagina. One published case involved a 23-year-old woman who developed a large fistula with complete sloughing of the front vaginal wall after obstructed labor.2PubMed Central. An Outside-the-Box Approach for Treating a Rare Case of Urethrovaginal Fistula This type of injury is far more common in regions with limited access to emergency obstetric care, where labor can go unassisted for dangerously long stretches.
Vaginal surgeries that operate near the urethra carry their own risk. Procedures to treat stress urinary incontinence, particularly those involving synthetic mesh slings placed beneath the urethra, have been documented as a cause. While urethrovaginal fistula after a sub-urethral sling is considered uncommon, it does happen.3PubMed. An uncommon case of urethrovaginal fistula resulting from tension-free vaginal tape A review of ten women who developed urinary fistulas after mid-urethral sling surgery found that symptoms appeared on average about two months after the procedure, but the delay before diagnosis averaged roughly 16 months, and the interval before fistula repair stretched to about 18 months.4PubMed. Management of urinary fistula due to midurethral sling surgery That gap between symptom onset and diagnosis is telling: because the condition is rare, it is not always the first thing clinicians suspect when a patient reports new urinary leakage after pelvic surgery.
Less common causes include pelvic fractures, radiation therapy for gynecologic or rectal cancers, and certain urethral or vaginal surgeries unrelated to incontinence. Pelvic fractures can be devastating, especially in younger patients. A series of four young girls who suffered urethrovaginal fistulas after pelvic fracture injuries required specialized reconstruction using tissue flaps from the labia minora.5PubMed. Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls
How It Is Recognized and Diagnosed
The hallmark symptom is continuous or near-continuous vaginal leakage of urine, which can be confused with severe stress urinary incontinence. Some women notice a persistent dampness that does not follow the typical pattern of leaking only with coughing or sneezing. Others may report recurrent urinary tract infections or irritation of the vaginal tissue. The leakage often has no relation to physical activity at all, which is a clue that something structural is going on rather than a problem with the sphincter muscles.
A physical examination can sometimes reveal the fistula directly, particularly if it is large. For smaller or more difficult-to-find openings, a dye test may be used: blue dye is instilled into the bladder, and the clinician looks for its appearance at the vaginal wall. Cystourethroscopy, where a small camera is passed through the urethra, can also help locate the tract and assess the health of the surrounding tissue.
When surgeons need to plan a repair, MRI has become the go-to imaging tool. Its ability to distinguish between soft tissues makes it particularly effective for mapping fistula tracts, identifying any associated inflammation or abscess, and evaluating the extent of damage to surrounding structures.6PubMed Central. Guided tour of hidden tracts in the pelvis: exploring pelvic fistulas Knowing the exact location and course of the tract is critical for choosing the right surgical approach, and MRI gives surgeons a detailed roadmap that other imaging methods struggle to match.
Can It Heal Without Surgery
Occasionally, very small fistulas discovered soon after their formation may close on their own if the urine is diverted away from the area with a catheter for several weeks. This conservative approach works best when the fistula is tiny, the surrounding tissue is healthy, and the patient has no prior history of failed repairs or radiation. In practice, though, most urethrovaginal fistulas do not resolve without surgical intervention. The tissue damage that created the opening tends to prevent the edges from sealing back together naturally, particularly when there has been significant tissue loss or scarring from obstetric trauma.
When conservative management fails, the standard of care shifts to surgical repair. Most experts recommend waiting at least three to six months after the initial injury before attempting surgery, allowing inflammation to subside and the tissue to become as healthy as possible. The exception is fistulas from pelvic fractures or acute surgical injury, where earlier repair may sometimes be considered depending on the circumstances.
Surgical Approaches and What They Involve
The vast majority of urethrovaginal fistula repairs are performed through the vagina rather than through an abdominal incision. The transvaginal approach avoids the morbidity of open abdominal surgery, and results from tertiary referral centers show it works well. In one series, a transvaginal approach cured eight of nine women with urethrovaginal fistulas.7PubMed. A tertiary experience of vesico-vaginal and urethro-vaginal fistula repair: factors predicting success The basic principle involves separating the vaginal wall from the urethra, excising the scarred fistula edges, closing the urethral defect in layers, and then closing the vaginal wall over top. Getting healthy, well-vascularized tissue between the urethra and vagina is the key to preventing recurrence.
Because the tissue around a urethrovaginal fistula is often thin, scarred, or poorly supplied with blood, surgeons frequently bring in an extra layer of healthy tissue to reinforce the repair. The most commonly used technique for this is the Martius flap, which harvests a pad of fat and its blood supply from the labia majora and tunnels it beneath the vaginal wall to sit between the repaired urethra and the vaginal closure. Studies have found that using a Martius flap lowers recurrence rates and reduces complications like incontinence and pain with intercourse compared to straightforward layered closure without a flap.8PubMed. Role of the martius procedure in the management of urinary-vaginal fistulas The technique has also been adapted for younger patients, with reports of functionally and cosmetically good outcomes in girls.9PubMed. Martius repair in urethrovaginal defects
For fistulas that have already failed one or more repair attempts, the tissue quality is even worse, and surgeons may turn to more distant tissue sources. The gracilis muscle flap, harvested from the inner thigh, is one option for these difficult recurrent cases.10PubMed Central. Successful Treatment of a Recurrent Urethrovaginal Fistula Using a Gracilis Muscle Flap Bringing in a muscle flap with its own robust blood supply can provide the bulk and vascularity that the scarred local tissues no longer offer.
Success Rates and the Incontinence Problem
Fistula closure rates are high by surgical standards. One large series of 71 women reported successful closure in about 90% after a first operation and close to 99% after a second.11PubMed. Management of urethrovaginal fistulas Another series reported an overall repair success rate of 95%, and notably, more than half of the women in that group had already undergone at least one prior failed repair before coming to the tertiary center.12PubMed. Long-term functional outcomes following non-radiated urethrovaginal fistula repair In a separate retrospective review of 41 surgical repairs, only two women experienced recurrence, putting the recurrence rate at about 5%.13PubMed Central. Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review
These numbers look encouraging, and they are, as far as sealing the hole goes. But closing the fistula is only part of the story. The urethra does more than act as a passive tube; it contains sphincter mechanisms that help maintain urinary continence. When a fistula damages the urethra or the tissue around it, closing the opening does not automatically restore normal sphincter function. In the large series mentioned above, more than half of the women developed stress urinary incontinence after their fistula was successfully closed.14PubMed. Management of urethrovaginal fistulas That means the uncontrolled leaking through the vagina stopped, but these women then experienced the more familiar kind of urine loss with coughing, sneezing, or physical exertion.
This post-repair incontinence often requires its own treatment. In the same series, women who developed stress incontinence after fistula repair were treated with slings. About 60% were fully cured and another third were improved, though a small percentage remained incontinent. Whether to place a sling at the same time as the fistula repair or wait and see if incontinence develops is a real debate among specialists. In one retrospective comparison, placing a fascial sling at the time of repair did not significantly change complication rates compared to repairing the fistula alone.15PubMed Central. Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review For many surgeons, the preference is to address one problem at a time: close the fistula first, allow recovery, and then assess continence status before deciding whether a sling is needed.
Living with the Condition Before and After Repair
The effects of a urethrovaginal fistula extend well beyond the urinary system. Constant urine leakage through the vagina leads to chronic skin irritation, odor, and a disruption of daily activities that many women find isolating. Research consistently shows that urogenital fistulas significantly affect quality of life, urinary function, and sexual health.16Asian Journal of Medical Sciences. Evaluation of quality of life, voiding, and sexual dysfunction following urogynecological fistula repair Women commonly report withdrawing from social situations, struggling with intimacy, and experiencing anxiety or depression linked to the condition. Even after successful surgical repair, some women continue to deal with residual urinary symptoms or sexual difficulties, making follow-up care and, in some cases, pelvic floor physical therapy important parts of long-term recovery.
The emotional recovery can be just as demanding as the physical one. In regions where obstetric fistula is more common, women may face stigma and social exclusion from their communities or even their families. But even in wealthier health-care settings, the embarrassment and loss of control associated with constant leakage can lead to months or years of diminished well-being before a woman receives the right diagnosis and referral to a specialist.
Pediatric and Pelvic Fracture Cases
While most urethrovaginal fistulas occur in adult women after childbirth or pelvic surgery, children are not immune. Pelvic fractures from high-energy trauma, such as car accidents, represent the most frequent cause in younger patients. These injuries can be complex. The urethra in a growing child is short and vulnerable, and when a fracture disrupts the bony architecture of the pelvis, the urethra and surrounding soft tissues can be torn or crushed. In severe cases, the urethral defect may be accompanied by an obliterative stricture, meaning the urethra scars shut entirely in addition to forming a fistula.
Repair in children requires techniques tailored to their smaller anatomy and the need for long-term growth. A combined vaginal and partial transpubic approach has been described as a reliable strategy for resolving complex obliterative urethral strictures and associated fistulas after pelvic fracture in female pediatric patients.17PubMed. Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls In one small series, three out of four girls treated with a labia minora skin flap achieved normal urinary control without needing further surgery. The Martius flap has also been used successfully in pediatric cases, with reports of good functional and cosmetic outcomes.18PubMed. Martius repair in urethrovaginal defects
Global Barriers to Treatment
In high-income countries, urethrovaginal fistulas are relatively rare and treatment is usually available through specialized centers. The picture is starkly different in sub-Saharan Africa, South Asia, and other low-income settings where obstetric fistula remains a major public health problem. Millions of women worldwide are estimated to live with untreated obstetric fistulas, many of which involve the urethra.
A systematic review of barriers to fistula treatment in low-income countries identified nine distinct categories of obstacles: psychosocial, cultural, awareness-related, social, financial, transportation-related, facility shortages, quality-of-care limitations, and gaps in political leadership.19PubMed. Barriers to obstetric fistula treatment in low-income countries: a systematic review Several of these barriers interact and compound. A woman living in a rural area may not know that her condition is treatable, may lack the money to travel, and may face stigma that prevents her family from supporting the journey to a hospital.
Research from Nigeria and Uganda illustrates the financial dimension. The costs of reaching a fistula repair center, combined with lost income during recovery, medications, food, and expenses for a companion, can be prohibitive. In Uganda, a single round trip to a repair camp cost anywhere from about three to 25 U.S. dollars for a woman and her caregiver, and Nigerian women in one region spent between roughly one and six dollars per trip.20PubMed Central. “Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda Those amounts may sound small, but in communities where daily income can be a dollar or less, they represent a genuine barrier. Many fistula repair campaigns and NGOs attempt to subsidize surgical care and transportation, but funding shortages mean that medical and non-medical costs are not covered evenly across all repair centers.
Why Specialized Referral Matters
Urethrovaginal fistula repair is not a procedure that every gynecologist or urologist performs regularly. The condition is rare enough that experience concentrates at tertiary referral centers, and outcomes reflect that concentration. The series reporting 95% success rates and the series reporting cure in nearly all transvaginal cases both come from institutions that handle a high volume of complex fistula repairs. When studies report long delays between symptom onset and definitive repair, part of the explanation is the time it takes for a woman to be referred to a surgeon who has real expertise in these cases.
For anyone dealing with persistent vaginal urine leakage after childbirth, pelvic surgery, or a pelvic fracture, seeking out a center with documented experience in fistula repair is worth the effort. The difference between a first surgery that works and one that fails is not trivial. A failed repair means more scarring, worse tissue quality for the next attempt, and a higher likelihood of needing advanced reconstruction with distant tissue flaps. The data on recurrent fistulas tell this story clearly: women who arrive at referral centers have often already been through one or more unsuccessful operations elsewhere. When the repair is done right the first time by an experienced team, the odds of a good outcome are substantially better.