Evaluate the localization and size of the fistula.

  1. Distal fistulas. (Fig. 1) Normally they do not need treatment when not associated to true urinary incontinence or important symptoms. In these cases, the lack of directional urinary flow or loss resulting from accumulation of urine inside the vagina may be bypassed with hygienic orientation after urination. Another alternative when the symptoms are severe is urethral marsupialization4.
  2. Proximal fistulas. Normally they need treatment because of the associated urinary incontinence. In determined situations a urethral reconstruction may be necessary5, associated to the interposition of the pubovaginal sling, in the cases of associated SUI.
  3. Small fistulas. In selected cases cauterization of the course of the fistula may be used and the injection of teflon around of the fistulous tract.
  4. Large dimension fistulas must be treated, preferentially with techniques that allow an interposition of well vascularized tissues, such as, the Martius graft (Fig. 2, 3 and 4) or the modifications of this technique 6-12 .

Evaluate the etiology of the fistula and the presence of associated lesions.

After radiotherapy: The treatment of these fistulas is complex. Associated problems may coexist like radiation cystitis and the loss of bladder compliance. Additionally the presence of intense vaginal atrophy and of improper tissues for the reconstruction of the urethra can make it unviable for the correction of the fistula. In these cases urinary diversion must be considered. In the cases where reconstruction of the urinary tract is possible it is fundamental the interposition of healthy tissues (Martius graft, of gracilis muscle, etc.)

Presence of associated Stress Urinary Incontinence (SUI)

SUI may be resulting from loss of suport of the urethra and the bladder neck through the pelvic floor or resulting of intrinsic sphincter dysfunction caused by multiple surgeries in which the anterior vaginal wall was approached. Not recognizing the problem may lead to the need, later in time, of additional surgical procedure. In these cases we chose the correction of the fistula, interposition of the Martius graft and the placement of the pubovaginal sling.