Medicolegal aspects of vesicovaginal fistulae

Vesicovaginal ®stulae (VVF) are a common ®nding in developing countries, because there is a high incidence of prolonged obstructed labour [1±4]. In the Western world VVF are less common and usually associated with iatrogenic injury, especially obstetric and gynaecological procedures [5±8]. VVF may also result from pelvic malignancy and its treatment by radiotherapy [6,9]. The subsequent urinary incontinence caused by VVF has a profound affect on the patient's quality of life and is a common cause of medicolegal claims. This is frequently compounded by an unnecessary delay in repair of up to 3 months from the time of injury [5,6]. For a small ®stula, the treatment is initially conservative, as a small percentage will heal spontaneously; however, most will require surgery [10,11]. Operative intervention is associated with an 80±90% primary cure rate [1±7,12]. Surgery can be undertaken by either a gynaecologist or urologist, provided they are a specialist in the ®eld. The timing and type of repair used depend on the experience of the surgeon and the aetiology of the ®stula [13]. The incidence of medicolegal claims is increasing, especially in the ®eld of obstetrics and gynaecology. Urological injury occurring during obstetric and gynaecological procedures accounts for 10% of all claims and represents 19.6% of claims actually settled, with VVF accounting for the second highest cause of claims within gynaecology [14,15]. The avoidance, recognition and treatment of these ®stulae is therefore a signi®cant issue given the associated morbidity and medicolegal implications [16]. This review discusses the aetiology, presentation, management and prevention of obstetric, iatrogenic and radiotherapy-induced VVF [17].