Ectopic ureter, a subtle congenital anomaly causing extraurethral urine loss, generally is detected early in life, but occasionally may escape detection until adolescence or early adulthood (20). In infancy, an ectopic ureter should be suspected when a mother seeks care for her baby, whom she says is never dry. Normally, infants have periods of dryness interspersed with periods of wetness. Most commonly, the ectopic ureter drains into the vagina, but occasionally, it may drain into the urethra distal to the point of continence. This condition can be diagnosed by excretory urography.
A traumatic opening between the urinary tract and the outside is called a fistula. Vesicovaginal fistulas, located between the bladder and urethra, are most common, but fistulas may occur between the vagina, uterus, or bowel, and the urethra, ureter, or bladder.
Worldwide, the most common cause of vesicovaginal fistulas is obstructed labor. This was true in the Western world 150 years ago, but advances in the provision of basic obstetric services and advanced obstetric intervention have virtually eliminated this problem in developed countries.
Obstructed labor can occur in rural areas where girls are married young (sometimes as early as 9 to 10 years of age) and where transportation is poor and access to medical services is limited. In such circumstances, pregnancy often occurs shortly after menstruation begins and before maternal skeletal growth is complete. When labor begins, cephalopelvic disproportion is common and little can be done to correct fetal malpresentations. Women may be in labor as long as 5 to 6 days without intervention, and if they survive, they usually give birth to a stillborn infant. In such cases, the soft tissues of the pelvis are crushed by constant pressure from the fetal head, leading to an ischemic vascular injury and subsequent tissue necrosis. When this tissue sloughs, a genitourinary or rectovaginal fistula develops. Many of these patients have complex or multiple fistulas, involving total destruction of the urethra and sloughing of the entire bladder base (Fig. 26.2). Obstetric fistulas are frequently as large as 5 to 6 cm in diameter.
After such fistulas develop, the lives of these young women (most of whom are younger than 20 years of age) are ruined unless they can gain access to curative surgical services. The constant, uncontrolled dribble of urine makes them offensive to their husbands and family members and they are often ostracized from their families. Most of them eventually become destitute social outcasts—and yet these are otherwise healthy young women. The social and economic costs of this problem are enormous, yet the world medical community largely ignores it. The morbidity associated with obstetric fistulas remains, along with the related maternal mortality, one of the single most neglected issues in international women’s health care.
Figure 26.2 Moderate-sized obstetric vesicovaginal fistula. A metal probe has been placed through the urethra and is clearly visible through the bladder base. (Copyright Worldwide Fistula Fund, used by permission.)
Figure 26.3 Posthysterectomy fistulas. Note three small fistulas in a row.