Vesicovaginal Fistula Classification and Management

Anatomical Classification

VVFs can be classified as high or low fistulas based on their anatomical location relative to the urinary tract, with high fistulas being a communication between the vagina and bladder above the sphincter complex, and low fistulas being a communication between the vagina and lower urinary tract involving the sphincter complex 1, 2, 3
Using the Parks classification system, fistulas can be categorized as superficial (low), intersphincteric (low or high), transsphincteric (low or high), suprasphincteric (high), or extrasphincteric (high) 2, 3, 4

VVFs are commonly classified as either simple or complex based on clinical characteristics, with simple VVFs being single, small fistulous tracts with low anatomical position and no associated pain or fluctuation, and complex VVFs being high anatomical position, multiple external openings, and associated with pain or fluctuation 2, 3, 5
Simple VVFs have a single external opening, no evidence of associated stricture, and no active inflammation in surrounding tissues 2, 3
Complex VVFs have multiple external openings, are associated with pain or fluctuation, and have active inflammation in surrounding tissues 2, 3

Iatrogenic VVFs result from surgical complications, particularly hysterectomy, and occur in approximately 1 in 1000 post-hysterectomy patients 6
Radiation-induced VVFs result from tissue damage following radiation therapy for pelvic malignancies and are often complex and difficult to repair 2, 6
Malignancy-associated VVFs are direct invasion of bladder and vagina by pelvic malignancies and often require more complex management 6

VVFs can be classified according to size, presence of single or multiple tracts, involvement of surrounding structures, and presence of associated abscesses or inflammation 3, 7

The American College of Radiology recommends that treatment approach varies significantly based on fistula type, with simple fistulas being amenable to endoscopic fulguration and complex fistulas requiring surgical repair 1
The strength of evidence for the treatment approach is based on clinical characteristics, with simple VVFs having a higher success rate with endoscopic fulguration and complex VVFs having a higher success rate with surgical repair 2, 3, 5