A 38-year-old woman, gravida 3 para 3, comes to the office for evaluation of vaginal discharge. She underwent a total laparoscopic hysterectomy 2 weeks ago for symptomatic uterine fibroids. The patient had an uncomplicated postoperative course. She was able to ambulate, void, and tolerate a regular diet within 12 hours of surgery and went home on postoperative day 1. However, over the past week, the patient has had persistent malodorous vaginal discharge, requiring her to change pads multiple times a day. She has also been voiding frequently in small volumes and is having increasing vulvar pruritus. She has had no fever, chills, hematuria, or dysuria. The patient has type 2 diabetes mellitus controlled with oral medications. Her other surgeries include 2 cesarean deliveries and laparoscopic cholecystectomy. The patient does not use alcohol or illicit drugs, but she smokes 1 or 2 cigarettes a day. Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, and pulse is 80/min. BMI is 32 kg/m². Abdominal incision sites are clean, dry, and intact. External genitalia are diffusely erythematous with superficial excoriations. Sterile speculum examination reveals a pool of clear, thin fluid in the vaginal vault. Nitrazine paper indicates a pH of 5. The vagina has a small, red area of granulation tissue over the anterior aspect; the cuff at the vaginal apex appears intact. On bimanual examination, there are no palpable masses in the vaginal vault. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf16_1a6c_8f63_cb651be64e74_MD0005_00 Following pelvic surgery (eg, hysterectomy), a small amount of serosanguinous vaginal discharge is expected (Choice E). However, this patient's continuous, clear vaginal discharge is concerning for a vesicovaginal fistula, an abnormal tract between the vagina and bladder. Postsurgical vesicovaginal fistulas are typically caused by unidentified intraoperative injuries to bladder or vaginal tissue, which become devascularized and necrotic, leading to a tissue defect and the aberrant connection. Risk factors include scarring from prior pelvic surgery (eg, cesarean deliveries) and poor tissue healing (eg, diabetes mellitus, smoking). vesicovaginal fistulas This surgical complication causes painless urinary leakage into the vagina, resulting in malodorous discharge that presents within days to weeks of surgery. The discharge has an elevated pH compared to the highly acidic vaginal secretions (eg, pH 4.0-4.5). Because some urine is lost through the vagina, patients may also have small-volume voids and erythematous, pruritic vulvar skin from constant contact with urine and a need for frequent sanitary pad changes. On speculum examination, large fistulas may appear as visible defects on the anterior vaginal wall. Smaller fistulas, however, often appear as subtle areas of red granulation tissue with fluid pooling, as in this patient. Clinical suspicion for a small fistula requires evaluation with bladder dye testing, which is performed by instilling a dyed fluid (eg, methylene blue) into the bladder. Staining of cotton swabs placed in the vagina is diagnostic. Minor fistulas sometimes heal on their own with continuous bladder drainage; otherwise, repair is surgical. bladder dye testing (Choice A) Gonorrhea and chlamydia are sexually transmitted infections that can cause vaginal discharge and, less commonly, vulvar pruritus or frequent voiding due to urethritis. However, these pathogens usually cause thick, mucopurulent discharge due to acute cervicitis. acute cervicitis (Choice C) CT scan of the abdomen and pelvis is used to identify postoperative complications such as bowel obstruction, intraabdominal bleeding, or abscess. However, these typically cause abdominal pain and systemic symptoms (eg, fever, hypotension), which are not seen in this patient. CT scan usually cannot detect small vesicovaginal fistulas. (Choice D) Urodynamic studies can differentiate between stress and urge incontinence by assessing bladder function (eg, storage, evacuation). However, neither type of incontinence is associated with pooling of urine in the vagina. incontinence Educational objective: A vesicovaginal fistula is a potential complication of pelvic surgery that presents as painless, continuous leakage of urine (eg, clear, malodorous fluid) into the vagina. Small vesicovaginal fistulas may be subtle on examination (eg, red area of granulation tissue) and require evaluation (eg, bladder dye testing). References: Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28225769) Urologic complications following obstetrics and gynecological surgery: our experience in a tertiary care hospital. (http://www.ncbi.nlm.nih.gov/pubmed/26834397) Management of genitourinary fistulas following benign gynecological and obstetric procedures: a single surgeon experience. (http://www.ncbi.nlm.nih.gov/pubmed/33384539)

A 38-Year-Old Woman, Gravida 3 Para 3, Comes to the Office