Vesicovaginal fistula in a dog with urinary incontinence

Emily K. Shea 1Interventional Radiology and Interventional Endoscopy Service, The Animal Medical Center, 510 E 62nd St, New York, NY 10065.

Search for other papers by Emily K. Shea in
Current site
Google Scholar
PubMed
Close
 VMD
,
Allyson C. Berent 1Interventional Radiology and Interventional Endoscopy Service, The Animal Medical Center, 510 E 62nd St, New York, NY 10065.

Search for other papers by Allyson C. Berent in
Current site
Google Scholar
PubMed
Close
 DVM
, and
Chick W. Weisse 1Interventional Radiology and Interventional Endoscopy Service, The Animal Medical Center, 510 E 62nd St, New York, NY 10065.
1Interventional Radiology and Interventional Endoscopy Service, The Animal Medical Center, 510 E 62nd St, New York, NY 10065.

Search for other papers by Chick W. Weisse in
Current site
Google Scholar
PubMed
Close
 VMD

Click on author name to view affiliation information

Abstract

CASE DESCRIPTION

A 5-year-old spayed female Maltese mixed-breed dog was referred for evaluation because of severe urinary incontinence refractory to medical management.

CLINICAL FINDINGS

Physical examination revealed constant dribbling of urine and urine scalding. Culture of a urine sample yielded methicillin-resistant Staphylococcus pseudintermedius and Proteus mirabilis. Abdominal ultrasonographic examination revealed absence of the left kidney, a small, nondistended urinary bladder, and diffuse hepatopathy. Urinary incontinence persisted despite appropriate antimicrobial treatment. Cystourethroscopy and vaginoscopy were subsequently performed and revealed a hypoplastic bladder and a vesicovaginal fistula with urinary leakage through the vaginal diverticulum; no left ureterovesicular junction was identified, consistent with suspected left renal aplasia.

TREATMENT AND OUTCOME

Exploratory laparotomy was performed, and the cranial aspect of the vagina was circumferentially ligated immediately caudal to the fistula. The urinary incontinence resolved immediately after surgery, and lower urinary tract signs improved over the next 2 weeks. Moderate urinary incontinence recurred approximately 6 months later, and a urinary tract infection with Escherichia coli was subsequently identified and treated; clinical signs resolved ≤ 48 hours after treatment was initiated.

CLINICAL RELEVANCE

To the author's knowledge, vesicovaginal fistulas in dogs have not been previously described and should be considered a differential diagnosis for persistent urinary incontinence and recurrent urinary tract infections in female dogs. Vaginoscopy in addition to cystourethroscopy was required to identify the abnormality in this patient. Because multiple concurrent anomalies can be present, both procedures should be performed in female dogs with these clinical signs, even if an abnormality is identified cystoscopically.

Abstract

CASE DESCRIPTION

A 5-year-old spayed female Maltese mixed-breed dog was referred for evaluation because of severe urinary incontinence refractory to medical management.

CLINICAL FINDINGS

Physical examination revealed constant dribbling of urine and urine scalding. Culture of a urine sample yielded methicillin-resistant Staphylococcus pseudintermedius and Proteus mirabilis. Abdominal ultrasonographic examination revealed absence of the left kidney, a small, nondistended urinary bladder, and diffuse hepatopathy. Urinary incontinence persisted despite appropriate antimicrobial treatment. Cystourethroscopy and vaginoscopy were subsequently performed and revealed a hypoplastic bladder and a vesicovaginal fistula with urinary leakage through the vaginal diverticulum; no left ureterovesicular junction was identified, consistent with suspected left renal aplasia.

TREATMENT AND OUTCOME

Exploratory laparotomy was performed, and the cranial aspect of the vagina was circumferentially ligated immediately caudal to the fistula. The urinary incontinence resolved immediately after surgery, and lower urinary tract signs improved over the next 2 weeks. Moderate urinary incontinence recurred approximately 6 months later, and a urinary tract infection with Escherichia coli was subsequently identified and treated; clinical signs resolved ≤ 48 hours after treatment was initiated.

CLINICAL RELEVANCE

To the author's knowledge, vesicovaginal fistulas in dogs have not been previously described and should be considered a differential diagnosis for persistent urinary incontinence and recurrent urinary tract infections in female dogs. Vaginoscopy in addition to cystourethroscopy was required to identify the abnormality in this patient. Because multiple concurrent anomalies can be present, both procedures should be performed in female dogs with these clinical signs, even if an abnormality is identified cystoscopically.

An approximately 5-year-old 4.8-kg (10.6-lb) spayed female Maltese mixed-breed dog was examined by the referring veterinarian after it was obtained from a local animal shelter and placed in a foster home. At the time of this examination, the dog was noted to have constant urinary leakage, vulvar mucosal ulceration, urine scalding, a cough, resolving otitis externa, and a healing abdominal incision from a recent ovariohysterectomy. The dog had been administered amoxi-cillin–clavulanic acid for the previous 7 days (dosage not reported) with no improvement in the cough or urinary incontinence. A urinalysis performed at this visit revealed alkaline urine (pH, 7.5) with adequate concentration (specific gravity, 1.036), moderate proteinuria (3+ by dipstick), mild pyuria (0 to 1 WBCs/hpf), moderate hematuria (11 to 20 RBCs/hpf), and moderate struvite crystalluria (4 to 10/hpf). Doxycycline hyclate (5.2 mg/kg [2.4 mg/lb], PO, q 12 h) was prescribed.

The dog was reevaluated 8 days later. At that time, the cough had resolved, but the urinary incontinence persisted. Evaluation of abdominal radiographs revealed no evidence of radiopaque uroliths. Diethylstilbestrol (0.1 mg/kg [0.05 mg/lb], PO, q 24 h) was prescribed for 7 days, followed by 0.1 mg/kg, PO, at a reduced frequency of every 5 to 7 days, but no clinical response was observed on follow-up. Phenylpropanolamine hydrochloride was added at an unreported date and dosage, but the urinary incontinence persisted. Three months after initial evaluation by the primary care veterinarian, referral was made to the Internal Medicine Service of The Animal Medical Center for further workup of severe urinary incontinence. The dog had been placed with various foster families by this time so that details of its clinical history were difficult to ascertain.

On examination at the Internal Medicine Service, the dog was leaking urine and had urine staining of the pelvic limbs, dermatitis over the ventral aspect of the abdomen with patchy erythema, and a superficial ulcer on the vulva consistent with urine scalding. Other findings on examination included cranial abdominal organomegaly, a cough elicited on tracheal palpation, medially luxating patellae (grade 4/4 bilaterally), mild ceruminous debris in the right ear, and periodontal disease. Digital rectal examination findings were unremarkable. A digital vaginal examination was not performed because of the patient's small size. Results of a CBC, serum biochemical analysis, and serum total thyroxine concentration were within the reference ranges except for the presence of mild thrombocytosis (475,000 platelets/μL; reference range, 143,000 to 448,000 platelets/μL). Cytologic examination of a sample collected by aural swab revealed no organisms. Ultrasonographic examination of the abdomen revealed that the left kidney was absent. There was no evidence of suture material associated with the left renal artery or ureter, and congenital left renal aplasia or agenesis was suspected. Other ultrasonographic findings included the presence of miniscule cystoliths in a very small, nondistended urinary bladder and a diffusely enlarged and hyper-echoic liver with well-defined hypoechoic nodules. Vacuolar hepatopathy with nodular hyperplasia was considered the most likely cause of the hepatic changes. Culture and susceptibility analysis were performed for a free-catch urine sample, and methicillin-resistant Staphylococcus pseudintermedius (susceptible to aminoglycosides, nitrofurantoin, chloramphenicol, and rifampin) and Proteus mirabilis (susceptible to all tested antimicrobials except for tetracycline and nitrofurantoin) were isolated. A 6-week course of nitrofurantoin (5.2 mg/kg, PO, q 8 h) and cefpodoxime proxetil (10.4 mg/kg [4.7 mg/lb], PO, q 24 h) was prescribed with follow-up urine culture recommended 7 to 10 days after treatment started, but a culture was not performed. One week after antimicrobial administration began, no change in urinary incontinence was observed, and the caregiver was advised to continue antimicrobial administration until the dog was reevaluated with cystourethroscopy.

The dog was examined at the Interventional Radiology and Interventional Endoscopy Service of the same hospital 9 weeks later. At the time of the examination, nitrofurantoin and cefpodoxime were still being administered at the prescribed dosages. A free-catch urine sample was collected for culture because the bladder was so small that cystocentesis could not be performed; the results were negative. The continence score of this dog at the time of examination was rated as 1 of 10 (where 10 = fully continent with no leakage; 7.5 = leakage only when resting and recumbent; 5 = leakage mostly when resting and recumbent, but also when walking with a full bladder in between urinations; and 1 = completely incontinent with constant leakage and never urinating a typical-size urine puddle during voluntary urination1).

With the patient anesthetized and positioned in dorsal recumbency, the vulva was clipped of fur and aseptically prepared. Cystourethroscopy and vaginoscopy were performed by use of a 1.9-mm rigid 30° cystoscope.a The urethra had a subjectively normal diameter and was considered a normal length (7 cm) for the size of the dog.2,3 The urinary bladder was examined, and the right UVJ was seen in a normal position and was considered to have a normal shape and size. The bladder mucosa and vasculature appeared normal with no evidence of a urachal diverticulum. Careful evaluation for the left UVJ in the bladder and urethra was performed, and no opening or evidence of an ectopic ureter was seen, consistent with the suspicion of left renal aplasia. Vaginoscopy was then performed and revealed a small amount of yellow fluid, similar to the urine observed in the urinary bladder, within the vagina and vestibule. As the rigid cystoscope was advanced into the vagina, the cervical opening was observed, and in the ventral aspect of the vagina, an additional opening that led to the urinary bladder was seen (Figure 1). The cystoscope was advanced into the fistula, and the right UVJ could be seen. The cystoscope was removed from the fistula and retracted back into the vestibule. An 8F red rubber urinary catheter was advanced into the vagina and through the fistula, and the cystoscope was readvanced into the urinary bladder through the urethral lumen. The red rubber catheter was seen entering the bladder from the most caudodorsal aspect of the trigone. This confirmed a vesicovaginal communication.

Figure 1—
Figure 1—

Vaginoscopic and cystoscopic images obtained during evaluation (A though E) and after surgical treatment (F) of a 5-year-old spayed female mixed-breed dog that was referred because of severe, persistent urinary incontinence. A 30° rigid cystoscope was used for both procedures. A—On vaginoscopic examination, an anomalous opening (white arrow) was seen ventral to the cervical opening (black arrow). B—The urinary bladder was entered by advancement of the cystoscope through the opening seen in panel A. C—The right UVJ (arrow) was visible in the dorsal wall of the urinary bladder. D—The cystoscope was retracted back into the vestibule, and an 8F red rubber urinary catheter (star) was advanced through the fistula (white arrow) beyond the cervical opening (black arrow). E—When the cystoscope was reintroduced into the urinary bladder via the urethra, the catheter (star) was seen entering the bladder from the caudodorsal aspect of the trigone via the fistula. F—After surgical ligation of the cranial aspect of the vagina (just caudal to the diverticulum into the bladder), closure of the fistula was confirmed by delivery of saline (0.9% NaCl) solution via a red rubber catheter into the urinary bladder, with no leakage into the vagina detected.

Citation: Journal of the American Veterinary Medical Association 255, 4; 10.2460/javma.255.4.466

The decision was made to perform an exploratory laparotomy for surgical ligation of the cranial aspect of the vagina just caudal to the communication so that urine would exit through the urethra rather than the vagina. The ventral aspect of the abdomen was clipped of fur and aseptically prepared. The abdomen was entered through an incision from the umbilicus to the pubis. The bladder and vagina were isolated, and adhesions were observed between the uterine stump and the dorsal aspect of the urinary bladder. An 8F red rubber urinary catheter was placed inside the urethra under endoscopic guidance to discern the urethral lumen from the vagina. The cranial aspect of the vagina was bluntly dissected circumferentially, avoiding penetration into the urethra. The vagina was then ligated with 3–0 polydioxanone suture. The bladder was filled with saline (0.9% NaCl) solution delivered through the catheter, and successful ligation with no leakage of fluid into the caudal portion of the vagina was confirmed. Vaginoscopic imaging of the opening to the fistula was performed, and complete closure of the communication was confirmed with no saline solution flowing from the urinary bladder through the vagina. The abdomen and left retroperitoneal space were examined for a left ureter and left kidney, and neither was found. Differential diagnoses included renal aplasia or an unreported prior ureteronephrectomy. Considering that no left ureteral orifice was seen cystoscopically, aplasia was considered most likely.

The patient recovered uneventfully from anesthesia. Abdominal ultrasonography was performed the day after surgery and revealed no evidence of a ureteral or proximal urethral obstruction (ie, no evidence of ureteral or urethral dilation). The patient had mild to moderate hematuria, pollakiuria, and stranguria for approximately 24 to 48 hours after recovery, but the urinary incontinence resolved completely immediately after surgery (continence score of 101). The dog's lower urinary tract signs following surgery were considered likely attributable to a combination of bladder hypoplasia secondary to chronic lack of filling and inflammation associated with the surgery and cystoscopy. In addition to antimicrobials (nitrofurantoin and cefpodoxime as previously prescribed), the dog was treated with prazosin hydro-chloride (0.1 mg/kg, PO, q 12 h), codeine (1.6 mg/kg [0.7 mg/lb], PO, q 6 h, as needed), and dexamethasone sodium phosphate (0.05 mg/kg [0.02 mg/lb], SC, once) after surgery. The dog was discharged from the hospital 2 days after surgery, with nitrofurantoin, cefpodoxime, and prazosin prescribed at the previously described dosages, as well as buprenorphine hydrochloride (0.01 mg/kg [0.005 mg/lb], transmucosally [applied to the buccal mucosa], q 8 to 12 h as needed for signs of pain), and prednisone (0.5 mg/kg [0.23 mg/lb], PO, q 24 h for 3 days). Antimicrobials were continued for 1 week after the dog was discharged from the hospital.

Two weeks after the surgery, the dog's caregiver reported no urinary incontinence, stranguria, or hematuria, but indicated that the dog continued to have mild pollakiuria. This pollakiuria was no longer reported after 3 months. Approximately 6 months after surgery, the dog began to dribble urine intermittently without pollakiuria, hematuria, or stranguria. The dribbling progressed over the course of 2 months, at which time the dog was reevaluated at the Interventional Radiology and Interventional Endoscopy Service. The dog was assigned a continence score of 6.1 A urine sample was obtained by cystocentesis, and culture results were positive for Escherichia coli susceptible to all antimicrobials tested except for amoxicillin and tetracycline. Enrofloxacin (13.6 mg/kg [6.2 mg/lb], PO, q 24 h for 4 weeks) was prescribed to treat the infection, and urinary incontinence resolved ≤ 48 hours after the treatment started. Nine months after surgery, the dog was reportedly doing well with no evidence of urinary incontinence or recurrent urinary tract infections. The dog was subsequently lost to follow-up after being adopted into a permanent home.

Discussion

To the authors’ knowledge, this was the first reported case of a dog with a naturally occurring direct communication between the urinary bladder and vagina (vesicovaginal fistula) leading to persistent severe urinary incontinence. One case of a vesicovaginal fistula in a dog was reported in a table in a review of urinary incontinence in dogs and cats4; however, no further information on the case was provided. Other urogenital fistulas, including urethrovaginal and ureterovaginal fistulas, have been previously reported in dogs secondary to congenital intersex conformation, a migrating vaginal foreign body, and surgical complications; similar clinical signs of persistent urinary incontinence and recurrent urinary tract infections were reported in those cases.4–7 Urinary incontinence secondary to vestibuloperineal fistulas in dogs with intersex conditions has also been reported.6,8–10 Urethrorectal fistulas, which most commonly lead to recurrent urinary tract infections and lower urinary tract signs, uncommonly cause urinary incontinence.10–12 Affected dogs may have urine eliminated from the rectum during active urination.10–12

Vesicovaginal fistulas are the most common type of urogenital fistula in people, and they are most often acquired secondary to complications from prolonged labor or laparoscopic hysterectomy.13,14 Congenital urogenital fistulas are less common, but in a recently published review article15 of congenital urogenital fistulas in people, 37 cases were identified, of which 30 were vesicovaginal communications. Notably, 29 of the 37 cases included other concurrent congenital anomalies, and 29 of 60 total concurrent anomalies were associated with the urinary tract. Renal agenesis or hypoplasia was the most commonly reported concurrent anomaly in human patients,15 similar to findings for the dog of this report.

Various theories have been proposed for the pathogenesis of congenital urogenital fistulas in people and in dogs. Persistence of the urogenital sinus and varying degrees of hypoplasia or agenesis of the urogenital ridge or mesonephric ducts are thought to lead to abnormal urogenital communications.15 A clinicoembryological classification system has been developed for people with various genitourinary malformations, and congenital vesicovaginal fistulas are included in the group of anomalies of the urogenital sinus.15,16 In dogs, most urogenital fistulas reported are associated with intersex conditions.6–9

As opposed to findings in people, acquired urogenital fistulas in dogs appear to be less common than congenital anomalies, and causes include migrating foreign bodies and surgical complications. Ureterovaginal fistulas resulting from inclusion of the ureter in the vaginal stump ligation during ovariohysterectomy are described4; however, urogenital fistulas were not included in a more recent review of complications of ovariohysterectomies.17 The cause of the fistula in our patient was unknown, but given the history of urinary incontinence beginning at a young age and suspected left renal aplasia, a congenital anomaly was suspected. A fistula secondary to an adhesion following ovariohysterectomy was also considered, but the congenital condition was deemed more likely given that the dog had a history of urinary incontinence at the time it was spayed as well as unilateral renal agenesis. For the dog of the present report, surgical ligation of the cranial aspect of the vagina just caudal to the communication with the urinary bladder resulted in immediate resolution of urinary incontinence and ultimately aided adoption of the dog into a permanent home.

Diagnosis in the case described here was made by means of vaginoscopy. The lesion was missed during routine cystourethroscopy owing to the dorsal nature of the fistula in the urinary bladder and the angle of the 30° cystoscope not permitting visual detection of the opening at this location in the dorsally recumbent dog. With a flexible endoscope, this communication could have been visualized. The findings emphasized the importance of thorough cystoscopy, urethroscopy, and vaginoscopy in incontinent female dogs and potentially the concurrent use of contrast medium to highlight any subtle communications that could be missed. Contrast-enhanced cystourethrography is a potentially less expensive and less invasive method of diagnosing urogenital fistulas than the methods used for this patient; however, false-negative and false-positive findings are possible if radiographic imaging is not timed correctly or performed with multiple tangential views. Other traditional imaging modalities such as ultrasonography or CT can be used but are less likely to be as definitive in finding a lesion such as this one. In this patient, the condition was not diagnosed by abdominal ultrasonographic examination.

The treatment of urogenital fistulas depends on the cause, location, and nature of the communication. In people, solitary, small (< 5-mm) iatrogenic fistulas can be managed conservatively with a period of urinary catheterization.13 Adjunctive interventional procedures such as cystoscopic cauterization, laser ablation, and injection of fibrin glue and platelet-rich plasma have been used successfully; however, to our knowledge, randomized studies evaluating these procedures versus catheterization alone have not been performed. Larger and more complex fistulas require more invasive methods of repair, and the choice of transvaginal versus transabdominal or laparoscopic repair methods depends on the location and size of the fistula, presence of concurrent anomalies, and surgeon experience.13 Transvaginal repair has traditionally been used in developing countries, where vesicovaginal fistulas are most commonly caused by complications of childbirth, and this method is associated with similar success rates, lower perioperative morbidity rates, and shorter hospitalization times, compared with an open abdominal approach.13,14,18 In the dog of the present report, the communication was very close to the bladder neck with relatively easy transabdominal access, so surgical correction with an open approach was considered appropriate. In addition, the dog was so small that the size of the scope needed for a transvaginal closure precluded this option. Additionally, the fistula was very close to the UVJ of the dog's only kidney, so intraluminal repair with clips did not seem to be the safest option. In the future, for a larger dog, intracorporeal suturing could be considered.

The most common cause of persistent urinary incontinence in juvenile dogs is ectopic ureters, and in older, spayed dogs, this type of incontinence most frequently results from urethral sphincter mechanism incompetence.19,20 The dog of the present report was referred to our facility because ectopic ureters were suspected, but normal right ureteral anatomy and an absent left ureter were found during cystoscopy. Additionally, this dog did not have a short or wide urethra, as would be expected in the authors’ experience for a dog with this severity of urinary incontinence (score, 1 of 101) in the absence of ectopic ureters. Although, to our knowledge, no reference ranges have been established for urethral length and diameter that account for size, sex, and reproductive status, on the basis of our experience and limited previous reports, this dog's urethra was considered of normal length (7-cm length in a < 5-kg [< 11-lb] dog)2,3 and subjectively normal in width. Further investigation to look for a cause of incontinence was therefore warranted. The cause of the dog's urinary incontinence, which was discovered on vaginoscopic examination, otherwise would likely have been attributed to urethral sphincter mechanism incompetence. At the time when this dog was treated, vaginoscopy was performed in addition to cystourethroscopy to investigate the cause of urinary incontinence, which is standard practice in female dogs at our facility, even if a cause (such as ectopic ureters) is discovered, because of the possibility of multiple concurrent anomalies. A urogenital fistula should be considered a differential diagnosis for persistent urinary incontinence or recurrent urinary tract infections in dogs, especially when the condition is unresponsive to medical management.

Because the dog had multiple homes and caretakers, its medical history was incomplete, and the preoperative duration of urinary incontinence was unknown. In addition, the patient was lost to follow-up after 9 months, although it was fully continent and free of urinary tract infection at last contact. The dog did have 1 urinary tract infection < 8 months after surgery, and it was unknown whether chronic urinary tract infections could be a long-term problem. Furthermore, although surgical ligation was successful in this dog, it is unknown whether the same procedure would be equally successful in another patient with similar signalment and diagnosis. However, the case of the patient reported here supported the benefit of cystourethroscopy and vaginoscopy as diagnostic tools for investigating causes of urinary incontinence in female dogs.

Acknowledgments

The authors declare that there were no conflicts of interest.

Footnotes

a.

Rigid endoscope with 1.9-mm, 30° lens, Karl Storz Endoscopy, Culver City, Calif.

References

  • 1. Currao RL, Berent AC, Weisse C, et al. Use of a percutaneously controlled urethral hydraulic occluder for treatment of refractory urinary incontinence in 18 female dogs. Vet Surg 2013;42:440447.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Johnston GR, Osborne CA, Jessen CR. Effects of urinary bladder distension on the length of the dog and cat urethra. Am J Vet Res 1985;46:509512.

    • Search Google Scholar
    • Export Citation
  • 3. Wang KY, Samii VF, Chew DJ, et al. Vestibular, vaginal and urethral relationships in spayed and intact normal dogs. Theriogenology 2006;66:726735.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4. Holt PE. Urinary incontinence in dogs and cats. Vet Rec 1990;127:347350.

  • 5. Agut A, Carrillo JD, Anson A, et al. Imaging diagnosis–urethrovaginal fistula caused by a migrating grass awn in the vagina. Vet Radiol Ultrasound 2016;57:E30E33.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. Connery NA, Spotswood T. An unusual case of urinary incontinence in an intersex West Highland White Terrier. Can Vet J 2012;53:11951198.

    • Search Google Scholar
    • Export Citation
  • 7. Holt PE, Long SE, Gibbs C. Disorders of urination associated with canine intersexuality. J Small Anim Pract 1983;24:475487.

  • 8. Gregory SP, Trower ND. Surgical treatment of urinary incontinence resulting from a complex congenital abnormality in two dogs. J Small Anim Pract 1997;38:2528.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Schwartz A, Lipowitz AJ, Burt J. Urinary incontinence due to multiple urogenital anomalies in a mature dog. J Am Vet Med Assoc 1974;164:10211024.

    • Search Google Scholar
    • Export Citation
  • 10. Tobias KS, Barbee D. Abnormal micturition and recurrent cystitis associated with multiple congenital anomalies of the urinary tract in a dog. J Am Vet Med Assoc 1995;207:191193.

    • Search Google Scholar
    • Export Citation
  • 11. Bula E, Gold AJ, Nelson N, et al. What Is Your Diagnosis? J Am Vet Med Assoc 2016;249:599601.

  • 12. Osborne CA, Engen MH, Yano BL, et al. Congenital urethrorectal fistula in two dogs. J Am Vet Med Assoc 1975;166:9991002.

  • 13. Moses RA, Ann Gormley E. State of the art for treatment of vesicovaginal fistula. Curr Urol Rep 2017;18:60.

  • 14. Spurlock J. Vesicovaginal fistula. Medscape website. Available at: emedicine.medscape.com/article/267943-overview. Accessed Nov 13, 2017.

    • Search Google Scholar
    • Export Citation
  • 15. Martínez Escoriza JC, Palacios Marqués AM, López Fernández JA, et al. Congenital vesicovaginal fistula with or without menouria: a literature review. Eur J Obstet Gynecol Reprod Biol 2014;175:3848.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16. Acién P, Acién M. Malformations of the female genital tract and embryological bases. Curr Womens Health Rev 2007;3:248288.

  • 17. Adin CA. Complications of ovariohysterectomy in companion animals. Vet Clin North Am Small Anim Pract 2011;41:10231039.

  • 18. Tatar B, Oksay T, Selcen Cebe F, et al. Management of vesicovaginal fistulas after gynecologic surgery. Turk J Obstet Gynecol 2017;14:4551.

    • Search Google Scholar
    • Export Citation
  • 19. Bartges JW, Callens AJ. Congenital diseases of the lower urinary tract. Vet Clin North Am Small Anim Pract 2015;45:703719.

  • 20. Labato MA, Acierno MJ. Micturition disorders and urinary incontinence. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 7th ed. St Louis: Saunders-Elsevier, 2010;160164.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 543 0 0
Full Text Views 1660 1202 258
PDF Downloads 938 445 47
Advertisement