Introduction

Genitourinary tract fistulas commonly occur as a complication of gynecologic operations. The common causes of these fistulas differ in different parts of the world. In industrialized countries, the most common cause (75%) is injury to the bladder at gynecologic surgery, usually abdominal hysterectomy, with the remainder due to vaginal hysterectomy or antiincontinence surgery, such as anterior colporrhaphy.(₁,₂) In developing countries, in which routine prenatal obstetric care may be limited, Genitourinary tract fistulas most commonly occur as a result of prolonged labor, with resulting pressure necrosis to the anterior vaginal wall and underlying trigone of the bladder from the baby's head. They can also result from cesarean section and the use of forceps (₃)

Nowadays, Genitourinary tract fistula is becoming more frequent because of the increasing use of cesarean section. The fistula site is typically at the posterior aspect of the bladder dome and main symptom of these fistula is urinary incontinence, often occurring immediately after cesarean section if injury to the bladder is unrecognized or treated inadequately. Hovewer sometimes it can cause cathastrophic results. We are presenting a case administered our hospital with acute abdomen and acute renal faiulure.

Case

A 33-year-old woman (gravida 2, para 1 ), underwent ceserean section on September 2006, which was uncomplicated. Overnight she passed 2 litre urine which was normal in apperance through a bladder catheter, the next morning the catheter was removed and the patient was sent home. During the following day she started to complain of tenderness and pain in her lower abdomen. Her physical examination revealed direct and indirect rebound positive. Due to her inability to pass urine spontaneously she was catheterized once, which resulted in approximately 150 ml of bloody urine. Abdominal discomfort and pain of varying intensity persisted over the following days. The laparotomy wound was unremarkable. An X-ray film of the abdomen suggested a subileus, but bowel sounds were present. Abdominal ultrasound showed a regularly involuting uterus, normal sized kidneys without evidence of urinary tract obstruction and masive intra-abdominal fluid accumulation, which was attributed to the recent section. On the third day after the Caesarean section. Upon physical examination she appeared well-hydrated overall. The patient's body temperature was 37.5°C. and blood pressure was 120/ 80 mmHg. The chest was clear on auscultation. But it was noticed that the patient's serum creatinine had increased to 3.38 mg/dl and serum urea increased to 64 mg/dl. C-reactive protein was elevated to 103 mg/dl. Liver enzymes were normal. The patient had a leucocytosis of 11400 /mm³ , her platelet count was 354 000 / mm³ and her hemoglobin level was 12.6 g/dl. A culture of a urine specimen obtained on the day after delivery had shown bacterial growth. Doppler ultrasound showed regular kidney perfusion; there was no evidence for thrombosis of the renal veins or the vena cava inferior. The suspected diagnosis of intra-abdominal urinary leakage was confirmed by cystogram, which showed extravasation of contrast medium into the abdominal cavity (Figure 1 ).

Figure 1

Figure 1:Cystogram showed extravasation of contrast medium into the abdominal cavity

Subsequently, cystoscopy performed by urologist revealed a 1.5x1.5 cm supratrigonal lesion in the bladder wall. After cystoscopy it was decided that second opaeration was not necessary, and chaterization was enough. following 48 hours, serum creatinine come its normal levels and 10 days later a bladder cathater was removed and second cystogram which showed no contrast medium extravasation in to abdominal cavity was performed.

Discussion

Acute renal failure is a most challenging clinical problem when it occurs in pregnancy. As in all patients who develop acute renal failure, prerenal and obstructive causes must be excluded. A particularly important cause of prerenal azotemia in pregnancy is uterine hemorrhage, especially if it is unsuspected as in abruptio placenta. Infectious causes of acute renal failure in the pregnant woman include acute pyelonephritis and septic abortion. The clinical presentation of both these conditions should be apparent, and appropriate diagnosis and treatment can then be promptly instituted. Renal cortical necrosis is another cause of renal failure that occurs more frequently in pregnancy, and it must be differentiated from the many causes of acute tubular necrosis that may be associated with pregnancy. Postpartum renal failure in previously healthy subjects is associated most often with preeclampsia and/or hypertension; HELLP syndrome, hemolytic uremic syndrome; or thrombotic thrombocytopenic purpura (₄). In our case, the patient did not show any signs or symptoms of pre-eclampsia. She had not experienced any episodes of hemodynamic compromise, nor was there any major blood loss, so ischemic renal failure due to systemic hypoperfusion could be ruled out. In addition, the possibility of renal hypoperfusion due to a renal vascular occlusion was excluded by Doppler ultrasound, as was the unlikely possibility of a bilateral renal vein thrombosis. The normal platelet count and hemoglobin levels excluded a pregnancy-associated microangiopathy, such as hemolytic uremic syndrome.

The urinary tract injuries in association with pregnancy have been reported at an incidence of 0.04% (₅) and bladder injury after Caesarean section has been documented in 0.1–5% of cases(₆) Urogenital fistulas usually present with vaginal urinary leakage, cyclic hematuira (menouria), amenorrhea, infertility, and first trimester abortions. But sometimes extravasation of urine into the abdominal cavity, may cause to peritonitis and abnormal renal chemistry. ‘Urine peritonitis' is believed to be inducible by chemical irritation in the absence of bacterial contamination of the urine, but urine colonization may lead to more severe disease (₇) Urine constituents are rapidly reabsorbed through the peritoneum, as they are excreted into the peritoneal cavity during peritoneal dialysis and it may mimicking acute renal failure akin our case (₈,₉,₁₀)

The disease treatment options include conservative treatment as well as surgical repair. In this case, conservative management has been done since we have known that there is good chance for spontaneous closure of the fistulous track. If its is samall insize and diagnosed during perioperative and early postoperative perid (₁₁).

In a conclusion, although main symptom of Genitourinary tract fistula is urinary incontinence, occurring immediately after cesarean section, sometimes it can cause cathastrophic results; mimicking acute abdomen or acute renal faiulure. Conservative management can be succesful if defect size is small and when it is detected peroperative or early postoperative perid.

Correspondence to

Hasan Kafali Address: Fatih University , Obstetrics and Gynecology Department Çankaya /ANKARA Tel: +90 0312 440 06 06 e-mail: hasankafali@hotmail.com