A ureterovaginal fistula is an abnormal path from a ureter to the vagina, most often caused by ureteric injury during pelvic surgery such as hysterectomy. The classic pattern is continuous watery vaginal leakage while the woman can still pass urine normally from the bladder, because the opposite kidney and/or part of the urinary tract continues to drain into the bladder. Flank pain, fever or hydronephrosis may also occur. CT urography with delayed images and cystoscopy or retrograde assessment help confirm the diagnosis. Treatment begins with restoring drainage, often DJ stenting if possible or nephrostomy, and persistent injuries may require ureteric reimplantation.

Why can normal urination continue?

The injured ureter leaks urine before it reaches the bladder. The bladder can still fill from the other kidney, so urethral voiding continues at the same time as vaginal leakage.

Symptoms

• Continuous watery vaginal leakage after hysterectomy or pelvic surgery.
• Normal voluntary urination may still be present.
• Flank or back pain on the affected side.
• Fever or UTI.
• Hydronephrosis on ultrasound.
• Reduced renal function if obstruction is severe or bilateral.

How is it distinguished from VVF?

Initial treatment

If the ureter can be crossed, a DJ stent may allow internal drainage and healing in selected partial injuries. When retrograde stenting is impossible or infection and obstruction require reliable decompression, a nephrostomy drains the kidney directly.

When is reconstruction needed?

Persistent complete injury, ischemic or thermal damage, mature stricture or failure of stenting often requires definitive repair. Distal injuries are commonly reconstructed by ureteric reimplantation, with psoas hitch or Boari flap if additional length is needed.

Why delay can matter

Ongoing obstruction or leakage can lead to infection and loss of renal function. Persistent vaginal leakage after hysterectomy should not be assumed to be ordinary postoperative discharge or incontinence.

Recovery after ureteric reconstruction

When reimplantation is required, a DJ stent protects the new ureter-to-bladder join and a bladder catheter may remain while the bladder incision heals. A nephrostomy, if used before surgery, may be removed once drainage through the reconstructed ureter is proven.

Vaginal leakage should stop when the fistulous path is no longer receiving urine, but the kidney still needs follow-up. Ultrasound or another imaging study after stent removal checks that the reconstruction remains open.

Temporary urinary frequency can come from the stent or bladder surgery. Fever, new flank pain, vomiting or reduced urine output is different and needs prompt assessment for infection or recurrent obstruction.

What to bring for consultation

• Operative and discharge records from the hysterectomy, Caesarean section or pelvic surgery.
• CT urography, ultrasound or MRI images/reports if already performed.
• Cystoscopy, dye-test or ureteric stent records if available.
• Serum creatinine, urine routine and culture.
• A simple description of when leakage started and whether normal urination still occurs.
• Details of fever, pelvic pain, drain output, wound leakage or previous repair attempts.

Why ureterovaginal fistula often presents differently from VVF

In ureterovaginal fistula, urine bypasses the bladder from an injured ureter into the vagina. Because the opposite kidney and the bladder outlet still work, many women can pass a normal amount of urine in the toilet and still remain continuously wet. This combination – normal voiding plus persistent leakage after hysterectomy – is an important clue.

A bladder dye test may remain negative because the fistula is above the bladder. CT urography with delayed images can show ureteric obstruction/extravasation and hydronephrosis. Retrograde pyelography is highly useful when attempting a DJ stent, while antegrade nephrostography can define anatomy if a nephrostomy is needed.

When the injury is partial and can be crossed, prompt DJ stenting can sometimes allow healing. If the ureter is completely obstructed or the injury is diagnosed late with infection/urinoma, nephrostomy may be needed first. Persistent distal injury is commonly reconstructed by ureteric reimplantation, with psoas hitch or Boari flap when additional length is required.

How treatment progresses when a stent cannot cross

If retrograde stenting from the bladder cannot cross the damaged ureter, a nephrostomy can drain the kidney and relieve infection or pressure. Through that tract, an antegrade wire or stent may sometimes cross the injury; a combined rendezvous approach from above and below is another option in experienced hands.

Persistent complete distal disruption generally requires reconstruction. The unhealthy distal segment is bypassed and healthy ureter is reimplanted into the bladder. A psoas hitch brings the bladder upward when more reach is required, while a Boari flap can bridge a larger mid or distal defect.

The kidney should remain drained during this process. A woman can feel relatively well because the fistula decompresses urine into the vagina even while the kidney is obstructed, which is why symptom relief alone cannot be used to decide that the ureter has healed.

How kidney function is protected while the fistula is treated

A ureterovaginal fistula can leak continuously and still leave the kidney partially obstructed. The first priority is therefore reliable upper-tract drainage rather than simply stopping vaginal wetness. A DJ stent that crosses the injury can both drain and splint the ureter; when it cannot be passed, nephrostomy protects the kidney from above.

Renal function, hydronephrosis and infection are followed during this period. Some partial injuries heal around a stent, whereas complete transection or a mature ischemic distal stricture usually does not. Definitive reconstruction is planned when the anatomy and tissue condition are clear.

After repair, disappearance of leakage is reassuring but not sufficient by itself. Follow-up imaging is used to confirm that the kidney drains into the bladder without silent recurrent obstruction.

FAQs

Related reading

• Ureteric Injury During Gynecological Surgery
• Urinary Leakage After Hysterectomy: Could It Be a Urinary Fistula?
• Vesicovaginal Fistula: Symptoms, Diagnosis and Treatment
• Ureteric Reimplantation Explained
• Vesicovaginal Fistula Repair Explained
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: Urinary Fistula, 2026 https://uroweb.org/guidelines/non-neurogenic-female-luts/chapter/disease-management
• European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
• Hook S, et al. Update on ureteral reconstruction 2024. Die Urologie. 2024;63:25-33. PMID: 37989869 https://pubmed.ncbi.nlm.nih.gov/37989869/