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Difficulty: HardGynecologic Procedures and Complications

A 39-year-old woman comes to the emergency department due to a 24-hour history of high fever, chills, and right-sided back pain. She also reports a constant sensation of vaginal wetness that requires her to change her sanitary pad multiple times a day. Ten days ago, the patient underwent an uncomplicated total abdominal hysterectomy for severe endometriosis. Her temperature is 39.0°C (102.2°F), blood pressure is 110/65 mmHg, and pulse is 112/min. She has no pain with urination and voids normally. Physical examination shows pronounced tenderness to percussion over the right costovertebral angle. On speculum examination, a pool of clear fluid is visualized in the vaginal vault. The vaginal cuff appears well-approximated without erythema. A transurethral catheter is placed, and a retrograde instillation of a dilute methylene blue solution into the bladder is performed. A sterile tampon placed in the vagina for 15 minutes is subsequently removed; it is saturated with clear, yellowish fluid but shows no evidence of blue discoloration. Which of the following is the most appropriate next step in management?

  1. Computed tomography urographyAnswer
  2. B
    Bedside pelvic ultrasonography
  3. C
    Initiation of intravenous antibiotics without further imaging
  4. D
    Immediate exploratory laparotomy
  5. E
    Transurethral Foley catheter placement for 14 days

Answer

Computed tomography urography
The patient presents with fever, right costovertebral angle tenderness, and continuous clear vaginal leakage 10 days after an abdominal hysterectomy. The normal voiding combined with continuous vaginal leakage suggests a urinary fistula. The negative retrograde bladder dye test (the tampon is wet but not blue) rules out a vesicovaginal fistula and strongly points to a ureterovaginal fistula. The right-sided CVA tenderness further suggests right ureteral involvement (likely from ischemic necrosis following thermal injury near the uterine artery crossing), leading to hydronephrosis and pyelonephritis. Computed tomography (CT) urography is the most appropriate next diagnostic step to visualize the exact location and extent of the ureteral injury before definitive surgical repair.

Step-by-Step Solution

1
Analyze the patient's postoperative presentation and symptoms.
The patient has a high fever, right CVA tenderness, and continuous clear vaginal leakage 10 days after a hysterectomy.
These signs suggest an infectious or structural complication of the recent pelvic surgery.
2
Interpret the results of the retrograde methylene blue dye test.
The vaginal tampon absorbed clear fluid but no blue dye.
This confirms the fluid is not originating from the bladder, ruling out a vesicovaginal fistula.
3
Synthesize the findings to identify the most likely anatomical injury.
Continuous vaginal urine leakage with a negative bladder dye test and upper urinary tract signs (fever, CVA tenderness) indicates a ureterovaginal fistula, likely on the right side.
Ureteral injury (such as thermal necrosis) can present days to weeks postoperatively with fistulization and proximal hydronephrosis or infection.
4
Determine the appropriate diagnostic imaging.
Computed tomography (CT) urography is required.
CT urography will identify the exact location of the ureteral leak, evaluate the extent of hydronephrosis, and guide definitive surgical repair.

Key Concept

Diagnosis and management of postoperative ureterovaginal fistula following hysterectomy.
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Topics

Gynecologic Procedures and Complications

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