Post hysterectomy (TLH) vaginal leak and its management

October 07, 2011

Dr. Rahul Manchanda
Dr. Vijay Patil

“X” had an uneventful total laparoscopic hysterectomy on 7/10/11 for DUB.
Abdominal Sutures were removed on the 8th day and wounds were nicely healed.
On the 3rd of November 2011 she complained of copious intermittent, clear discharge vaginally for 4-5days. This was intermittently copious and less and occurred on straining.
She was well otherwise, bowel and bladder functioning normally. No fever or abdominal or flank pain.
Speculum Examination revealed a small amount of fluidy dirty discharge, and cough reflex was negative.
The vault seemed fine. A swab was taken for culture.
Ultrasound done on the same day was essentially normal with no collection and kidneys were normal.
Haemogram and blood urea and routine urine was ordered and she was scheduled for a EUA and cystoscopy and Cysto-ureterogram and proceed if required the next day.
She was put on Norflox and pyridium (pyridium colours the urine orange and can help in differentiating a true urine leak) in the mean time and the sister was asked to save all pads.

EUA and cystoscopy and Cysto-ureterogram done on the 4/11/11 was normal showing normal vault, bladder and ureters.
She was discharged the same day after the procedure on an antibiotic.

Causes of leak from vagina after hysterectomy

  1. Bladder fistula- generally occurs just after surgery or 7-10 days after.
  2. Ureteric fistula- generally occurs 10-12 days after surgery (0.5% incidence)
  3. Infective collection
  4. Stress incontinence
  5. Urine after micturition can dribble into the vagina and then suddenly collected urine can come out masquerading as leak.
  6. Peritoneal collection due to any irritation leading to ascites can come out as vaginal leak- viz reactionary, tuberculosis
  7. Ascites due to decompensated liver disease or any other pathology.

It is important to realize that if one does surgery then one is bound to have complications. The books on complications are written because they occur!
However what is important is to recognize them and manage them responsibly.
A patient’s complaints must always be given due cognizance and it is always better to err on the side of caution.
Despite the timing being wrong and original surgery not being a difficult one and review of the surgical procedure recording showing no apparent problem, the history was so strong that one needed to rule out various complications in order to manage them.
The protocol followed was textbook like and various causes outlined are not exhaustive but must be kept in mind.