Interesting Clinical Cases - A Rare Case of VVF due to McDonald Encerclage:By Dr. Somshekhar Patil (Miraj)

A Rare Case of VVF due to McDonald Encerclage: Its unusual presentation and its repair concurrently with subsequent LSCS

By  Dr. Somshekhar Patil (Miraj)

Mrs. S.S.P. aged 22 years presented on 22nd August 2005 with term pregnancy and premature rupture of means. There was h/o Mc Donald’s encerclage done in 5th month in another hospital.

 This was her presentation to us.

Obs. History   :-  G4 P1 L0 D1 A2

·         1st  Pregnancy  --  Spontaneous abortion at end of 2nd  month

·         2nd Pregnancy  --  Spontaneous abortion at end of 3rd month

·         3rd Pregnancy -- PT delivery at 8th month and that was FSB.

·         4th Pregnancy  --  Present Pregnancy


Patient was not in labour, she had frank leak. The stitch was removed. And the labour was induced. Ultimately she required LSCS for PROM with failed induction. CS was technically uneventful. Baby cried immediately. She had an uneventful post op recovery and discharged on 7th post op day and had no complaints at the time of discharge. There was no follow up in puerperal period.       

She comes to us again after a gap of 1½ years with 3 ½ months amenorrhea and continuous leak of urine for last 15 days. The leak started spontaneously and there was the smell of urine. In a week’s time it increased. She stopped passing urine from urethra and the whole urine was leaking through the vagina. In interval period of 1½ years, she did not have significant urinary symptoms except for mild frequency and dysuria. A KUB sonography and obstetrics sonography was undertaken and clinically, she was diagnosed as a pregnancy of 18 weeks with a small VVF. Diagnostic cystoscopy was undertaken and confirmed it as VVF arising from posterior wall. Ureteric opening and trigone were normal.


·         G.C.       -  Satisfactory   

·         Uterus     - Corresponding to 16 – 18 weeks size.

·         Perineum - Wet and smelling of urine

·         P/S - When Cervix was little displaced both there was a jet of urine seen coming from the anterior at the level of Cervix vaginal in.

·         P/V    - Cervix closed and normal in and the fistula palpated.

It was decided to allow her undergo a routine ANC and a perineal hygiene. At term – She came to us in labor and she required LSCS after a short trial for previous LSCS with soft tissue dystocia. It was planned before hand that if she required LSCS this time, we would take a chance to repair the VVF during LSCS since it was the small VVF and had no much fibrosis around it. 

2nd LSCS was performed as a routine fashion and after uterine incision was closed the bladder was dissected and separated further from the lower uterine segment till we reached the fistula tract. That tract was excised. The edges in bladder opening were freshened and it was noted that the bladder opening was away from both the ureters. The bladder opening was closed in 3 layers vertically with 3 – 0 PGA sutures. Bladder was catheterized before hand with 18 Foley’s catheter.                

The vaginal opening of the fistula could not be approached easily from the abdominal route. The abdomen was closed and the patient was given the lithotomic position. The vaginal opening could be easily visualized. The edges of opening were freshened and closed transversely. Post operatively indwelling catheter was kept for 10 days and the leak had stopped completely. Catheter was removed and patient was discharged and had a follow up after 1 ½ months. During that time there was no leak and the repair was successful.


This case was rare and interesting because the etiology of VVF appears to be the previous Mc Donald’ s Encerclage and the fistula presented after a gap of    1 ½ years in next pregnancy was also unusual and we could repair VVF during LSCS successfully which was also a rare event.              

We attribute fistula to be due to encerclage.

1)    By exclusion of other causes (trauma, TB etc.)

2)    By its anatomical situation with was corresponding to the Mc Donald’s encerclage.

3)    It was a small VVF with not much of fibrosis may be because of the non-irritant suture material used.            

Its unusual presentation with gap of 1 ½ years is likely to be due to the fat that the tract might have been small and direction of tract might have been oblique which might have acted as a flap mechanism during non-pregnant state and when she conceived again the uterus started enlarging and bladder also started ascending and at one patient of time the tract might have got straightened and stretched, thereby nullifying the flap mechanism and the leak started there onwards.

--   In literature, we found one case of an uretero vaginal fistula due to Mc Donald’s encerclage. Hence it is a very rare etiology of VVF.     

--   We did not find much in literature about the repair of VVF with LSCS. In fact books advise against such repair. But in this case it was feasible and hence we did it with a favorable result.



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