Three weeks after total abdominal hysterectomy, a 48-year-old woman reports continuous leakage of urine per vaginum, but she also passes urine normally at intervals and has no urge symptoms. Three swab test shows the uppermost swab is wet and stained blue, the middle swab is wet but unstained, and the lowest swab is dry. Which structure is most likely injured?

• A Bladder base (vesicovaginal fistula)
• B Bladder trigone with urethral involvement
• C Urethra (urethrovaginal fistula)
• D Ureter (ureterovaginal fistula) ✓

Explanation

Preserved spontaneous voiding alongside continuous vaginal leakage indicates the kidney drains partly through the vagina, pointing to a ureterovaginal fistula. In the three swab test, blue-stained urine reaching the uppermost swab means the leak arises above the bladder neck from a ureteric source; a vesicovaginal fistula would stain the middle swab blue after intravesical methylene blue. Confirmation is by CT urogram or intravenous urogram showing contrast extravasation and possible distal ureteric injury near the clamped angle of the vault.

Reference: Shaw's Textbook of Gynaecology, 18th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.