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most uterine fistulae are between the uterine and the bladder or bowel ( uterovesical or uterocolonic ) due to postoperative injuries or infectious conditions .
a uterocutaneous fistula ( communication between uterine and skin ) is a rare condition , and there are only a few reports in this regard in the existing literature .
the causes include multiple surgeries , use of drains , and incomplete closure of the incisions .
because of the uncommon presentation of the uterocutaneous fistula , the exact treatment is challenging .
we describe a patient with this kind of rare fistula after cesarean section with multiple operations . eventually , she had successful management of the fistula
a 25-year - old woman referred to our department with infected discharge at her previous pfannenstiel incision .
two months later , she had surgery for the drainage of her collection with a drain left in place . however , afterward she had discharge from other points in the incision line .
finally after 2 months , she was subjected to another surgery , consisting of wound exploration , excision of the fistula tract , and open drainage .
nevertheless , the discharge continued and she referred to our clinic . on examination , she had a cesarean section scar in the suprapubic region with some holes with a pussy discharge .
we performed fistulography by injecting the contrast material from one of the holes in the skin ( figure 1 ) under the guidance of computed tomography ( ct ) ( figure 2 ) .
intraoperatively , we first injected methylene blue dye from the fistula opening and followed the tracts in the skin and subcutaneous tissue , muscles , and peritoneal cavity .
we found the main route to the abdominal cavity , and then we did laparotomy and enterolysis .
we debrided the whole necrotic tissue in the uterus and performed drainage with a catheter ( # 18 ) .
computed tomography of the patient shows the collection site under the skin in the pelvis .
pathological examination showed foreign body reaction , inflammatory necrosis of the uterine muscle , and a fistula tract in the muscular wall of the uterus with granulation tissue formation , hemorrhage , and fibrin deposition ( figures 3 and 4 ) .
this slide shows the fistula tract in the muscular wall of the uterus with granulation tissue formation , hemorrhage , and fibrin deposition .
there are a large number of causes for the formation of uterocutaneous fistulae such as lower - segment type of cesarean section , abdominal pregnancy , and high delivery .
inflammatory processes like the rupture of diverticulitis or sigmoid carcinoma into the bowel and uterus can lead to uterocolonic fistulae .
radiation therapy or traumas to the uterine wall during curettage can also cause this kind of fistula .
nonetheless , a uterocutaneous fistula is a very rare condition , whose pathophysiology is not fully understood but whose causes include multiple surgeries in the abdomen , use of drains , and in complete closure of incisions .
our patient had a fistula following cesarean section , similar to the report by dragoumis et al .
in contrast , other reports have shown a similar presentation after septic abortion , pelvic abscesses , and true intra - abdominal pregnancy because of incomplete placenta removal .
uterovaginal malformation , infection with actinomycosis due to intrauterine devices , curettage , difficult vaginal delivery , or use of forceps may be the other causes .
our patient presented 2 months after surgery , but presentation tends to vary from 2 months to 6 years after the last surgery .
sometimes the patient has a clear finding like bloody discharge from the abdominal scar during the menstrual period ; nevertheless , other investigations may be needed in some conditions such as pelvic pain or abdominal masses or abscesses .
fistulography with the injection of the contrast material through the skin opening shows the connection to the uterus
. if the skin hole is too small in the case of a suspected uterocutaneous fistula , hysterosalpingography with a methylene blue injection via the cervix can be helpful .
believed that hysteroscopy is very helpful in detecting fistula opening in the uterine with its direct vision .
suggested that ct scan with an intravenous contrast and sagittal reconstructions may confer a prompt diagnosis .
because a uterocutaneous fistula is a rare condition ( fewer than 15 cases reported in the last 20 years worldwide ) , a standard treatment has yet to be introduced .
previously , authors maintained that there was no nonsurgical treatment and the range of the surgeries varied from the excision of the fistula tract to hysterectomy , which presents a challenge in young patients .
more recent reports , however , have introduced combined surgical and medical treatment for the reduction in the risk of hysterectomy .
reported a patient treated with gonadotropin - releasing hormone agonist ( gnrh ) alone : the gnrh agonist induces atrophic changes in the epithelium and assists in the closure of the fistula .
nonetheless , a larger size of fistula opening in patients prompt surgeons to opt for the surgical approach .
used medical treatment and minimally invasive surgery ( laparoscopy ) for the excision of a fistula tract .
we injected methylene blue through the external opening of the patient s skin to find the tracts and excise the fistula .
injected the blue dye from the cervix and internal opening and successfully treated their patients .
finally , we believe it is advisable that this kind of rare fistula be borne in mind if the patient has chronic pelvic pain secondary to a uterine abscess .
despite the uncommon presentation of a uterocutaneous fistula , it should be considered after cesarean section , injury during operation , and abortion .
a uterocutaneous fistula is a rare clinical presentation that occurs following cesarean section and other pelvic operations . 
 there are only a few reports discussing the treatments . 
 we describe a patient with successful surgical management and review the literature . 
 a 25-year - old woman referred to our department 13 months after her first cesarean section . 
 she had a history of an abdominal mass and collection 2 months after surgery and some fistula opening with discharge from her previous incision . 
 she had a previous surgical operation and antibiotic therapy without complete response . 
 we performed fistulography to evaluate the tracts . in the operation 
  she had fistula tracts , one of which was between the uterus and skin . 
 we debrided the necrotic tissue in the uterus , excised the fistula tracts , and drained the uterine cavity . at 8 months postoperative follow - up , she had no recurrence . 
 a uterocutaneous fistula is a rare condition with many causes and needs proper investigation and timely medical and surgical management .