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The anatomy of the female pelvis is very complex. In addition to the extensive support structures for the uterus and vagina, closely neighboring and somewhat delicate organs are susceptible to injury during childbirth and gynecologic surgery. The ureters (the tubes that deliver urine from the kidneys to the bladder) pass very close to the blood vessels that must be cut in order to remove the uterus. A small amount of tension, heat, or mere distortion can lead to leakage or narrowing of this delicate tube. The bladder (a balloon-shaped organ in the pelvic area that stores urine) lies on top of the uterus and vagina, and is also susceptible to similar harm, even when not directly manipulated by the surgeon. Considering that female pelvic anatomy often becomes very distorted during childbirth and when there is a need for gynecologic surgery, it is surprising that these injuries are not more common.
Injuries to the urinary tract can be difficult to detect during the initial surgery, particularly since these injuries may take time to develop. Urinary leakage can be suspected post-operatively with unexpected abdominal pain or bloating, a decrease in urine production, fever, watery discharge from the vagina or other incision, and changes in certain blood tests. With time, a leaking ureter or bladder can form an abnormal connection (fistula) with the nearby vagina (ureterovaginal or vesicovaginal fistula, respectively). If a ureter becomes obstructed, flank (side) pain and fever are the most common symptoms. Damage to the support structures of the vagina often does not become apparent for months to years following childbirth or pelvic surgery. As a result, prolapse (falling out) of the small intestine, rectum, bladder, and urethra (the tube that empties the bladder) can occur, thereby affecting the function of these organs.