the surgery entailed removing the uterine body and the left appendages due to myoma . in september 2003 , the patient was admitted to the department of gynecology at the medical university of lublin due to genital bleeding combined with cervicitis and vaginitis ( for a 1 year ) . after several days of antibiotic treatment , the uterine cervix and the right appendages were removed . the histopathological examination revealed erosion and a bloated atypical partly purulent inflammatory process with an extended necrosis of the endocervical mucosa . in december 2003 , the patient was admitted to the department of gynecology , due to purulent inflammation of the vaginal stump , which was treated conservatively . the urine culture for tb gave negative results , but a ct of the pelvis revealed inflammatory infiltration in the vaginal stump with possible metastasis to the rectum . examination of the vaginal excretion showed the presence of microorganisms from the enterococcus group as well as gram  negative bacteria . in september 2004 , a diagnostic laparotomy was performed in the department of gynecology , because of the continually defective healing of the vaginal stump ( surgery showed that the organs of the lesser pelvis were normal ) . however , the laparotomy caused atony of the urinary bladder , which it necessary to insert a foley catheter . after two weeks of treatment with catheter and ubretid ( 5 mg x day ) , the action of the urinary bladder was restored . , the patient was admitted to the department of urology at the medical university of lublin due to luts and an early stage of a bilateral hydronephrosis with continued purulent inflammation of the vaginal stump that transposed into the corpus of the urinary bladder . the examination revealed a nodular inflammatory infiltration in the trigone and the vesical cervix . due to a suspected bladder tumor , tissue samples were collected and reported a bloated and chronic inflammatory processes involving nonspecific granulation . in may 2005 , the patient was again admitted to the department of urology due to a bilateral hydronephrosis . the ct performed showed an inflammatory infiltration in the bladder wall and in the posterior bladder area and consequently bilateral percutaneous nephrostomies were performed . in july 2005 , bilateral dj catheters were inserted . in the trigone of the bladder a vvf with a diameter of approx . 1.5 cm was diagnosed , which resulted from the chronic inflammation process in the vaginal stump . , the dj catheters were removed and anti  inflammatory treatment was applied ( doxycycline and urosept ) . in november 2005 , the cystoscopy performed revealed closure of the vesicovaginal fistula . , an inflammatory change was observed in the area of the left ureter orifice ( the macroscopic image triggered suspicions of a tumor that was resected ) . a histopathological examination revealed a bloated chronic / acute inflammatory process involving granulation , as well as an unspecific inflammatory infiltration comprising lymphocytes , plasmacytes , and both acidophilic and neutrophilic granulocytes . it was also observed that the inflammatory reaction in the vaginal stump had intensified , and so had the inflammatory reaction with dermal necrosis in the area of the former right  sided nephrostomy . this treatment proved unsuccessful despite the surgical wound preparation and skin grafting . in may 2007 , the patient was treated in the department of dermatology at the medical university in lublin , which involved collecting skin samples that revealed nonspecific inflammatory infiltration with ulceration ( unknown etiology ) . the examinations performed in october 2007 in the department of urology revealed a narrowed inflexible urethra and stress urinary incontinence ( sui ) . the last medical follow up in november 2010 revealed a limited capacity of the urinary bladder , sui , and a narrowed inflexible urethra together with an average inflammatory vaginal reaction and fistula with a diameter of 12 mm in the trigone . we have focused on this case due to its atypical course , as well as to the difficulties we encountered while diagnosing and treating the patient . we performed a full set of image examinations , such as ultrasonography , ct scan , and urography . such analyses as urinary culture and vaginal swab ( including for tb ) were performed . each histopathological examination revealed a nonspecific chronic inflammatory reaction , whereas the urinary culture and vaginal swabs indicated changing bacterial floras ( enterococcus sp , gram positive cocci , staphylococcus aureus , and streptococcus pyogenes ) with 50% of the cultures performed being negative . the one  year gynecological treatment , comprising eight hospital stays and two surgeries , combined with the general and local anti  inflammatory therapy based on the urinary culture results proved ineffective . the four  year therapy , generally recommended in treating vesicovaginal fistulas and bladder inflammation , comprising nine diagnostic and treatment stays in the department of urology , as well as regular checks in the urological out  patient department , prevented the further development of the disease . however , its outcomes , such as fibrotic changes in the urinary bladder and urethra , sui , a persistent micro fistula , and dermal inflammation in the post  nephrostomy area , have notably lowered the patient 's living comfort . the case analyzed poses a significant dilemma for the medical staff as to whether they should apply surgical treatment or whether such treatment would lead to intensified inflammatory reactions in the operated area , as was the case with previous gynecological surgeries . inflammatory infiltration of the urinary bladder , resulting from a long  term purulent inflammation of the vaginal stump that is accompanied by a vvf and a bilateral hydronephrosis arising from infiltration on the ureter orifice , is an uncommon disease of the lower urinary tract . other reasons for such fistulas are radiotherapy , advanced cancer processes in the lesser pelvis , tuberculosis , and genital injuries connected with childbirth or sexual activity . the vvf originated from the local chronic inflammatory condition of the vaginal stump , which occurred 10 months after the previous gynecological surgery . the spontaneous closure of vvf without surgical intervention has already been encountered in clinical practice . in this case , it took six months until the fistula was reduced from 1.5 cm to 12 mm . the history of the surgical treatment of vesicovaginal fistulas has always recognized the problem of timing the reconstruction surgery  based treatment . it has been assumed that under proper healing conditions , the fistula surgery should not be performed until the fistula edges have healed , which usually takes place within three to six months . in the case analyzed , since diagnosis , i.e. for the last three years , no conditions have occurred that would allow the performance of surgical treatment for the micro  fistula and sui . taking into account the distorted healing processes , the authors are afraid that the reconstructive surgery may not bring satisfactory effects .
we shall discuss the case of a female patient , aged 64 years , who was suffering from long  term purulent inflammation of the vaginal fornix that later involved the vaginal stump . 
 this inflammatory process spread to the bladder trigone and resulted in vesicovaginal fistula ( vvf ) formation together with a bilateral hydronephrosis that required the placement of a temporary percutaneous nephrostomy . 
 a non  cicatrized inflammatory reaction occurred at the right  sided insertion of the nephrostomy , which has yet to be successfully treated despite intensive dermatological and surgical approaches that included skin grafting . 
 in the course of five  year treatment we observed a gradual regression of the inflammatory infiltration of both the trigone of the bladder and the vagina as well as a gradual closing of the vvf . 
 the extremely long  lasting and uncommon local inflammatory reactions in the vagina , bladder , and dermal layers mandated the application of conservative treatment . 
 the possibility of difficulties and defective healing of tissues that could result from surgical correction of the vvf are discouraging for both the patient and medical staff .