Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Obstetric Fistula
Dr. A. P. Soibi-Harry
Dept. of Obstetrics & Gyneacology
Lagos University Teaching Hospital
Outline
• Introduction
• Brief History
• Epidemiology
• Etiology
• Pathogenesis
• Classification
• Clinical Presentation
•...
Introduction
“Every minute, a woman dies in
pregnancy or childbirth, and for
every woman who dies, 20-30 others
will survi...
Definition
– obstetric fistula is an abnormal communication between the vagina
and the bladder or rectum.
– Occurred in th...
Brief history
• The oldest evidence of obstructed labor:
• In the remains of Queen Henhenit, of Egypt c. 2050 BC.
• 1923: ...
Epidemiology 1
• Globally:
WHO estimates -> 2 million women live with untreated fistula, with
about 50,000 -100,000 new ca...
Epidemiology 2
www.EndFistula.org.
Epidemiology 3
2.1/1000 deliveries
Etiology
• Obstructed labour- >80%
• Lack of access to emergency obstetric care
• Iatrogenic causes:
– Caesarian section
–...
• Risk Factors
– Poverty
– Early marriage and child bearing age
– Harmful traditional practices:
• Female genital mutilati...
Obstetric fistula pathway
Pathogenesis
Classification of Obstetric fistulas
• Site of Injury
Goh’s system
• Urethral length
 Type 1: Distal edge of fistula >3.5 cm from the external urethral orifice (EUO), i.e.
the...
Waaldijk’s system
• Type I:
– Fistula =5 cm from the External Urethral Orifice and therefore not
involving the closing mec...
Clinical Presentation 1
Clinical Presentation 2
• Constant urine drainage per vagina
• Excoriation of skin around the vulva
• Recurrent cystitis o...
The Obstructed Labour Injury Complex
Obstructed
Labour
Urologic
Injury
Gyneacol
ogical
Injury
Gastroint
estinal
Injury
Neu...
Diagnosis
• History
• Physical Examination
• Investigations
• FBC, Serum E/U/CR, Urine for urinalysis and M/C/S, Abdominop...
Figure 1. Obstetric vesico-vaginal fistula from prolonged obstructed labor.
Wall LL (2012) Obstetric Fistula Is a “Neglect...
Sim’s Position
3 Swab test
Fistula opening in
Bladder
Cystoscpy
Cystoscopy
Management
• Conservative Management
• Surgical Therapy
• Nonsurgical Intervention
CONSERVATIVE MANAGEMENT
• Indications
– Simple fistulae
– <1 cm in size
– Diagnosed within 7 days of occurrence
• Continuo...
NON SURGICAL INTERVENTION
• Electrocautery fulguration
• Fibrin glue
• Laser welding with Nd YAG(neodymium-doped yttrium
a...
Surgical Management
• FISTULA REPAIR IS NOT AN EMERGENCY
• Most surgeons advise waiting at least 3 months from time of
inj...
Preoperative care
• Improve the patient’s general condition- Nutrition, Infection,
Dermatitis, Urine acidification, Psyche...
Intraoperative Care
• Anesthesia: Spinal or GA
• Antibiotics: broad spectrum
• Suture material:
– Vicryl 2-0 - bladder and...
Patient positioning
ROUTE OF REPAIR
• Depends upon access to the fistula site, mobility of the vagina
and surgeon expertise.
SITE APPROACH
LOW...
Principles of fistula repair
• First attempt is best .
 Tissue mobilization
 Hemostasis
 Adequate exposure
 Aseptic me...
Repair of Vesicovaginal Fistula
• Vaginal approach
– Flap splitting technique
– Saucerization
– Latzko technique
• Abdomin...
Abdominal approach
• Indications
– High inaccessible fistula
– Multiple fistulas
– Involvement of uterus or bowel
– Need f...
Post-operative Management
• Continuous bladder drainage 10-14 days
• Vaginal packing for 24hrs
• Maintain output at 100ml ...
Discharge Advice
• To pass urine frequently
• Avoid sexual intercourse for at least 3 months
• To defer pregnancy for at l...
Rectovaginal Fistula
• DEFINITION:
Abnormal communication between the rectum and vagina with
involuntary escape off flatus...
• Confirmation
– Thin Probe is passed from the vagina through the
fistulous tract into the rectum/anal canal
– Methylene b...
CLASSIFICATION
• Based on anatomical location of vaginal opening
– Low - vaginal opening near the posterior fourchette
– M...
Management
• SURGERY
Route:
– Transvaginal Approach
– Transanal Approach
– Abdominal Approach
Timing:
– Wait 8-12 weeks be...
Prevention 1
• Primary Prevention
– Girl Child Education
– Women’s empowerment
– Collaboration with religious and cultural...
Prevention 2
– Caesarian section in indicated cases
– Avoidance of difficult forceps and destructive operations
– Prolonge...
The Nigerian Scenario
• Federal ministry of health: National strategic framework for
the elimination of obstetric fistula ...
Fistula Centres 1
• Babbar Ruga Hospital, Katsina State
• Birnin Kebbi Specialist Fistula Center, Kebbi State
• Faridat Ya...
Fistula Centres 2
• National Fistula Center, Ebonyi State
• Ningi General Hospital, Bauchi State
• Ogoja General Hospital,...
Conclusion
www.opfistula.org
References
• Vesicovaginal Fistula: A Review of Nigerian Experience by M. A.
Ijaiya et al. West African Journal of Medicin...
References
• Arrowsmith S, Hamlin C, Wall L. Obstetric labour injury complex:
obstetric fistula formation and the multifac...
• Obstetric fistula is a preventable and curable
cause of maternal mortality and morbidity with
Nigeria accounting for abo...
Obstetric fistula
Obstetric fistula
Obstetric fistula
Upcoming SlideShare
Loading in …5
×

Obstetric fistula

4,031 views

Published on

Obstetric Fistula,the hidden condition.
The Nigerian perspective.

Published in: Health & Medicine
  • I hope this will be useful to someone
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Obstetric fistula

  1. 1. Obstetric Fistula Dr. A. P. Soibi-Harry Dept. of Obstetrics & Gyneacology Lagos University Teaching Hospital
  2. 2. Outline • Introduction • Brief History • Epidemiology • Etiology • Pathogenesis • Classification • Clinical Presentation • Diagnosis • Management • Prevention • Recent advances • Conclusion • Reference
  3. 3. Introduction “Every minute, a woman dies in pregnancy or childbirth, and for every woman who dies, 20-30 others will survive but with morbidity, one of which is obstetric fistula” Source: G. Lewis, WHO Press.
  4. 4. Definition – obstetric fistula is an abnormal communication between the vagina and the bladder or rectum. – Occurred in the course of pregnancy and results in uncontrolled passage of urine, feaces or flatus into the vagina. – Psychosocial injury
  5. 5. Brief history • The oldest evidence of obstructed labor: • In the remains of Queen Henhenit, of Egypt c. 2050 BC. • 1923: review of the Queen’s mummy found a defect in the bladder communicating directly with the vagina. • 1663: Von Roonhuyse - surgical principles of VVF repair • 1838: Dr. John Peter Mettauer - first American to perform a successful VVF repair • 1852: James Marion Sims- refined and described technique for the surgical treatment of VVF using a transvaginal approach • 1855: The first fistula hospital was opened in New York. • 1888: Trendelenburg successfully performed a transabdominal VVF repair. • 1975: The second and worlds largest fistula hospital was opened in Addis Ababa by Catherine and Reginald Hamlin.
  6. 6. Epidemiology 1 • Globally: WHO estimates -> 2 million women live with untreated fistula, with about 50,000 -100,000 new cases each year. • Almost all cases live in sub-Saharan Africa and south Asia. • The reported incidence rates of vesicovaginal fistula in West Africa range between 1– 4 per 1,000 deliveries. • Nigeria accounts for 40% of the worldwide fistula prevalence with approximately 20,000 new cases occurring each year.
  7. 7. Epidemiology 2 www.EndFistula.org.
  8. 8. Epidemiology 3 2.1/1000 deliveries
  9. 9. Etiology • Obstructed labour- >80% • Lack of access to emergency obstetric care • Iatrogenic causes: – Caesarian section – Repair of ruptured uterus – Forceps Delivery – Destructive operations
  10. 10. • Risk Factors – Poverty – Early marriage and child bearing age – Harmful traditional practices: • Female genital mutilation • Gishiri- 15% fistula cases in Northern Nigeria • Caustic soda exposure – Infections – schistosomiasis, lymphogranuloma Venerum, tuberculosis
  11. 11. Obstetric fistula pathway
  12. 12. Pathogenesis
  13. 13. Classification of Obstetric fistulas • Site of Injury
  14. 14. Goh’s system • Urethral length  Type 1: Distal edge of fistula >3.5 cm from the external urethral orifice (EUO), i.e. the urethra is not involved  Type 2: Distal edge 2.5–3.5 cm from the EUO  Type 3: Distal edge 1.5–<2.5 cm from the EUO  Type 4: Distal edge <1.5 cm from the EUO. • Fistula size  (a): Size <1.5 cm  (b): Size 1.5–3 cm  (c): Size >3 cm. • Scarring  I. No or mild fibrosis around fistula/vagina, and/or vagina length >6 cm or normal capacity  II. Moderate or severe fibrosis around fistula and/or vagina, and/or reduced vaginal length and/or capacity  III. Special considerations, e.g. circumferential fistula, involvement of ureteric orifices.
  15. 15. Waaldijk’s system • Type I: – Fistula =5 cm from the External Urethral Orifice and therefore not involving the closing mechanism. • Type II: – Fistula <5cm from the EUO therefore involves the closing mechanism A. Without total involvement of the urethra: – (a) without a circumferential defect – (b) with a circumferential defect B. With total involvement of the urethra: – (a) without a circumferential defect – (b) with a circumferential defect. • Type III: Miscellaneous fistulae, e.g. uretero-vaginal and other exceptional fistulae.
  16. 16. Clinical Presentation 1
  17. 17. Clinical Presentation 2 • Constant urine drainage per vagina • Excoriation of skin around the vulva • Recurrent cystitis or UTI • Unexplained fever, hematuria, flank discomfort and suprapubic pain • Flatulence and or fecal incontinence • Foul-smelling vaginal discharge • Decubitus ulcers • Psychosocial problems- social recluse; depression, low self-esteem, and insomnia
  18. 18. The Obstructed Labour Injury Complex Obstructed Labour Urologic Injury Gyneacol ogical Injury Gastroint estinal Injury Neurologi cal Injury Psychoso cial Injury Fetal Injury Dermatol ogical Injury Musculos keletal Injury
  19. 19. Diagnosis • History • Physical Examination • Investigations • FBC, Serum E/U/CR, Urine for urinalysis and M/C/S, Abdominopelvic USS • 3 swab test • Cystourethroscopy • Intravenous Urogram
  20. 20. Figure 1. Obstetric vesico-vaginal fistula from prolonged obstructed labor. Wall LL (2012) Obstetric Fistula Is a “Neglected Tropical Disease”. PLoS Negl Trop Dis 6(8): e1769. doi:10.1371/journal.pntd.0001769 http://www.plosntd.org/article/info:doi/10.1371/journal.pntd.0001769
  21. 21. Sim’s Position
  22. 22. 3 Swab test
  23. 23. Fistula opening in Bladder Cystoscpy Cystoscopy
  24. 24. Management • Conservative Management • Surgical Therapy • Nonsurgical Intervention
  25. 25. CONSERVATIVE MANAGEMENT • Indications – Simple fistulae – <1 cm in size – Diagnosed within 7 days of occurrence • Continuous bladder drainage– By transurethral or suprapubic catheter for up to 4-6 weeks. • Small fistulas may resolve spontaneously or decrease in size.
  26. 26. NON SURGICAL INTERVENTION • Electrocautery fulguration • Fibrin glue • Laser welding with Nd YAG(neodymium-doped yttrium aluminium laser) • Psychosocial counseling and rehabilitation
  27. 27. Surgical Management • FISTULA REPAIR IS NOT AN EMERGENCY • Most surgeons advise waiting at least 3 months from time of injury before operating. • In the early months, the surrounding tissues are oedematous and hyperemic, making them friable and difficult to handle.
  28. 28. Preoperative care • Improve the patient’s general condition- Nutrition, Infection, Dermatitis, Urine acidification, Psyche. • Contractures should be treated before surgery if possible. • Encourage liberal clear fluid intake until about 4hrs before surgery. • Bowel preparation should include enema the night before.
  29. 29. Intraoperative Care • Anesthesia: Spinal or GA • Antibiotics: broad spectrum • Suture material: – Vicryl 2-0 - bladder and vagina – Polydioxanone 4-0 - ureter
  30. 30. Patient positioning
  31. 31. ROUTE OF REPAIR • Depends upon access to the fistula site, mobility of the vagina and surgeon expertise. SITE APPROACH LOW FISTULA Urethral Juxtaurethral VAGINAL CIRCUMFERENTIAL LOSS OF BLADDER NECK COMBINED ABDOMINOVAGINAL MIDVAGINAL FISTULA TRANSVAGINAL HIGH VAGINAL FISTULA Post hysterectomy Juxtacervical ABDOMINAL OR VAGINAL
  32. 32. Principles of fistula repair • First attempt is best .  Tissue mobilization  Hemostasis  Adequate exposure  Aseptic measures  Tension free closure  Reinforcement  Expertise
  33. 33. Repair of Vesicovaginal Fistula • Vaginal approach – Flap splitting technique – Saucerization – Latzko technique • Abdominal approach – Transvesical repair – Transperitoneal repair – Combined repair
  34. 34. Abdominal approach • Indications – High inaccessible fistula – Multiple fistulas – Involvement of uterus or bowel – Need for ureteral re-implantation – Complex fistula
  35. 35. Post-operative Management • Continuous bladder drainage 10-14 days • Vaginal packing for 24hrs • Maintain output at 100ml / hr • Antimicrobials • Plenty of fluids for continuous bladder drainage • Watch for any bladder block, fluid imbalance
  36. 36. Discharge Advice • To pass urine frequently • Avoid sexual intercourse for at least 3 months • To defer pregnancy for at least 1 year • Subsequent deliveries should be abdominal • If repair fails, local repair should be reattempted after 3 months
  37. 37. Rectovaginal Fistula • DEFINITION: Abnormal communication between the rectum and vagina with involuntary escape off flatus and/or feces into the vagina resulting in fecal incontinence. • Clinical presentation: • Involuntary escape of flatus and/or feces into the vagina • Foul smelling vaginal discharge with periodic uncontrolled escape of gas • Appear immediately or 7-10 days after delivery
  38. 38. • Confirmation – Thin Probe is passed from the vagina through the fistulous tract into the rectum/anal canal – Methylene blue dye test – Examination under anaesthesia • INVESTIGATIONS – Barium enema – Gastrograffin Enema – Barium meal+ follow through – Sigmoidoscopy – CT scans – MRI – Ultrasound
  39. 39. CLASSIFICATION • Based on anatomical location of vaginal opening – Low - vaginal opening near the posterior fourchette – Mid - from the level of the cervix to just superior to the posterior fourchette – High -the fistula is in the area of the posterior fornix. • Simple vs Complex – Simple are small fistulas – Complex are large
  40. 40. Management • SURGERY Route: – Transvaginal Approach – Transanal Approach – Abdominal Approach Timing: – Wait 8-12 weeks before surgical intervention to allow surrounding inflammation to resolve completely
  41. 41. Prevention 1 • Primary Prevention – Girl Child Education – Women’s empowerment – Collaboration with religious and cultural practitioners – Delayed age at child birth/access to contraceptives – Widespread antenatal care coverage and policies – Nutritious diet since childhood – Political will • Secondary Prevention – Prevention of the 3 stages of Delay – Trained birth attendants and early referrals – Availability of emergency obstetric care
  42. 42. Prevention 2 – Caesarian section in indicated cases – Avoidance of difficult forceps and destructive operations – Prolonged Catheter drainage in prolonged or obstructed labour. • Tertiary Prevention – Subsidized treatment – Rehabilitation – Re-integration into the society
  43. 43. The Nigerian Scenario • Federal ministry of health: National strategic framework for the elimination of obstetric fistula in Nigeria 2011-2015  Provide framework to train health workers and guide them in the provision of holistic, simple, affordable and evidenced based care for obstetric fistula patients. http://www.fistulacare.org/pages/da/files/5/5.4/Nigeria_National_Strategy_2011-2015.pdf • 23rd May- International Day to End Obstetric fistula
  44. 44. Fistula Centres 1 • Babbar Ruga Hospital, Katsina State • Birnin Kebbi Specialist Fistula Center, Kebbi State • Faridat Yakubu General Hospital, Zamfara State • Laure Fistula Center at Murtala Mohammed Specialist Hospital, Kano State • Maryam Abacha Women and Children’s Hospital (MAWCH), Sokoto State
  45. 45. Fistula Centres 2 • National Fistula Center, Ebonyi State • Ningi General Hospital, Bauchi State • Ogoja General Hospital, Cross River State • Sobi Specialist Hospital, Kwara State • University College Hospital Ibadan, Oyo State
  46. 46. Conclusion www.opfistula.org
  47. 47. References • Vesicovaginal Fistula: A Review of Nigerian Experience by M. A. Ijaiya et al. West African Journal of Medicine Vol. 29, No. 5 September–October 2010 • Zacharin RF. A history of obstetric vesicovaginal fistula. ANZ Journal of Surgery,2000, 70:851-854. • Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA,Geneva, World Health Organization, 2003,www.who.int/reproductive-health/publications. • The World Health Report, 2005–Make every mother and child count, 2005, Geneva
  48. 48. References • Arrowsmith S, Hamlin C, Wall L. Obstetric labour injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. CME review article. Obstet Gynecol Surv 1996; 51: 568–74. • Goh JWT, Krause HG. Female Genital Tract Fistula. Brisbane: University of Queensland Press, 2004. • Waaldijk K. Step by Step Surgery of Vesico-Vaginal Fistulas. Edinburgh: Champion Press, 1994. Waaldijk K. The immediate management of fresh obstetric fistula. American Journal of Obstetrics and Gynecology. 2004, 191 :795-9. Waaldijk K. Surgical classification of obstetric fistula. International Journal of Gynecology and Obstetrics, 1995, 49 :161-163.
  49. 49. • Obstetric fistula is a preventable and curable cause of maternal mortality and morbidity with Nigeria accounting for about 10% of global mmr. • However it has continued to be a hidden condition because it affects the the most marginalized members of the society- poor,young,illiterate girls and women. • We all as obstetricians and gynecologist have an oppurtunity to turn despair to hope and restore dignity to these women.

×