types of fistula and management

1. Dr. Swati Singh
Department of Obstetrics &
Gynaecology
UDUTH
1
OBSTETRIC FISTULA

2. OUTLINE OF PRESENTATION
2
An Overview
Principles of fistula management
Treatment options
Post-operative care
Recto-vaginal fistula: features &
management
Prevention
conclusion

3. Source: G. Lewis, WHO Press.
3
“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”
An Overview

4. An Overview
4
 Millions of girls and young women in
resource-poor countries are living in
shame and isolation, often abandoned
by their husbands and excluded by
their families and communities.
 They usually live in abject poverty,
shunned or blamed by society and,
unable to earn money, many fall
deeper into poverty and further

5. An Overview
5
 The reason for this suffering is that
these young girls or women are living
with an obstetric fistula (OF) due to
complications which arose during
childbirth.
 Their babies are also probably dead,
which adds to their depression, pain
and suffering.

6. Nigeria Program
Fistula Care supports six
hospitals:
1. Faridat Yakubu General
Hospital, Zamfara State
2. Maryam Abacha Women
and Children‟s Hospital,
Sokoto State
3. Birnin Kebbi Specialist
Fistula Center, Kebbi State
4. Laure Fistula Center at
Murtala Mohammed
Specialist Hospital, Kano
State
5. Babbar Ruga Hospital,
Katsina State

7. RESULT OF FISTULA TREATMENT: The UNFPA
Fistula fortnight - 2005
7
•As part of the global Campaign
to End Fistula
• 2-week mass obstetric fistula
treatment project,
•reducing the backlog of
untreated fistulas and raise
awareness regarding obstetric
fistulas and safe motherhood.

8. 8
PRINCIPLES OF FISTULA
MANAGEMENT
 Preparation of patient for surgery
Improve nutrition
Treat infections
Treat other existing complications
 Perform operation
By trained surgeon
Hospital admission up to 2 weeks after
 Scrupulous postoperative care

9. PREOPERATIVE CARE
9
 Rx infection – appropriate antibiotics
 Frequent pad change – to minimize inflammation,
oedema and vulvar irritation
 Zinc oxide + lanolin – for perineal and vulvar
dermatitis
 Divertion of urinary stream –
 By passing folleys cather
 by gluing pezzer catheter to a fitted contraceptive
diaphragm with rubber cement
 Medical therapy
 Haematinics
 Steroid /estrogen

10. INSTRUMENTS
11

11. CHOICE OF ANAESTHESIA
12
 General anesthesia
 complicated and expensive needing an anesthetic
machine,
 anesthetic fluids (ether or halothane), oxygen, a variety of
drugs
 special skill, for intubation
 Also for safety reasons intensive monitoring is necessary
intra- and postoperatively
 Regional anesthesia
 does not require special equipment,
 is easy to learn,
 does not need intensive intra- and/or postoperative
monitoring,
 is as effective as general anesthesia,

12. Principles of fistula repair
(intraoperatively)
13
 Good exposure
Position of the patient
Episiotomy
 Wide mobilisation of the vaginal epithelium
to expose the bladder
 Excision of scared tissue
 A tension- free closure of bladder and
vagina
 Good haemostasis

13. OPERATIVE CONSIDERATIONS
14
 Vaginal Surgery
Single-layered technique (using non-
absorbable suture)
Saucerization technique
Flap-splitting technique
Urethral reconstruction
Graft use
oMartius graft
oLabial graft

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15. 16

16. 17

17. OPERATIVE
CONSIDERATIONS
18
 Abdominal Surgery
Transperitoneal technique
Transvesical, extraperitoneal technique
Combined Abdomino-Vaginal Repair
 Ureteric Surgery
 Simple repair
 Resection and anastomosis
Reimplantation

18. POST-OP. (EARLY) CARE:
Catheterization
19
 Site:
 Transurethrally in most cases.
 Suprupubic in Urethral reconstruction &
Transabdominal fistula repair
 Type:
 “three-way” Foley‟s catheter is preferred
 Retention:
 By inflated balloon.
 Stitch to Labia (in Juxta-Urethral, Large fistulae
or fisulae with Circumferential tissue loss),
 Duration for primary repair is 14 days (but longer
if urethral reconstruction or bladder-neck repair
was performed or a postoperative leakage was
noticed

19. Cont…
20
 Drainage:
 Connected to closed urine bags usually
 Into open receptacles (relative
inexpensiveness
 Vaginal Pack;
 Used as tamponade
 Removed within 48 hours.
 Pain Relief:
 Narcotics (Pethidine or Morphine)
 Given six-hourly intervals for 24 hours
 paracetamol.

20. EARLY CARE Cont…
21
 Fluid Intake:
 Target Urine output of at least 100ml per
hour
 Over 4000ml Daily (tropical environment
with daily insensible fluid loss of about
2000 ml)
 Intravenous infusion for the first 24 to 48
hours, depending on when her resumed
oral fluid intake can meet this
requirement.

21. EARLY CARE Cont…
22
 Urine Output Monitoring:
 Performed hourly or
 2-4 hourly intervals.
 If Heavy Blood Stains or Clots in Urine:
 Increased intravenous or oral fluid
administration until the urine color
clears.
 Persistent passage of clots warrants
irrigation of the bladder.

22. EARLY CARE Cont…
23
 If Urine Drainage Ceases:
 external compression of catheter;
 Catheter kinks;
 internal catheter blockage by
clots or sediments;
 diminished renal urine secretion.

23. EARLY CARE Cont…
24
 Antimicrobial use:
 Prophylactical use / treatment as mcs result
 Postoperative urine cultures repeated every
2-3 days interval, the last culture being of the
tip of the removed catheter.
 Types of antimicrobial in common use:
 Options include: Co-trimoxazole,
Nitrofurantoin, Ampicillin and Ampiclox.
 Parenteral preparations are used on the more
extensive repairs or to address obvious
sepsis.

24. EARLY CARE Cont…
25
 Patient Ambulation:
 As early as the day after repair
 Late for patients with transabdominal
repairs and urethral reconstructions
 Vulvo-Vaginal Toileting:
 Nurses trained in the care of obstetric
fistula employ irrigation techniques,
using warm water or dilute antiseptic
solution to clean the vulva and
perineum each day and after bowel
movements.

25. POSTOPERATIVE CARE: Concluding
Early Care
26
 Outcome Determination:
2 hours after catheter removal, the
vestibule is inspected for normality, stress
incontinence or introital urine leakage.
 If there is introital leakage: patient is
reassured and re-catheterization for
further 7-10 days.
 If stress incontinence: repair is
regarded as partially successful and
patient is counseled and encouraged to
void urine at hourly intervals until
reviewed each day.

26. Outcome Determination
27
 If no leak or stress incontinence:
 adjudged successful repair,
 undergoes bladder training to improve
the bladder capacity, urine storage
and voidance capability

27. POSTOPERATIVE CARE: Concluding Early
Care
28
Patients with partial or complete success be
counseled on:
 Resumption of coitus after three months
 Contraceptives use unless pregnancy is
desired
 Early antenatal care when pregnant and
her detail history told to clinic attendants.
 Subsequent deliveries should be by
elective caesarean section but never

28. Rehabilitation/ reintegration
 Social workers ensure vocational training
in tailoring and basket weaving, dyeing to
earn an income.
 Counseling (the need for a lot of
encouragement, support and someone
simply to talk to about their lives)

29. MANGEMENT OF OTHER PROBLEMS
THAT CO-EXISTED WITH FISTULA
30
a. Obstetric Palsy:
 complicates over 15% of obstetric
fistulae from obstructed labour
 Mostly unilateral but occasionally
bilateral
 physiotherapy facilities for the
necessary physical and electro-therapy
 Shoe calipers and foot elevators
required for passive treatment of this
problem are generally unavailable and
unaffordable to fistula patients.

30. MANGEMENT OF OTHER PROBLEMS
THAT CO-EXISTED WITH FISTULA
Cont…
31
a. Secondary Amenorrhea:
• Co-exists with up to 2/3 of fistula
patients
• Treatment of underlying causes:
 hypothalamic dysfunction,
 panhypopituitarism, or
 uterine synaechia.

31. MANGEMENT OF OTHER PROBLEMS
THAT CO-EXISTED WITH FISTULA
Cont…
32
a. Sexual Dysfunction:
• Gynaetresia complicates about 10% of
obstetric fistulae.
• Treatment is with:
 counseling and
 use of lubricants during sexual
intercourse (from inert Aqueous
Jelly to Xylocaine cream).

32. PRE-OPERATIVE CARE FOR
RVF
 Improve nutritional status
 Treat infections
 Correct anaemia
 Treat other complications
- Bed sores
 Ammoniacal dermatitis
- Foot drop – physiotherapy

33. PRE-OPERATIVE CARE (Low
RVF)
 Counsel patient on her condition & proposed
surgery
 Obtain consent
 Low residue diet
 3-day Bowel preparation
Neomycin tablet 1g twice daily – 72hrs
Enema saponis (preceding night & morning
of operation
 Nil per os – at least 8hours before surgery

34. PRE-OPERATIVE CARE (High
RVF)
35
 5-day bowel preparation
 Initial Descending colon colostomy
 Closure of fistula
 Colostomy closure after 2-3 months

35. TECHNIQUE OF REPAIR
 Same principle for fixing VVF (flap-splitting):
Adequate exposure
Tissue dissection to separate vagina from
rectum
Independent repair of rectum and then
vagina using 2/0 polyglactin (Vicryl) suture on
25mm heavy taper-cut needle, making sure
mucosal edges are inverted

36. Post Operative Care
 Fluid diet for 5days
 Low residue diet for further 3-5 days in
high fistula
 Liquid paraffin after 48hrs daily for 3-5
days
 Intestinal anti microbial – Neomycin or
Thalazole 500mg 6hrly for 5 day

37. At Discharge
 Avoid intercourse or vaginal object insertion for
3months
 All subsequent pregnancies be booked & full
history volunteered
 Delivery by CS in subsequent pregnancy.

38. PREVENTION – Always better than
cure!
STRATEGIES
39
 Alleviate: poverty, illiteracy and harmful
traditional practices
 Improve health systems and social
infrastructure

39. - Promote & improve EmOC
services in remote rural areas !!

40. - Help rural population understand and better
implement this proverb:
“The sun should not rise or set twice on a
labouring woman”
—African proverb

41. 42
 Advocacy to policy makers and
governments
 Information, Education & Counseling of
the public
 Fundraising to support prevention and
treatment of obstetric fistula
 To increase collaboration between
institutions providing repairs
 Launch public awareness campaign on
issues

42. The UNFPA's Key Strategies to Address
Fistula
43
 „Postpone marriage and pregnancy for young
girls
 „Increase access to education and family
planning services for women and men
 „Provide access to adequate medical care for all
pregnant women and emergency obstetric care
for all who develop complications
 „Repair physical damage through medical
intervention and emotional damage through
counselling'
 Source: UNFPA Campaign to End Fistula: “Fast Facts”

43. CONCLUSION
44
 A very real problem with an annual rate of new
cases > indigenous repair capability.
 Prevention through safe motherhood is the way
towards elimination of obstetrical fistula
 Success will require fundamental changes:
In tradition and cultural more so regarding
early marriage,
 An elevation in the respect for the human rights
of women in general, and young girls in
particular.
 Further progress is best made by apprenticeship with one
of the master surgeons

44. Cured Fistula Patient
What a smile for a new
life !!

45. Cured Fistula Patient
Life with restored
dignity
THANK
YOU

46. 47
References
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Africa. Am J Obstet Gynecol 2006; 195: 1748-
1752
3. WHO. In: Lewis G, de Bernis L, editors.
Obstetric fistula: guiding principles for clinical
management and program development.
Geneva: WHO Press; 2005.
4. Wall LL, Karshima JA, Kirshner C, Arrowsmith
SD. The Obstetric vesicovaginal fistula:
characteristics of 899 patients from Jos,
Nigeria. Am J Obstet Gynecol 2004; 190:
1011-1019.
5. John A, Howard W. Vesicovaginal fistula In:
Te Linds’s OPERATIVE GYNAECOLOGY
Tenth ed Walter Kluwer India pvt Ltd 2009.

47. 48
6. Christopher NH,Marcus ES. Genital fistula In:
Shaw’s Textbook of Operative Gynaecology 6th ed
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VVF projects in northern Nigeria and Niger; 27
pp.
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