Obstetric Fistula,the hidden condition. The Nigerian perspective.

1. Obstetric Fistula
Dr. A. P. Soibi-Harry
Dept. of Obstetrics & Gyneacology
Lagos University Teaching Hospital

2. Outline
• Introduction
• Brief History
• Epidemiology
• Etiology
• Pathogenesis
• Classification
• Clinical Presentation
• Diagnosis
• Management
• Prevention
• Recent advances
• Conclusion
• Reference

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. 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. 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. 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. Epidemiology 2
www.EndFistula.org.

8. Epidemiology 3
2.1/1000 deliveries

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. • 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. Obstetric fistula pathway

12. Pathogenesis

13. Classification of Obstetric fistulas
• Site of Injury

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. 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. Clinical Presentation 1

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. 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. 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

21. 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

22. Sim’s Position

23. 3 Swab test

24. Fistula opening in
Bladder
Cystoscpy
Cystoscopy

25. Management
• Conservative Management
• Surgical Therapy
• Nonsurgical Intervention

26. 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.

27. NON SURGICAL INTERVENTION
• Electrocautery fulguration
• Fibrin glue
• Laser welding with Nd YAG(neodymium-doped yttrium
aluminium laser)
• Psychosocial counseling and rehabilitation

28. 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.

29. 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.

31. Intraoperative Care
• Anesthesia: Spinal or GA
• Antibiotics: broad spectrum
• Suture material:
– Vicryl 2-0 - bladder and vagina
– Polydioxanone 4-0 - ureter

32. Patient positioning

33. 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

34. Principles of fistula repair
• First attempt is best .
 Tissue mobilization
 Hemostasis
 Adequate exposure
 Aseptic measures
 Tension free closure
 Reinforcement
 Expertise

35. Repair of Vesicovaginal Fistula
• Vaginal approach
– Flap splitting technique
– Saucerization
– Latzko technique
• Abdominal approach
– Transvesical repair
– Transperitoneal repair
– Combined repair

36. Abdominal approach
• Indications
– High inaccessible fistula
– Multiple fistulas
– Involvement of uterus or bowel
– Need for ureteral re-implantation
– Complex fistula

37. 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

38. 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

39. 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

40. • 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

41. 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

42. Management
• SURGERY
Route:
– Transvaginal Approach
– Transanal Approach
– Abdominal Approach
Timing:
– Wait 8-12 weeks before surgical intervention to allow surrounding
inflammation to resolve completely

43. 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

44. 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

45. 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

46. 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

47. 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

48. Conclusion
www.opfistula.org

50. 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

51. 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.

52. • 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.