a case study presentation on physiotherapy approach to continuing urinary incontinence post VVF repair surgery

1. Urinary Incontinence post
VVF repair, a Physiotherapy
case report
ENWELUNTA OBED O.
DEPARTMENT OF PHYSIOTHERAPY,
AMINU KANO TEACHING HOSPITAL, KANO STATE

2. SYNOPSIS
• INTRODUCTION
• HISTORY
• EPIDEMIOLOGY
• AETIOLOGY
• RISK FACTORS
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• DIAGNOSIS
• DIFFERENTIAL DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS
• CASE STUDY
• PROGNOSIS
• CONCLUSION
• RECOMMENDATION
• REFERENCES

3. INTRODUCTION
• Vesico-Vaginal Fistula (VVF) occurs when an abnormal opening develops between
the bladder and the vagina, causing continuous leakage of urine through the
vagina.
• This is the most common type of obstetric fistula and develops typically after a
long period of prolonged or obstructed labour.
• Termed ‘the most dehumanizing condition to afflict women’, this menace
continues to affect millions in Third-World countries.
• And the focus has been on Surgical repair, sidelining the importance of PFM
Rehabilitation in the management of the condition.
(Stamatakos et al, 2014)

4. Classification
• VVF can be classified according to size or location;
• According to size;
• Simple Fistula; single non radiated with size < or= 0.5cm
• Intermediate Fistula; with size between 0.5 and 2.5cm
• Complex Fistula; with size > or = 2.5cm or previously failed fistula repairs
• According to location;
• Juxta-urethral fistula
• Mid-vaginal fistula
• Juxta-cervical fistula

5. HISTORY
• The existence of VVF is believed to have been known to the physicians of Ancient
Egypt, with examples present in mummies before 2000 BC.

6. EPIDEMIOLOGY
• Globally, more than 2 million women are living with VVF and majority are in Sub-
Saharan Africa and South Asia.
• Reported incidence in West Africa is estimated at 1-4 per 1,000 deliveries.
• Obstetric fistula annual incidence in Nigeria is estimated at 2.11 per 1,000 births.
• One hundred thousand to one million Nigerian women are living with unrepaired
VVF.
• 50,000 to 100,000 new cases occur annually in Nigeria.
• More prevalent in Northern Nigeria than in Southern Nigeria.
• Primiparous women are the most affected population.
(Ojewola et al, 2018)

7. AETIOLOGY
• Prolonged obstructed labour
• Accidental surgical injury
• Advanced cervical cancer
• Radiotherapy treatment
• Harmful traditional practices such as FGM and Gishiri
cuts
• Congenital VVF
(Ahmed et al, 2013)

8. Risk factors
• Poverty/low socioeconomic status.
• Lack of access to health care services or late presentation to health facilities.
• Early marriage and childbirth.
• Unskilled birth attendance.
• Poor nutrition and Compromised development.
(Ijaiya et al, 2010)

10. Pathophysiology
Prolonged obstructed labour
Pressure ischaemia
Tissue Necrosis
Formation of hole/fistula
between UT and vagina
Continuous leakage of urine
into vagina
Prolonged impactation of
fetal head on bladder base

11. Clinical features
• Continuous leakage of urine from the
bladder into the vagina.
• Unpleasant odour.
• Foul smelling vaginal discharge.
(Hancock, 2005)

12. Diagnosis
• Comprehensive Medical History and Physical examination.
• Tampon test/dye test
• Cystoscopy
• Transvaginal sonographic Evaluation.
(Spurlock et al, 2016)

13. Differential Diagnosis
• Urethrovaginal fistula
• Ureterovaginal fistula
• Ureterouterine fistula
• Ureterocervical fistula

14. Management
• Conservative approach; catheterization,
urethral plug
• Surgical approach; Transvaginal,
Transabdominal route.
(Browning, 2012)

15. Complications
• Urinary incontinence
• Foot drop
• Vulvar dermatitis
• Secondary amenorrhea
• Anxiety, depression, stigmatization, divorce, etc.
• Recurrent fistula formation
• Dehydration and bladder stones
(Mohammed, 2004)

16. Incontinence after VVF repair
• With a success rate of 75-92%, about 18-33% of pts who underwent repair
surgery still experience some form of incontinence.
• Factors associated with incontinence after repair are Urethral involvement,
significant vaginal scarring, large fistula, reduced bladder volume, etc.
• A good structured physiotherapy program improves the likelihood of successful
outcome after surgical repair of obstetric fistula and Just PFM exercises have
proven to be beneficial for mild(stress) incontinence if done for 6 months
• In the case of severe incontinence, another repair surgery might be attempted or
the pt can resort to a lifelong use of urethral plug to keep dry.
(Berghmans, 2016)

17. Case study
Informant: Patient
C/C: Inability to hold urine while coughing or after long distance walking X 3yrs
Hx: The pt was apparently healthy until 17yrs ago, when she conceived and came to
deliver, had a prolonged labor and delivered by assisted method(forceps). After
delivery, she noticed that she can’t hold urine and was put a catheter for about
5/52 and was removed when the symptoms reduced. She conceived again 2yrs
later and delivered through CS. She conceived the third time and delivered again
through CS 2yrs later. After the delivery, the symptoms of incontinence increased
and later decided to go for surgical procedure (VVF repair) at MMSH. She started
coming to Gynae clinic in AKTH for mgt where she spent about 2yrs and later was
referred to the O/G unit of the dept. of physiotherapy for expert mgt.
PmHx: HTN-, DM-, PUD+
PsHx: VVF repair, CS(twice)
ObsHx: P3A1

18. Case study
No. of Delivery Mode of
Delivery
Weight of
baby
Complications
1 SVD/forceps - Episiotomy
and VVF
2 CS - -
3 CS - -
FsHx: A 35yr old married
businesswoman in a monogamous
setting.
O/E: An apparently healthy middle-
aged woman walked into the
assessment cubicle with a normal
gait pattern, shy, afebrile to touch,
not in any obvious form of distress.
Systemic Assessment;
CNS- Conscious and alert, OTPP
CVS- BP: 110/80 mmHg
Segmental Assessment;
H&N- NAD
T&A- NAD

19. Case study
Back- NAD
ULs- NAD
LLs- NAD
Pelvis & Perineum: Cough test- +ve,
PFM cognition- -ve
Skin- intact
Functional limitations/abilities;
- Pt leaks urine on coughing and after walking for long distances.
- Pt is independent in all ADLs
Dx: Stress incontinence post VVF repair
Rx Plan;
- Pelvic floor muscle awareness
- Lifestyle modification

20. Case study
After 2wks;
PFM assessment: P-4 , E-10 sec , R-10 , F-10
Rx Plan;
- Pelvic floor muscle strengthening 7 reps X 7sec hold + 4sec Relax X 5 sets X 3 times
daily
- Pelvic relaxation on pillow X 3mins X 3 times daily
- Pillow squeeze X 10 reps X 5 sets X 3 times daily
- Sniff flop drop X 10 reps X 5 sets X 3 times daily
- Butterfly bridging with PFM activation X 10 reps X 5 sets x 3 times daily
- Knack Maneuver
- Bladder diary
- H/P

21. Case study
On 3rd week,
Rx Plan;
- Breathing excs in sitting with pelvic floor activation X 10reps X 5 sets X 3 times daily
- Pelvic floor muscle strengthening 7 reps X 7sec hold + 4sec Relax X 5 sets X 3 times daily
- Side lying with pillow squeeze X 10reps X 5sec hold X 5 sets X 3 times daily
- Forward flexion 90 degrees with pillow squeeze X 10reps X 5 sets X 3 times daily
- Forward hip flexion with toe taping X 10reps X 5 sets X 3 times daily
- Bridging with pillow squeeze X 10reps X 5sec hold X 5 sets X 3 times daily
- Sniff flop drop X 10reps X 5 sets X 3 times daily
- Butterfly bridging X 10reps X 5 sets X 3 times daily
- Squatting excs X 10reps X 3 sets X 3 times daily

23. Case study
After the 3rd session, the pt stopped coming for her sessions.
All efforts to reach her proved abortive as even the phone number she provided was
a fake number.
The improvement recorded as follows;
- She gained increased pelvic floor muscle awareness and strength.

24. Conclusion
• Pelvic floor physical therapy could have significant results in post op rehabilitation
of VVF patients and can be an important adjunctive treatment in comprehensive
fistula care, and warrants further investigation.

25. Challenges
• Language barrier prevented effective communication and psychotherapy
• Pt was shy and it affected her cooperation during her Rx
• Pt absconded before her Rx yielded very obvious results

26. Recommendation
• More awareness on the role of Physiotherapy in the post op rehabilitation of VVF
pts.
• Provision of health facilities with skilled birth attendance in areas of low socio-
economic status to reduce the prevalence of VVF.
• Employment of a women health physiotherapist in the Fistula centres across the
country.
• Increasing the number of fistula centers operating in the country.

27. References
Ahmed ZD, Abdullahi HM, Yola AI, Yakasai IA. Obstetric fistula repairs in Kano, Northern Nigeria: The
journey so far. Ann Trop Med Public Health 2013;6:545-8
Browning A. The problem of continuing urinary incontinence after obstetric vesicovaginal surgery.
International News 2012 Sept
Ijaiya MA, Rahman AG, Aboyeji AP, Olatinwo WO, et al. Vesicovaginal Fistula: A Review of Nigerian
Experience. W African J Med 2010 Sept-Octo;29(5):293-8
Stamatakos M, Sargedi C, et al. Vesicovaginal fistula: Diagnosis and management. Indian J Surg.
2014 Apr;76(2):131-136
Spurlock J, Isaacs C, et al. Vesicovaginal fistula. Medscape. Reviewed 15 April 2019
Hancock B. Vesicovaginal Fistula Repair. The Royal Society of Medicine Press. 2005
Mohammad RH. Vesicovaginal fistula. A Problem of Underdevelopment. Foundation for Women’s
Health, Research and Development, Nigeria. 2004
Berghmans B. Vaginal Fistulae and Pelvic Floor Rehabilitation. IUGA 41st Annual Meeting, 2016
August