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
Diagnosis
Management
Prevention
Recent advances
Conclusion
Reference

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.

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

Brief history
The oldest evidence of obstructed labor:

In the remains of Queen Henhenit, of Egypt c. 2050 BC.

1923: review of the Queens 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.

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

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
Repair of ruptured uterus
Forceps Delivery
Destructive operations

 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

Obstetric fistula pathway

Pathogenesis

Classification of Obstetric fistulas

Site of Injury

Gohs 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 2.53.5 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 1.53 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.

Waaldijks 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

Clinical Presentation 1

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

The Obstructed Labour Injury

Complex

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

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

Sims Position

3 Swab test

Cystoscopy

Cystoscpy

Fistula opening in
Bladder

Management
Conservative Management
Surgical Therapy
Nonsurgical Intervention

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.

NON SURGICAL INTERVENTION

Electrocautery fulguration
Fibrin glue
Laser welding with Nd YAG(neodymium-doped
yttrium aluminiumlaser)
Psychosocial counseling and rehabilitation

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.

Preoperative care
Improve the patients 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.

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

Patient positioning

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
COMBINED
LOSS OF BLADDER NECK ABDOMINOVAGINAL
MIDVAGINAL FISTULA

TRANSVAGINAL

HIGH VAGINAL FISTULA

Post hysterectomy
Juxtacervical

ABDOMINAL OR
VAGINAL

Principles of fistula repair

First attempt is best .

Tissue mobilization
Hemostasis
Adequate exposure
Aseptic measures
Tension free closure
Reinforcement
Expertise

Repair of Vesicovaginal Fistula

Vaginal approach
Flap splitting technique
Saucerization
Latzko technique

Abdominal approach
Transvesical repair
Transperitoneal repair
Combined repair

Abdominal approach
Indications

High inaccessible fistula

Multiple fistulas
Involvement of uterus or bowel
Need for ureteral re-implantation
Complex fistula

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

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

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

 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

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

Management
SURGERY
Route:
Transvaginal Approach
Transanal Approach
Abdominal Approach

Timing:
Wait 8-12 weeks before surgical intervention to allow
surrounding inflammation to resolve completely

Prevention 1
Primary Prevention

Girl Child Education

Womens 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

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

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

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 Childrens Hospital
(MAWCH), Sokoto State

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

Conclusion

www.opfistula.org

THANKS FOR
LISTENING

References
Vesicovaginal Fistula: A Review of Nigerian Experience
by M. A. Ijaiya et al. West African Journal of Medicine
Vol. 29, No. 5 SeptemberOctober 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/reproductivehealth/publications.

The World Health Report, 2005Make every mother

and child count, 2005, Geneva

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: 56874.
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

Journalof Obstetrics and Gynecology. 2004, 191 :795-9.
Waaldijk K.Surgical classification of obstetric
fistula.International Journal ofGynecology and Obstetrics,
1995, 49 :161-163.

 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 societypoor,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.