‘Obstetric fistulae are the most devastating consequence of obstructed labor’

Vesico-Vaginal fistula

vvs

Obstetric fistulae are the most devastating consequence of obstructed labor and one of the most dehumanizing conditions that afflict women. They are abnormal communication between the lower genital tract and adjacent urinary or alimentary tract complicating an obstetric event and vesico-vaginal fistula is the most common type.

The estimated incidence in West Africa is 3-4 per 1000 deliveries. The high prevalence seen in developing countries is a reflection of the inadequacy of our maternal health services and is attributed to poverty, illiteracy, ignorance, poor road and communication network and poor availability and utilization of health services.

The most common aetiology of vesico-vaginal fistula (VVF) in this environment as in other developing countries is prolonged obstructed and unsupervised labor. This is unlike the situation in developed countries where majority of the genital tract fistulae are secondary to gynecological surgeries.




Several studies have reported higher incidences of VVF in teenage, primiparous women who are especially predisposed because of early sexual intercourse in a milieu of malnutrition, stunted growth, ignorance and poverty. Multiparous women in this environment also usually engage themselves in unsupervised home deliveries based on their previous successful deliveries, though poverty, illiteracy, inaccessibility and unaffordability of health care facilities are major contributory factors to this attitude.

Other causes of VVF include caesarean section, instrumental deliveries, ruptured uterus, symphysiotomy and destructive operations like craniotomy as well third degree perineal lacerations not properly repaired. Gynaecologic causes of VVF include hysterectomy, anterior colporraphy and Manchester repair, advanced carcinoma of the cervix and radiotherapy. Other general causes include coital trauma, penetrating injuries including uterine evacuation by untrained personnel and traditional practices such as Gishiri cut by the Hausa, Fulanis in the Northern Nigeria.

The typical presentation is that of uncontrollable dribbling of urine per vaginam about 3-10 days after delivery following prolonged labor. This is about the time it takes for necrotic part of the bladder to slough off following pressure necrosis. Some other people develop foot drop due to neuropraxia sustained from pressure effect on the nerve roots. Other complications that can be associated with VVF include recto-vaginal fistula, loss of perineal body tissue, vaginal strictures, skin excoriation from chemical dermatitis, amenorrhea and secondary infertility. An important social aspect is that of neglect, marital disharmony and divorce.

Justa-urethral fistula is the commonest fistula type following prolonged obstructed labor. Fistula following caesarean section usually manifests earlier and is usually juxta cervical in location. Other types of VVF are mid-vaginal and massive fistulas, while other possible genital tract fistulae include yretero-vaginal, vesico-cervical or vesico-uterine fistulae.




The diagnosis of genital tract fistula can be made by detailed history and thorough pelvic examination. Examination with Sim’s speculum and digital examination may suffix but some other cases may require dye testing in the theatre. Pre-surgery evaluation in the theatre helps to determine the site, number of fistulae, state of the tissues around the fistula, state of the urethra, whether patent or blocked and accessibility of the fistula for the purpose of surgical repair. Intravenous urogram or intravenous dye injection with indigo carmine may be necessary in some cases to assess the lower and upper urinary tracts, especially in ureteric injuries.

The main treatment of vesico-vaginal fistula is surgical closure. Small fistulae are known to have closed spontaneously following prolonged catheterization.

Post-operative continuous bladder drainage with adequate fluids therapy is necessary to ensure high urinary output. This is to prevent catheter blockage by clots or debris, which could lead to bladder distension, tension on the repair site and subsequent breakdown of suture lines. Other early complications of VVF include haemorrhage and urinary tract infection. None of these occurred in this patient. Late complications following repair include vaginal scarring and stenosis, small bladder syndrome and fistula recurrence. Partial or total destruction of the bladder sphincter especially in the juxta-urethral fistula may lead to other incontinence problem.

It is important that patients abstain from sexual intercourse for 3 months after repair of genital VVF to allow the repair to heal fully and prevent trauma which could result from it. Use of contraceptives are also advised and in the event of another pregnancy, caesarean section is the advocated method of delivery.






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