Obstetric fistula

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

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

20. 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

21. Sim’s Position

22. 3 Swab test

23. Fistula opening in Bladder Cystoscpy Cystoscopy

24. Management Conservative Management Surgical Therapy Nonsurgical Intervention

25. 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.

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

27. 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 .

28. 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.

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

30. Patient positioning

31. 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

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

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

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

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. Prevention 1 • Primary Prevention – Girl Child Education – Women’s empowerment – Collaboration with religious and cultural practitioners – Delayed age at child birth/a ccess 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

42. 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

43. 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   23 rd May- International Day to End Obstetric fistula

44. 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

45. 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

46. Conclusion www.opfistula.org

47. THANKS FOR LISTENING

48. 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

49. 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.

50. 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.