Obstetric Fistula in the Developing World

Introduction

A fistula is an abnormal connection between two internal organs or between an internal organ and the surface of the body. It may be caused by disease, radiation therapy, surgery, traumatic injury, or a number of other rarer causes. It can lead to abnormal continual leakage of the contents of one organ into another organ or to the outside of the body. Obstetric fistula in the developing world most commonly results from prolonged or obstructed labour, often lasting several days, when the baby cannot pass through the pelvis and usually dies without skilled medical attention. As such, obstetric fistula should be seen as a wholly preventable condition if appropriate medical facilities are available.

Obstructed labour can cause damage to the tissue of the vagina, bladder, urethra and rectum of the woman when the pressure of the baby’s head for an abnormally long time results in damage to the blood vessels supplying these tissues (ischaemia). This cuts off the supply of oxygen and leads to the death of the affected tissue (necrosis). The dead tissue then sloughs away, leaving a hole between adjacent organs. There are several possible types of obstetric fistula: tissue damage between the bladder and vagina is called a vesicovaginal fistula (VVF); between the urethra (bladder outlet) and vagina, a urethrovaginal fistula (UVF); while damage between the rectum and vagina is known as a rectovaginal fistula (RVF). Abnormal connections can also occur between the bladder and the womb and/or the neck of the womb and more rarely between the ureters (kidney tubes) and the vagina or neck of the womb. Other causes of vesicovaginal and rectovaginal fistula in the developing world include violent sexual assault and rape, particularly in war-torn regions, although this is believed to account for less than 10% of the fistulas encountered in these regions.

Prevalence

While obstetric fistula has been virtually eradicated in the developed world due to the availability of good medical care, this is regrettably not the case in developing countries. It is estimated that there may be at least two million women and young girls, living in poverty, who suffer from fistula. Often, many of them are outcasts from their society, rejected by their husbands, families and community because they are suffering from the devastating consequences of obstetric fistula. This problem is particularly prevalent in sub-Saharan Africa, parts of Asia (India and Bangladesh), remote rural regions of China and in parts of South America. However, since many of the affected women live in isolation and never seek help, actual prevalence figures may be much higher.

Risk factors for obstetric fistula

The primary risk factors for obstetric fistula are:

• A lack of access to medical facilities, obstetric care and emergency caesarean section delivery.
• A lack of adequately trained, skilled medical staff.
• A lack of medical supplies and equipment.

Other contributory risk factors include poverty and malnutrition leading to stunted growth that could make women more susceptible to obstructed labour. Furthermore, in some traditional cultures very young adolescent girls often marry and begin childbearing before their body is sufficiently developed to cope with this. Many of the women have received no formal education and had no access to accurate information about healthcare, family planning, pregnancy and childbirth. Moreover, cultural beliefs and traditions may prevent them from seeking the necessary medical care.

Symptoms

The continual leakage of urine and/or faeces caused by obstetric fistula means that the woman is constantly wet and soiled with an unpleasant odour. This condition can lead to other complications such as infection, kidney disease, genital ulceration, sores, dehydration, pain, extensive scarring making sexual intercourse impossible or painful and secondary infertility.

Assessment

The first step in the assessment of each patient includes obtaining a detailed account of their obstetric history, surgical history and bladder/voiding symptoms. A careful physical examination is the mainstay in diagnosis including vaginal inspection of the fistula(s), sometimes with the use of intravesical methylene blue dye to detect and confirm the point(s) of leakage; cystourethroscopy to visualise the fistula from inside the bladder and to understand the relation to ureteric orifices and the bladder neck; and a rectal assessment if an RVF is suspected. Fistulas may be defined as high or low, big or small and single or multiple. Comprehensive assessment of the fistula is critical to determining the best surgical approach.

Treatment

The aim of treatment for obstetric fistula is to surgically repair the abnormal opening, restore continence and rehabilitate the patient into the community. Fistula repair is best carried out by experienced fistula surgeons and preferably at a dedicated fistula centre. Surgical repair ideally has to be successful at the first attempt since the best surgical results are usually obtained with the first repair. Second and third attempts at repair are associated with lower success rates and more complications. Follow-up healthcare and counselling are essential for lasting results - to assist rehabilitation and reintegration into the community and to help the patient get back her life. Successful repair can lead to a dramatic change in the woman’s quality of life. However, reducing the stigma and taboos associated with incontinence will help those who remain incontinent.

Prevention

The immense number of obstetric fistulas occurring in developing countries is of great concern, particularly since they are preventable. Since surgical repair is not always successful, prevention is paramount. However, prevention means tackling the many different factors which contribute to their widespread occurrence. These factors include:

• Access to skilled maternity healthcare close to the community, such as maternity waiting homes.
• Easy access to emergency caesarean section for women in obstructed labour.
• Providing girls and women with formal education, including health education concerning family planning, pregnancy and childbirth.
• Involvement of the whole local community in promoting fistula awareness.
• Better training of locally based nurses, midwives, doctors and surgeons.
• Raising the legal age of marriage to prevent child pregnancy.
• Combating poverty in the developing world.

References

1. De Ridder D, Badlani GH, Browning A, et al. Fistulas in the developing world. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence, 4th ed.Paris: Health Publications Ltd. UK; 2009. pp. 1419–1458.
2. Singh S, Chandhiok N, Singh Dhillon B. Obstetric fistula in India: current scenario. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Dec;20(12):1403-5.
3. Safan A, Shaker H, Abdelaal A, et al. Fibrin glue versus martius flap interpositioning in the repair of complicated obstetric vesicovaginal fistula. A prospective multi-institution randomized trial. Neurourol Urodyn. 2009;28(5):438-41.
4. De Ridder D. Vesicovaginal fistula: a major healthcare problem. Curr Opin Urol. 2009 Jul;19(4):358-61.
5. Hassan MA, Ekele BA. Vesicovaginal fistula: Do the patients know the cause? Ann Afr Med. 2009 Apr-Jun;8(2):122-6.
6. Elneil S, Browning A. Obstetric fistula--a new way forward. BJOG. 2009 Oct;116 Suppl 1:30-2.
7. Wittman AB, Wall LL. The evolutionary origins of obstructed labor: bipedalism, encephalization, and the human obstetric dilemma. Obstet Gynecol Surv 2007 Nov; 62:739-48.
8. Wong MJ, Wong K, Rezvan A, et al. Urogenital fistula. Female Pelvic Med Reconstr Surg 2012; 18(2):71-8.