Obstetric Fistulae, RVF

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Definition

Obstetric fistula (OF) is a genito-urinary or rectovaginal fistula occurring after labor and its complications.

WHO defines OF as an abnormal connection between vagina and bladder or/and between vagina and rectum which may develop after prolonged obstructed labor and lead to continuous urinary or fecal incontinence.

Vesicovaginal fistula (VVF)
Rectovaginal fistula (RVF)
Vesico-uterine fistula connection between bladder and uterus
Cervico-vesical fistula - connection between bladder and cervix
Uretero-vaginal fistula - connection between Ureter and vagina

VVF: is a clinical condition characterized by continuous leakage of urine per vaginam as a result of communication between the urinary bladder and the vagina.

Is a preventable condition

Still prevalent in developing countries

Due to high level of poverty, illiteracy, ignorance and poor utilization of inadequate health facilities

Most dehumanising condition

Prevalence of VVF is a reflection of quality of obstetric care in a community

VVF is an issue of public health concern

Historically, VVF was thought to be incurable

In 1675, Johann Fatio performed the first successful VVF repair

Marion J. Sims achieved his first successful VVF repair at his thirtieth attempt in 1849.

Sims popularized the repair of VVF

He was regarded as the greatest of all VVF surgeons and the father of modern gynecology

Prevalence/Incidence

Over 2million women live with VVF

50,000- 100,000 new cases occur per year

Most cases are in developing countries of the world (Africa, Middle East, and Asia) with high maternal mortality ratio - Confined to "fistula belt" across the northern part of sub-Saharan Africa from Mauritania to Eritrea and in the developing countries of the Middle East and Asia.

West Africa: 1-4 per 1000 deliveries

Estimated 12,000 cases occur annually in Nigeria. UITH: 1.4 per 1000 deliveries

84.1% from obstetric causes

Classification

There are various classification systems based on anatomical site, size, affectation of continence mechanism, presence of circumferential defect, involvement of ureter, degree of scarring, probable complexity of repair etc.

WHO classification
Waaldijk's classification-use in W/Africa & East Africa
Goh classification-used in East Africa
Tafesse classification

The first three have highest predictive accuracy of fistula closure.

All have poor to fair predictive accuracy

WHO Classification of fistula

Simple fistula with good prognosis

Single fistula <4cm
VVF
Closing mechanism not involved
No circumferential defect
Minimal tissue loss
Ureters not involved
First attempt

Complex fistula with uncertain prognosis

Fistula >4cm
Multiple fistula
RVF, Mixed fistula, cervical fistula
Closing mechanism involved Scarring
Circumferential defect
Extensive tissue loss
Intravaginal ureters
Failed previous repair
Radiation fistula

Types of VVF

Juxtaurethral VVF
Midvaginal VVF
Juxtacervical VVF
Large VVF, multiple

Causes

Obstetric Causes

Pressure necrosis
Caesarean section
Ruptured uterus
Caesarean hysterectomy
Forceps delivery
Symphysiotomy
Destructive operation

Gynecological causes

Advanced carcinoma of the cervix
Hysterectomy
Manchester repair
Anterior colporrhaphy
Gishiri cut
Radiotherapy

Rare causes

Insertion of corrosive substance into vagina
Neglected foreign body in the vagina
Vaginal pessary
Female genital cutting
Coital injury
Lymphogranuloma venerum

Pathogenesis

Prolonged Obstructed labor is the most common cause of VVF in this environment

The impacted fetal head compresses the urinary bladder and the proximal part of the urethral against the pubic symphysis

Leads to pressure necrosis

Affected necrotic area sloughs off

Urine passes through the defect/opening

Risk Factors

Teenage pregnancy

Primigravida

Short statured women

Pelvic deformity

Low socioeconomic status (poverty, poor empowerment of women, lack of education encourage early marriage. Malnutrition leads to short stature & inadequate pelvis)

Gender in-equality, non-permission from husband/family member (surrogate husband) to seek emergency obstetric care, ANC, Facility delivery resulting in unskilled birth attendance.

Cultural practices- early marriage, Gishiri cutting, insertion of caustic agent

Management

Clinical presentation

Symptoms: continuous leakage of urine per vaginam usually follows a difficult labor.

Leakage starts between the 3rd and 10th day postpartum

May be associated with fecal incontinence and/or foot drop, amenorrhea

Lower abdominal pain

Psychosocial complications: loss of self-esteem, depression

FSHX; divorced / separated, social outcast

Examination

General examination

Abdominal examination

Musculoskeletal exam - to assess lower limbs muscle power to assess for foot drop

Vaginal examination

Vulva excoriation
Digital examination first
Speculum examination using Sims speculum in modified Sims position (left lateral position)

Rectal exam- is mandatory to assess for RVF

Differential Diagnosis

Ureterovaginal fistula

Vesicouterine fistula

Stress incontinence

Detrusor instability

Retention with overflow

Investigations

FBC

Pipette specimen of urine for m/c/s, urinalysis

E & U, Creatinine

IVU

3 Swab test

EUA + Dye test- to determine number, site and size.

+/- Cystoscopy to visualize the urethra and bladder

Pre-operative Management/Supportive Management

Hematinics to correct anemia

Application of cream to perineum (zinc oxide)

Catheterization

+/- Physiotherapy for those who developed foot drop

Treatment

Catheterization- expects spontaneous closure in small fistulas

Surgery- usually done after 2-3months of insult

Position- usually done in the lithotomy or knee-chest/genupectoral position

Anesthesia- regional (spinal or combine spinal/epidural) or general anesthesia can be used.

Route of repair

Abdominal (preferred by urologists)
Vaginal
Laparoscopically

Principles of repair

Good access- e.g. with episiotomy
Good light source
Repair in layers
Repair should be tension free
Good nursing care
Good post-op care
Use absorbable sutures

For concomitant VVF and RVF, a colostomy is done for the patient to divert the feces through the abdomen, then VVF repair. The VVF is done first so that the surgeon has more room to work as it is the more difficult surgery. When you achieve cure for the VVF then the RVF is done. The colostomy is then closed.

Post-operative Management

Indwelling urethral catheterization for 14days

Fluid intake - 4litres per day

Antibiotics- e.g. nitrofurantoin, ampicillin, fluoroquinolone

Causes of Non-draining Catheter

Kinking of the catheter
Blood clots
Debris
Catheter is out of the urethral.

Advice before Discharge

Avoid sexual intercourse for 3months
Subsequent delivery is by elective c/s

Other Treatment (Technique) Options

Use of graft for VVF closure e.g. Martius graft, omentum
Use of posterior cervical lip for juxtacervical vesicovaginal fistula closure( M. Ijaiya's technique)
Urinary diversion
Colpocleisis

Communication between rectum and vaginal leading to passage of feces per vaginam

Types

High RVF
Low RVF

Causes

Pressure necrosis

Broken down repaired 4th degree perineal laceration

Advanced carcinoma of the cervix, rectum, vagina

Radiotherapy burns

Injury during pelvic surgery

Rape

Management

Clinical presentation

Very small fistula- leakage of mucus from rectum

Most fistulae-flatus escapes and feces whenever the stool is loose

Vaginal & rectal examination

Digital
Speculum
Probing

Treatment

Surgery

Prevention: can be discussed under primordial/primary level, secondary, & tertiary level of prevention

VVF can be largely prevented by preventing obstructed labor since it is major cause of VVF

Improve nutrition to prevent childhood malnutrition (osteomalacia)

Poverty alleviation

Encourage female education and women empowerment

Legislate against some negative traditional practices such as FGM, Gishiri cut, gender inequality Good transport and communication services Every delivery should be supervised by SBA Use of Partograph to monitor labor

Prompt referral of difficult labor cases

All prolonged labor cases should have indwelling urethral catheter inserted for about 10-14days

Skilled abdominal and pelvic surgeries and instrumental deliveries

Perineal laceration occur commonly in vaginal deliveries and the severity of lacerations varies from minor lacerations that affect the skin or superficial structures of the perineum to more severe lacerations that damage the muscles of the anal sphincter complex and rectum.

Laceration classification (RCOG, 2007)

First degree— Injury to the perineal skin or lining of the vagina.

Second degree— Injury to the perineum involving perineal muscles but not involving the anal sphnter.

Third degree— njury to the perineum involving the anal sphincter complex.

3a— < 50% thickness of external anal sphincter is torn
3b— > 50% thickness of external anal sphincter is torn
3c— Both the external and internal anal sphinters are torn

Fourth degree— Injury to the perineum involving the anal sphincter complex and anal epithelium.

Obstetric anal sphincter injury (OASIS)

Obstetric anal sphincter injuries (OASIS) are complications that occur during vaginal delivery.

Also referred to as third- and fourth-degree perineal lacerations, these injuries involve the anal sphincter complex and, in more severe cases, anal mucosa.

In addition to contributing to short-term morbidity, such as wound breakdown and perineal pain, OASIS is a leading risk factor for subsequent loss of bowel control in women.

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