OBSTETRIC FISTULA

Obstetric fistula is an abnormal communication between the birth canal, and either the bladder, ureters, or rectum.
It is one of the major causes of maternal morbidity making the women with the condition suffer from constant urinary incontinence which can lead to skin infections, kidney disorder or death if left untreated.

Causes

  • Obstructed labour (main cause): most fistula develops in 2 weeks after an obstructed labour, causing an often
    expansive crush injury to the vaginal tissues
  • Sexual abuse and rape (Gender-based violence)
  • Complication of unsafe abortion
  • Surgical trauma usually following a caesarean section
  • Gynaecological cancers and radiotheraphy

Predisposing factors

  • Lack of access to maternity care
  • Lack of/inadequate skilled care at birth
  • Lack of facilities for ANC and childbirth
  • Lack of knowledge to identify danger signs and promptly respond
  • Poverty and lack of women empowerment
  • Early marriage and childbirth
  • Inadequate family planning access
  • Harmful traditional practices such as Female Genital Mutilation

Clinical features

  • Unncontrolled leakage of urine or faeces from vagina

Differential diagnosis

  • Stress, urge or overflow incontinence
  • Ureterovaginal fistula (UVF)

Investigations

  • Speculum examination to visualise leakage; site, size and amount
  • Confirm by dye test on pelvic examination/speculum examination, and/or examination under anaesthesia (EUA)

MANAGEMENT

A fundamental part of the management of obstetric fistula is the appropriate standard management of ALL women
who have survived prolonged or obstructed labour, since it can prevent fistula formation and cure small ones.

Aims of management are to:

  • Prevent fistula formation
  • Close the fistula
  • Make the woman continent and able to resume a full and active life


Principles of immediate care of women who have survived prolonged/obstructed labour, or who present immediately after delivery with obstetric fistula

  • Insert appropriate sized (Foley size 16-18) catheter and leave in situ
  • Refer for follow-up care:
    • The vagina should be examined by speculum as soon as possible and necrotic tissue gently excised
      under aseptic conditions
    • Repeat this until vagina is clean
  • The mother can be discharged with the catheter and advised on care and to come back for review
    and/or removal
  • Recommend increase in fluid intake up to 5 litres a day
  • Perineal Sitz or salt baths twice daily to help the perineum to heal
  • Treat any intercurrent infection and give prophylaxis against UTI:
    • Nitrofurantoin 100 mg 1 tablet in the evening
  • Remove the catheter:
    • After 2 weeks, only if no damage is shown to have occurred
    • After 4-6 weeks in case of small fistula
  • After removing the catheter, if there is no evidence of fistula, discharge with the following
    advice:

    • Avoid sexual intercourse for 3 months. Once it has resumed, it should be gentle and with
      consideration for the woman
    • Avoid pregnancy for about 6 months to one year
    • Advise on family planning/contraception and spacing of children, and the importance of good
      ANC during her next pregnancy
    • All future babies should be delivered in a unit equipped to undertake caesarean section

Management of women who presents with an established obstetric fistula

These are women in whom the conservative management described above failed or they presented with an established fistula.

TREATMENT

  • Refer to regional level for assessment and appropriate management
  • Each woman who has been successfully repaired should receive a card with details of her history,
    a diagram of the injury and a summary of the operation done which should be presented to
    every health worker wherever she may go for care
Note
  • Fistula repair has to be performed by a trained doctor

Prevention

  • Provide skilled attendance at births and improve on emergency obstetric care at all levels
  • Increase access to accurate and quality family planning information and services, especially for adolescents
  • Establish appropriate and effective referral system at all levels (early referrals)
  • ENSURE ALL WOMEN WHO HAVE SUFFERED OBSTRUCTED LABOUR ARE MANAGED ACCORDING
    TO THE STANDARD MANAGEMENT PROTOCOL FOR FISTULA PREVENTION