VECICOVAGINAL & RECTAL

VAGINAL FISTULAE

Dr L. Kasonka
Consultant Obstetrician &
Gynaecologist
 Dr LEE- Jong-Wook
13/07/45 - 22/05/06

Knowledge with out action is a useless investment

and action without knowledge is a wasted effort.
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 Incontinence of urine - definition

Uncontrollable escape of urine resulting in

constant wetting

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 Types of incontinence cont’d

Urgency
Normal sphincter mechanism but over
powered by abnormal activity of bladder;
- hypertonic detrusor muscle.
- hypersensitive or outside CNS control

Urine leaks in large amounts following a

desire to void.
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 Types of incontinence cont’d

Stress
Escape of urine through the urethra when
the intra-abdominal pressure is raised by
a sudden movement, coughing, laughing
walking etc

Small drops of urine lost at any one time.

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 Types of incontinence

Continual (true)
Continuous flow of urine by day and by night

Overflow
Sequel of prolonged and neglected retention.

Occurs when pressure in bladder overcomes urethra

Resistance.
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 Fistula

Definition,

An abnormal (false) communication

between two epithelial surfaces (body
cavities).

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 Causes of Fistula
Congenital malformations
Foreign bodies in vagina
Surgery
Extension of malignant disease
Radiation therapy
Chemical burns
Sexual assault
Accident
Old age
Obstetric trauma
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 Types of Fistula
• Vaginal-perineal
• Tubo-intestinal
• Utero-intestinal
• Vaginal-intestinal
• Recto-vaginal
• Vesico-colic
• Utero-colic
• Vesico--uterine
• Vesico-vaginal
• Utero-rectal
• Perineo-intestinal
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 Obstetric Fistula

Injury to the pelvic tissue caused by

prolonged and unrelieved obstructed labour
that may last several hours or days.

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 Pathophysiology of Fistula

During obstructed labour, prolonged

pressure of the fetal presenting part,
commonly the head, severs blood supply
to the soft tissue on the bladder resulting
in ischemic necrosis. The necrotic tissue
on the bladder or rectum soon sloughs off
resulting in urine or stool incontinence.

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 Consequences of obstructed
labour

Death of baby, mother or both.

Mother who survive;

– Still birth
– Sepsis
– VVF/RVF

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“I was pregnant for the first time.
I was so happy and proud that I was going to be a
mother. When my pain started, it was in the
middle of the night. I got up and crouched on the
floor and waited for my baby to come out. But it
didn’t come no matter how hard I pushed. The
pain was so great I kept falling. It was a Tuesday.
Then it was Wednesday. After the first couple of
days, I didn’t feel the baby inside kicking
anymore. At last I gave birth to a dead baby boy.
I was very tired and slept for a long time. When I
woke up, the bed was wet and there was a foul
smell." 14
 Consequences of obstructed labour
cont’d

The WHO has called fistula “the single most

dramatic aftermath of neglected childbirth”.

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 Risk factors for Obstetric
Fistulas

Poverty
Relative poor health
Poor nutrition
Stunted growth
Limited access to maternal health care
Cultural influences

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 Epidemiology of Obstetric
Fistula

The young (teenage)

The poor

The Uneducated

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 Global context

Most prevalent in Asia & Africa

Aprox. 2 Million women presently live with

fistula.(WHO)

50 000 – 100 000 women are affected each

yr
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 Zambian context

Has received minimum attention from policy

makers.

Not yet on the reproductive health agenda

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A long walk in search of treatment

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Incidence of Obstetric Fistula in
Zambia
Exact incidence not known

UNFPA global program

Situation analysis Nov 2003 to;

– determine magnitude in Zambia
– Asses the capacity of health services to deal with the
problem
– Explore community perceptions of the syndrome

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Consoling a fistula patient in Kawambwa Hospital

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Combining efforts for the fistula patient at
Mansa General Hospital

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On a Fistula mission at Lubwe mission
hospital

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 Background
Poverty 83% rural
56% urban population

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Background continued

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 Background cont’d

Early marriages

Teenage pregnancies

32% teenage women (15-19 yrs old) are

pregnant/given birth to one child.

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 Clinical Consequences of
Obstetric Fistula

Leaking urine
Offensive smell
Genital sores
Infections
Foot drop

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 Psychosocial consequences

Loss of ability to earn an income

Rejection,misery,depression and solitary life

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 Management of Obstetric Fistula
Sanitary care

Forley catheter

Antibiotics

Surgical repair
– after three months of delivery

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 Approaches to Surgical repair of
Fistula
• Anaesthsia
– General
– regional

• Peri-operative prophylactic antibiotics

• Surgical approach
– Transvaginal
– Trancervical
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 Approaches to Surgical repair of
Fistula cont’d..

• Suture material
– Vycryl No. 0
– Dexon No.0, 2/0

• Position
– Supine steep reclined (trendreburg)
– Knee chest position
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Reginald & Catherine Hamlen

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Hamlen Hospital

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 Post operative Care

• Ensure continuous urine drainage for 14 days.

• Prophylactic antibiotics

• Nutritional support

• Child birth after repair

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 Prevention of Obstetric Fistula

Raise awareness for prevention and

treatment.
– Advocacy
– Community education
– Community workers and clinicians
– Medical & Midwifery schools

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 Prevention cont’d…

Emergency obstetric care for complicated

Pregnancy

– Improved access to family planning info

– Wider antenatal coverage
– Skilled attendance at birth
– Improved communication & transport
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 Prevention cont’d….

Increased opportunities for safer

Motherhood

– Traditional birth attendants

– Waiting homes
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Where there is no ambulance for the pregnant woman

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