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A review of postoperative care for obstetric fistulas in Nigeria
International Journal of Gynecology and Obstetrics (2007) 99, S79–S84
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
ISSUES IN CLINICAL MANAGEMENT
A review of postoperative care for obstetric fistulas in Nigeria O.S. Shittu a,⁎, O.A. Ojengbede b , L.H.I. Wara c a
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria c Department of Obstetrics and Gynaecology, Federal Medical Center, Birnin Kebbi, Nigeria b
KEYWORDS Care; Management; Nigeria; Obstetric fistula; Postoperative; Rehabilitation
Abstract Nigeria harbors an estimated 40% of all the women affected with obstetric fistulas today, and at the current rate of treatment in this country, it would take about 300 years to treat them if no new fistulas occurred. This situation obviously runs contrary to the ideals of the United Nations Millennium Development Goals and needs to be reversed. We reviewed the literature on fistula treatment in Nigeria to identify strategies and practices that, if adopted, would likely accelerate the pace of fistula repair and improve postoperative fistula care in this country. A comprehensive nationwide survey, a stronger political will and commitment of resources, a systematic postoperative care and follow-up, more fistula centers, and more fistula campaigns are necessary. Technically, the involvement of all surgeons trained in fistula repair and an experience-based postoperative management protocol will relieve the disease burden carried by women living with fistulas in Nigeria. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The World Health Organization estimated that about 2 million women are currently affected with obstetric fistulas (OFs) worldwide, and that between 50,000 and 100,000 new cases occur annually [1]. Most of these women reside in developing countries where the predisposing factors of poverty, ignorance, poor health facilities, and prolonged obstructed labor
⁎ Corresponding author. Office of Medical Advisory Committee, Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, P.M.B. 1026, Zaria, Kaduna State, Nigeria. Tel.: +234 805 268 2064; fax: +234 69 555 001. E-mail address: [email protected] (O.S. Shittu).
prevail. About 800,000 women are thought to be living with OFs in Nigeria today, and as many as 20,000 more are affected each year [1,2]. An analysis of a recent survey by the United Nations Population Fund (UNFPA) on the capacity of Nigeria to address its fistula problem suggests that about 2500 repairs are performed annually in this country [3]. At this pace, assuming that no new OFs occur, it will take more than 300 years to restore all affected women to urinary continence and a normal life in Nigeria! As efforts to achieve the United Nations Millennium Development Goals (MDG) of reducing maternal mortality by three-quarters by 2015 are intensified, it is expected that new OFs will be prevented. However, the women living a life of misery because they have fistulas must still be helped. The
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.014
S80 MDG endeavor would better improve the quality of life of women, in Nigeria and all other poor countries, if it also addressed the repair of existing OFs. Such a consideration obviously requires a review of the frequency and modes of fistula repair in Nigeria. The review would help accelerate the pace and improve the overall success rate of fistula treatment by the 2015 target. Experts agree on 2 prerequisites for successful repair: skillful closure of the fistula and meticulous postoperative care. The former signifies that case selection must be determined by the level of experience and skill of the surgeon and adequate patient preparation, and that fistula closure actually occurs. The success of the latter depends on factors associated with the treatment (such as the patient's compliance with instructions), and on external factors such as the prevailing economic and social milieu. We searched the literature and performed a review of the published articles on the treatment of OFs in Nigeria. Our objective was to determine which postoperative practices and strategies were successful and could be widely adopted in Nigeria and other countries with a high OF prevalence. Special attention was given to postoperative management. This article emphasizes the magnitude of the fistula problem and the ongoing efforts to provide better care, and proposes strategies for early and later stages of care.
2. Present state of fistula care There has been no comprehensive, nationwide assessment of the fistula problem in Nigeria, and the successive Demographic Health Surveys have ignored it. Most of the information on OFs has come from hospital-based and small-scale studies [4–15], and the same is true of the data on patterns in obstetric care. One of the most recent and outstanding surveys, conducted by EngenderHealth for UNFPA in October 2002, captured the characteristics of fistula care as it is delivered across the country [3]. The survey revealed that: • About 33 surgeons were providing fistula repair services • About 2286 fistula repairs were performed annually across the country • About 155 (6.8%) of all fistula repairs were performed annually at the country's University Teaching hospitals, implying that each of the 25 teaching hospital surgeons performed, on average, 6 repairs per year • About 2131 (93.2%) of the repairs were performed annually at the fistula centers, with each of their collective 8 surgeons performing, on average, 266 repairs per year • About 57.5% of the repairs were performed at 3 fistula centers and 3 teaching hospitals located in the North– West zone, one of the 6 geopolitical zones of the country; the survey did not report fistula activities from the North– East and South–East zones, suggesting that few or no fistulas were repaired in these 2 zones • Treatment at the fistula centers was essentially free, whereas the median cost of a fistula repair at the teaching hospitals was 166 US dollars (range, 90–50 US dollars) (the Nigerian per capita income at the time of the survey was 310 US dollars per year) [3].
O.S. Shittu et al. The most recent strategy for addressing the problem in Nigeria was the Fistula Campaign organized by UNFPA in February 2005. It involved assembling, for a specified time, fistula surgeons and patients at designated fistula centers. In that first campaign 564 women with OFs were surgically treated, with 87% of success [1,2]. Performed within a fortnight, this remarkable number of repairs would have taken about 4 months at the prevailing pace. Most of the Nigerian fistula surgeons operate at teaching hospitals, where very few women with fistulas seek treatment because of the high service charges. This situation reflects a generally ineffective use of the resources allocated to fistula repair. The high performance of the Fistula Campaign in Nigeria confirms that the absence of a nationwide, coordinated effort is hindering fistula control in this country, and clearly designates the Campaign as a model to draw from. The recent development of a “National strategic framework and plan for VVF [vesico-vaginal fistula] eradication in Nigeria” confirms this view; more significantly, as a manifestation of a positive government response, it needs to be vigorously pursued [11]. When the approach to be implemented nationwide is determined, the strategies and costs involved at the regular fistula centers and during the Fistula Campaign should be compared. The fact that Nigerian surgeons served as volunteers during the last fistula campaign will benefit any national approach.
3. Present postoperative care There are few surgical operations where postoperative care is as critical for success. Marion Sims' remarkable success over his predecessors was attributed to his adherence to 5 postoperative requisites: “a tin catheter for continuous drainage; quiescent bowel for 10 to 15 days; opium analgesia; normal fluid intake; and perineum irrigation” [17]. These have remained the “ingredients” to the recipe for the successful management of repaired fistulas. The current standard of postoperative care could be categorized into 3 phases: (A) early postoperative care (the catheterization period); (B) late postoperative care (the postcatheterization period); and (C) the treatment of conditions associated with the fistula.
3.1. Early postoperative care 3.1.1. Catheterization Continuous bladder drainage is considered essential to proper healing as it maintains the repair site free of tension and allows the bladder to rest. Most fistula surgeons use a transurethral catheter except when urethral reconstruction has been performed; in such cases, a suprapubic catheter is often used [4,7,10,15,16]. Moreover, a suprapubic catheter and a transurethral catheter are both used following a transabdominal fistula repair to permit bladder irrigation and the elimination of blood and clots. The ideal type of catheter for bladder irrigation is the 3way Foley catheter, but it is seldom available in Nigeria because it is more expensive than the 2-way type. The 2-way Foley catheter will probably remain in use unless it is found to have adverse effects.
A review of postoperative care for obstetric fistulas in Nigeria In most fistulas repairs, the Foley catheter is maintained in place by its inflated balloon. However, to avoid exerting pressure on the repair site when the operation involved the bladder neck (large juxtaurethral fistulas or fistulas with circumferential tissue loss), surgeons stitch the catheter to the labia using the Charlewood or another technique [15,16]. The duration of catheterization for a primary fistula repair is usually about 14 days, but it is 21 days if a urethral reconstruction or bladder-neck repair was performed or a postoperative leakage has occurred. These intervals are based on experience but have no scientific explanation. Whether shorter intervals are possible, especially with the recent advances in suture technology, will have to be determined from carefully designed prospective studies. Although in Nigeria most fistula surgeons connect catheters to closed urine bags that are periodically emptied, catheters are made to drain into open receptacles placed at the foot of the patient's bed at some fistula centers [3,5,9]. This practice involves the patient in the monitoring and emptying of her urine, but concerns have been raised about the untidiness of these open drains and the risks of retrograde urinary tract infection. Until these issues are resolved, the closed drainage system will be advocated for all settings in Nigeria. 3.1.2. Vaginal pack Applying a vaginal pack as a tamponade to obliterate any postoperative dead space at repair sites is not universally done, as the usefulness of the practice is uncertain. It is always removed within 48 h [3,5,16,18]. 3.1.3. Pain relief Irrespective of the form of anesthesia used during the repair, postoperative pain relief is ethically imperative. Strong analgesics (narcotics such as pethidine or morphine) are administered every 6 h for 24 to 48 h, after which paracetamol is given orally for 2 days. 3.1.4. Fluid intake Adequate fluid intake is essential for successful fistula repair, as ample urine secretion is needed to prevent clot formation, catheter occlusion, urine stasis, infection, and stone formation. A urine output of at least 100 mL per hour is regarded as the appropriate target [5,16,18]. Consequently, in a tropical environment, where the daily insensible fluid loss is about 2000 mL, the daily need for the fistula patient is about 4000 mL. An intravenous infusion is given for the first 24 to 48 h. Once oral intake is tolerated, the patients are instructed to drink water liberally, usually from jars kept at their bedside. 3.1.5. Urine output monitoring The need for close urine output monitoring cannot be overemphasized. It serves as an early indicator of a catheter blockage, of ureteric ligation, or of impaired renal secretion. The frequency of urine output monitoring differs from one facility to another in Nigeria. The persistent passage of clots warrants an irrigation of the bladder with a citrated solution. Whenever urine outflow is decreased or has ceased, the patient is examined to exclude any of the following causes, in this sequence: external compression of the catheter; catheter kinks; catheter blockage from clots or sediment; ureteric obstruction (from ligation or edema); or diminished
S81 urine secretion. The directions compiled in Table 1 can serve as a guide for distinguishing the causes and rectifying the problem. 3.1.6. Antimicrobial use Whereas some surgeons do not use antimicrobial agents unless there is a clinical infection [3,5,9], others use them prophylactically [3,5,9,10,13,15]. At teaching hospitals, the common practice is to perform a routine preoperative urine culture to determine bacterial sensitivity and the appropriate antimicrobial agent to administer. The prophylactic treatment is continued during the postoperative period. In the postoperative period, urine cultures are usually repeated every 2 to 3 days, the final culture being of the tip of the removed catheter. Until a large-scale study is performed on microbial urinary tract patterns in fistula patients, the prophylactic use of affordable broad-spectrum antimicrobial agents (such as cotrimoxazole and nitrofurantoin) may have to be adopted for the duration of the catheterization period in large-scale fistula care protocols. 3.1.7. Patient ambulation The principle that early ambulation stems thrombo-embolic complications and pressure sores after pelvic surgery applies to fistula patients, especially when the repair was done transabdominally. The practice is customized to suit the specific needs of patients, who ambulate as early as the next day if they underwent repair for a simple fistula. Those who had transabdominal surgery for bladder neck and/or urethral reconstruction wait longer [4,7,8,10], but these time intervals are experiential. 3.1.8. Vulvo-vaginal toileting This care is considered necessary. Nurses trained in the care of women with OFs use irrigation techniques to clean the vulva and perineum of blood, menstrual effluent, and any other discharge or debris with warm water or a diluted antiseptic solution each day and after bowel movements.
3.2. Late postoperative care 3.2.1. Determination of repair outcome From the patient's point of view, the success of her fistula repair is determined by the restoration of her urinary continence; from the surgeon's point of view, however, the definition of success is much less precise. Although, from the reports, the rate of success ranges between 72% and 92%, there is no universal criterion for declaring success. For some surgeons success is the confirmation that a fistula is closed and for others it is the restoration of complete continence. With the latter criterion the surgery would be categorized as a failure if a patient experienced postrepair stress incontinence, whereas with the former criterion the surgery would be categorized as a success. It is necessary to harmonize criteria to facilitate meaningful comparisons of treatment outcomes. The patient-centered criterion of continence restoration should be the one universally adopted when fistula treatments are evaluated. When the intended period of continuous bladder drainage is over, the catheter is removed and the patient examined to assess the outcome of the surgical repair. About 2 h after
S82 Table 1
O.S. Shittu et al. Guidelines for identifying and remedying postoperative urine outflow problems
Guideline sequence no.
Likely cause of reduced urine outflow
Observable features
Recommended action
1
External compression of catheter system Catheter kinks
• The patient lies on the catheter or drainage tube
• Redirecting the drainage system to pass over the patient's thighs
• Examination of the entire drainage system for any acute angulations (this is more likely with the small-sized catheters) • External factors excluded, but urine outflow not resumed
• Ensuring that no curvature of the drainage system is less than 120°.
2
3
4
Internal catheter blockage
Ureteric obstruction
• Suprapubic percussion suggests urine within bladder but gentle pressure does not move urine into catheter • Surgical repair that involved the trigone or any of the ureters • Loin pain • Vomiting • Persistent fever
5
Diminished renal secretion of urine
• • • • •
Abdominal distention (Increased creatinine level) Circulatory shock Increased creatinine Increased urea
Using aseptic means, sucking out suspected blockage with a 50-mL syringe connected to the catheter; if this fails, gently instilling a few mL of saline solution and resuming the procedure. • Once patency is restored, irrigating the bladder with a saline or sodium citrate solution • Referring the patient in the absence of facilities for imaging and/or laparotomy • Renal tract imaging: ultrasonography, intravenous urogram, CT scan or MRI (if available) • Strong clinical or radiologic suspicion mandates 2nd laparatomy to identify and free obstruction • (Prevention by routine catheterization of ureters if repair is proximal to them)
• Resuscitation • Dialysis (or referral for dialysis)
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.
removing the catheter, the vestibule is inspected for normality and the introitus for urine leakage and stress incontinence. If there is introital leakage, the outcome is reassessed following recatheterization for a further 7 to 10 days. The repair is declared successful in patients found to have no leakage or stress incontinence. The patients are then given bladder training to improve bladder capacity and voiding function. They initially void urine at hourly intervals, and the interval is progressively extended until a convenient schedule is attained [16]. On the other hand, the repair is declared only partially successful in patients left with stress incontinence after successful fistula closure. Regardless of whether the success of the repair was partial or complete, the patients are counseled on a wide range of topics regarding their future reproductive health [5,7,10,19]. Emphasis is placed on the following: Coitus should not resume for 3 months; unless a pregnancy is desired, contraceptives should be used when coitus is resumed; antenatal care should be sought as early as a pregnancy is suspected and medical history told to the clinic attendants; and any subsequent delivery should be by cesarean section—certainly no home delivery should ever be considered again. At this stage, the patient is discharged to her relatives if they are willing and supportive; otherwise, she is transferred to a rehabilitation center for further care.
3.2.2. Rehabilitation In Nigeria, all fistula centers and a few teaching hospitals (including the facilities where both lead authors work) have active rehabilitation programs where women are able to acquire elementary education and practical skills such as cooking, tailoring, knitting, and other craft-making that will empower them to earn their own living when they return home [12,20]. Social workers attached to these centers help the women renew their ties with their immediate relatives, and some women even return with their husbands. If the Millennium Development Goals are to be achieved, eliminating the poverty, illiteracy, and social isolation of these women needs to be more vigorously addressed through the provision of such services at every fistula care site.
4. Care of clinical conditions associated with OFs The overwhelming distress experienced by women with continual urinary incontinence often relegates coexisting conditions to the background until the fistula is repaired. These include obstetric palsy, secondary amenorrhea, and sexual dysfunction. Since the care of women with OFs should aim at restoring their reproductive health as well as their urinary continence, these conditions deserve intervention.
A review of postoperative care for obstetric fistulas in Nigeria
4.1. Obstetric palsy More than 15% of women with OFs have footdrop, which, like fistulas, arises from prolonged obstructed labor. Most cases of footdrop are unilateral [21,22]. Presently, only teaching hospitals are equipped with the facilities necessary for electrotherapy and proper physical rehabilitation. Even at these centers the shoe calipers and foot elevators needed for passive treatment are generally unavailable; and when they are available, few patients can afford using them. It is necessary to establish physiotherapy services at fistula centers where the bulk of the patients are seen, and other sites where fistula care is given will need to refer their patients.
4.2. Secondary amenorrhea Up to two-thirds of women with OFs also have secondary amenorrhea [7,10,21]. Investigating and treating secondary amenorrhea is beyond the scope of the services available at the fistula centers; and although some of the teaching hospitals are equipped to investigate such possible underlying causes as hypothalamic dysfunction, panhypopituitarism, and uterine synechiae, few patients are able to afford the treatment. Referral arrangements between fistula centers and the closest teaching hospitals will facilitate care for the more affluent patients.
4.3. Sexual dysfunction Whereas in the southern part of Nigeria most of the women with OFs can count on the support of their husbands [3,7,13,15], their northern counterparts are often divorced or separated [8,10,19,23]. In either situation, complaints of coital difficulties emerge after the mandatory 3-month postoperative period of abstinence. Gynatresia is the leading cause of such complaint, as it is present in about 10% of cases following fistula repair [7,8,10,24]. The surgeons skilled in vaginal plastic surgery are all employed by the teaching hospitals [18]; all that can be done at the other fistula treatment facilities is counsel the women and recommend the use of lubricants during sexual intercourse. Fortunately, intercourse with lubrication has been shown to be a superior therapy in the long term.
5. Conclusion The prevalence of OFs in Nigeria is among the highest in the world, and the situation will worsen unless the standards of obstetric care are improved and the rate of fistula repair greatly accelerated. Conducting a more detailed and nationwide survey to assess with workable precision OF prevalence in Nigeria will be an essential first step toward the meaningful planning of any nationwide intervention. Establishing more fistula centers and organizing more fistula campaigns are necessary to harness the enormous surgical expertise presently underutilized at the country's teaching hospitals. The “hightech,” expensive, and unaffordable postoperative protocol currently offered at the teaching hospitals needs to be scaled down in favor of the minimum but safe standard of postoperative care just proposed. The latter was designed to give
S83 not a few, but a multitude of women with fistulas a new chance at enjoying a normal reproductive health. It is needless to emphasize that increased funding is necessary for the provision of resources that will make a difference in the lives of these indigent and socially dislocated women, who may not otherwise benefit from the worldwide efforts aimed at achieving the Millennium Development Goals by 2015. Conflict of interest None. The authors have no financial or personal relationship with any of the persons or organizations that have prompted or encouraged the compilation of this work. Role of the funding source None.
References [1] United Nations Population Fund (UNFPA). Obstetric Fistula in Brief. www.endfistula.org/fistula_brief.htm, 2006. Accessed May 19, 2007. [2] United Nations Population Fund (UNFPA). Nigerian ‘Fistula Fortnight’. www.endfistula.org/fortnight, 2006. Accessed May 19, 2007. [3] United Nations Population Fund (UNFPA) and EngenderHealth. Obstetric fistula needs assessment: findings from nine African countries. New York, NY: UNFPA; 2003. p. 57–76. www.unfpa. org/profile/nigeria.cfm. Accessed May 19, 2007. [4] Lister UG. Obstructed labour: a series of 320 cases occurring over a 4-year period in a hospital in southern Nigeria. J Obstet Gynecol Br Emp 1960;67:188–95. [5] Ejembi CL, editor. The vesico-vaginal fistula scourge: a preventable social tragedy. Proceedings of the National Workshop on Vesico-Vaginal Fistula. Lagos, Nigeria: National Task Force on Vesico-Vaginal Fistula; 1995. [6] Tahzib F. Epidermiological determinants of vesico-vaginal fistulas. Br J Obstet Gynecol 1983;90:1291–3. [7] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(4):189–94. [8] Ghatak DP. A study of urinary fistulae in Sokoto, Nigeria. J Indian Med Assoc 1992;90(11):285–7. [9] Waaldijk K. Immediate indwelling bladder catheterization at post partum urine leakage: personal experience of 1,200 patients. Trop Doct 1997;27:227–8. [10] Wall LL, Kershima JA. The obstetric vesico-vaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011–9. [11] Federal Ministry of Health and the United Nations Population Fund (UNFPA). National Strategic Framework and Plan for VVF Eradication in Nigeria: 2005–2010. New York, NY: UNFPA; November 2005. [12] Shittu O, Ifenne D, Hord C. A hospital in Nigeria reinvents its reproductive health care system. In: Haberland N, Measham D, editors. Responding to Cairo: Case Studies of Changing practice in Reproductive Health and Family Planning. New York, NY: Population Council; 2002. p. 223–35. [13] Gharoro EP, Abedi HO. Vesico-vaginal fistula in Benin City, Nigeria. Int J Gynecol Obstet 1999;64:313–4. [14] Waaldijk K. Step-by-step surgery of vesico-vaginal fistulas. Edinburgh UN: Campion Press; 1994.
S84 [15] Iloabachie GC. 260 cases of juxtacervical fistula. East Afr Med J 1992;69:188–90. [16] Ekwempu CC. Fistulae. In: Agboola A, editor. Textbook of Obstetrics and Gynaecology for Medical Students, vol. 1. Lagos, Nigeria: University Services Educational Ltd; 1988. p. 46–59. [17] Sims JM. On the treatment of vesico-vaginal fistula. Am J Med Sci 1852;23:59. [18] Danso KA. Genital tract fistula. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Gynaecology in the Tropics. Accra, Ghana: Graphic Packaging Ltd; 2005. p. 174–81. [19] Harrison KA. Obstetric fistula: one social calamity too many. Br J Obstet Gynecol 1983;90:385–6.
O.S. Shittu et al. [20] Harrison KA. The importance of educated healthy women in Africa. Lancet 1997;349(9052):644–7. [21] Lewis Wall L. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of Northern Nigeria. Stud Fam Plann 1998;29(4):341–59. [22] Waaldijk K, Eklins TE. The obstetric fistula and peroneal nerve injury: an analysis of 947 consecutive patients. Int Urogynecol J Pelvic Floor Dysfunct 1994;5:12–4. [23] Murphy M. Social consequences of vesico-vaginal fistula in northern Nigeria. J Biosoc Sci 1981;13:139–50. [24] Ojengbede OA, Anifowose IO, Nylander PP. Coital problems of the urinary system in obstetrics urinary fistula. Trop J Obstet Gynaecol 1992;10(2):32–5.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
ISSUES IN CLINICAL MANAGEMENT
A review of postoperative care for obstetric fistulas in Nigeria O.S. Shittu a,⁎, O.A. Ojengbede b , L.H.I. Wara c a
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria c Department of Obstetrics and Gynaecology, Federal Medical Center, Birnin Kebbi, Nigeria b
KEYWORDS Care; Management; Nigeria; Obstetric fistula; Postoperative; Rehabilitation
Abstract Nigeria harbors an estimated 40% of all the women affected with obstetric fistulas today, and at the current rate of treatment in this country, it would take about 300 years to treat them if no new fistulas occurred. This situation obviously runs contrary to the ideals of the United Nations Millennium Development Goals and needs to be reversed. We reviewed the literature on fistula treatment in Nigeria to identify strategies and practices that, if adopted, would likely accelerate the pace of fistula repair and improve postoperative fistula care in this country. A comprehensive nationwide survey, a stronger political will and commitment of resources, a systematic postoperative care and follow-up, more fistula centers, and more fistula campaigns are necessary. Technically, the involvement of all surgeons trained in fistula repair and an experience-based postoperative management protocol will relieve the disease burden carried by women living with fistulas in Nigeria. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The World Health Organization estimated that about 2 million women are currently affected with obstetric fistulas (OFs) worldwide, and that between 50,000 and 100,000 new cases occur annually [1]. Most of these women reside in developing countries where the predisposing factors of poverty, ignorance, poor health facilities, and prolonged obstructed labor
⁎ Corresponding author. Office of Medical Advisory Committee, Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, P.M.B. 1026, Zaria, Kaduna State, Nigeria. Tel.: +234 805 268 2064; fax: +234 69 555 001. E-mail address: [email protected] (O.S. Shittu).
prevail. About 800,000 women are thought to be living with OFs in Nigeria today, and as many as 20,000 more are affected each year [1,2]. An analysis of a recent survey by the United Nations Population Fund (UNFPA) on the capacity of Nigeria to address its fistula problem suggests that about 2500 repairs are performed annually in this country [3]. At this pace, assuming that no new OFs occur, it will take more than 300 years to restore all affected women to urinary continence and a normal life in Nigeria! As efforts to achieve the United Nations Millennium Development Goals (MDG) of reducing maternal mortality by three-quarters by 2015 are intensified, it is expected that new OFs will be prevented. However, the women living a life of misery because they have fistulas must still be helped. The
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.014
S80 MDG endeavor would better improve the quality of life of women, in Nigeria and all other poor countries, if it also addressed the repair of existing OFs. Such a consideration obviously requires a review of the frequency and modes of fistula repair in Nigeria. The review would help accelerate the pace and improve the overall success rate of fistula treatment by the 2015 target. Experts agree on 2 prerequisites for successful repair: skillful closure of the fistula and meticulous postoperative care. The former signifies that case selection must be determined by the level of experience and skill of the surgeon and adequate patient preparation, and that fistula closure actually occurs. The success of the latter depends on factors associated with the treatment (such as the patient's compliance with instructions), and on external factors such as the prevailing economic and social milieu. We searched the literature and performed a review of the published articles on the treatment of OFs in Nigeria. Our objective was to determine which postoperative practices and strategies were successful and could be widely adopted in Nigeria and other countries with a high OF prevalence. Special attention was given to postoperative management. This article emphasizes the magnitude of the fistula problem and the ongoing efforts to provide better care, and proposes strategies for early and later stages of care.
2. Present state of fistula care There has been no comprehensive, nationwide assessment of the fistula problem in Nigeria, and the successive Demographic Health Surveys have ignored it. Most of the information on OFs has come from hospital-based and small-scale studies [4–15], and the same is true of the data on patterns in obstetric care. One of the most recent and outstanding surveys, conducted by EngenderHealth for UNFPA in October 2002, captured the characteristics of fistula care as it is delivered across the country [3]. The survey revealed that: • About 33 surgeons were providing fistula repair services • About 2286 fistula repairs were performed annually across the country • About 155 (6.8%) of all fistula repairs were performed annually at the country's University Teaching hospitals, implying that each of the 25 teaching hospital surgeons performed, on average, 6 repairs per year • About 2131 (93.2%) of the repairs were performed annually at the fistula centers, with each of their collective 8 surgeons performing, on average, 266 repairs per year • About 57.5% of the repairs were performed at 3 fistula centers and 3 teaching hospitals located in the North– West zone, one of the 6 geopolitical zones of the country; the survey did not report fistula activities from the North– East and South–East zones, suggesting that few or no fistulas were repaired in these 2 zones • Treatment at the fistula centers was essentially free, whereas the median cost of a fistula repair at the teaching hospitals was 166 US dollars (range, 90–50 US dollars) (the Nigerian per capita income at the time of the survey was 310 US dollars per year) [3].
O.S. Shittu et al. The most recent strategy for addressing the problem in Nigeria was the Fistula Campaign organized by UNFPA in February 2005. It involved assembling, for a specified time, fistula surgeons and patients at designated fistula centers. In that first campaign 564 women with OFs were surgically treated, with 87% of success [1,2]. Performed within a fortnight, this remarkable number of repairs would have taken about 4 months at the prevailing pace. Most of the Nigerian fistula surgeons operate at teaching hospitals, where very few women with fistulas seek treatment because of the high service charges. This situation reflects a generally ineffective use of the resources allocated to fistula repair. The high performance of the Fistula Campaign in Nigeria confirms that the absence of a nationwide, coordinated effort is hindering fistula control in this country, and clearly designates the Campaign as a model to draw from. The recent development of a “National strategic framework and plan for VVF [vesico-vaginal fistula] eradication in Nigeria” confirms this view; more significantly, as a manifestation of a positive government response, it needs to be vigorously pursued [11]. When the approach to be implemented nationwide is determined, the strategies and costs involved at the regular fistula centers and during the Fistula Campaign should be compared. The fact that Nigerian surgeons served as volunteers during the last fistula campaign will benefit any national approach.
3. Present postoperative care There are few surgical operations where postoperative care is as critical for success. Marion Sims' remarkable success over his predecessors was attributed to his adherence to 5 postoperative requisites: “a tin catheter for continuous drainage; quiescent bowel for 10 to 15 days; opium analgesia; normal fluid intake; and perineum irrigation” [17]. These have remained the “ingredients” to the recipe for the successful management of repaired fistulas. The current standard of postoperative care could be categorized into 3 phases: (A) early postoperative care (the catheterization period); (B) late postoperative care (the postcatheterization period); and (C) the treatment of conditions associated with the fistula.
3.1. Early postoperative care 3.1.1. Catheterization Continuous bladder drainage is considered essential to proper healing as it maintains the repair site free of tension and allows the bladder to rest. Most fistula surgeons use a transurethral catheter except when urethral reconstruction has been performed; in such cases, a suprapubic catheter is often used [4,7,10,15,16]. Moreover, a suprapubic catheter and a transurethral catheter are both used following a transabdominal fistula repair to permit bladder irrigation and the elimination of blood and clots. The ideal type of catheter for bladder irrigation is the 3way Foley catheter, but it is seldom available in Nigeria because it is more expensive than the 2-way type. The 2-way Foley catheter will probably remain in use unless it is found to have adverse effects.
A review of postoperative care for obstetric fistulas in Nigeria In most fistulas repairs, the Foley catheter is maintained in place by its inflated balloon. However, to avoid exerting pressure on the repair site when the operation involved the bladder neck (large juxtaurethral fistulas or fistulas with circumferential tissue loss), surgeons stitch the catheter to the labia using the Charlewood or another technique [15,16]. The duration of catheterization for a primary fistula repair is usually about 14 days, but it is 21 days if a urethral reconstruction or bladder-neck repair was performed or a postoperative leakage has occurred. These intervals are based on experience but have no scientific explanation. Whether shorter intervals are possible, especially with the recent advances in suture technology, will have to be determined from carefully designed prospective studies. Although in Nigeria most fistula surgeons connect catheters to closed urine bags that are periodically emptied, catheters are made to drain into open receptacles placed at the foot of the patient's bed at some fistula centers [3,5,9]. This practice involves the patient in the monitoring and emptying of her urine, but concerns have been raised about the untidiness of these open drains and the risks of retrograde urinary tract infection. Until these issues are resolved, the closed drainage system will be advocated for all settings in Nigeria. 3.1.2. Vaginal pack Applying a vaginal pack as a tamponade to obliterate any postoperative dead space at repair sites is not universally done, as the usefulness of the practice is uncertain. It is always removed within 48 h [3,5,16,18]. 3.1.3. Pain relief Irrespective of the form of anesthesia used during the repair, postoperative pain relief is ethically imperative. Strong analgesics (narcotics such as pethidine or morphine) are administered every 6 h for 24 to 48 h, after which paracetamol is given orally for 2 days. 3.1.4. Fluid intake Adequate fluid intake is essential for successful fistula repair, as ample urine secretion is needed to prevent clot formation, catheter occlusion, urine stasis, infection, and stone formation. A urine output of at least 100 mL per hour is regarded as the appropriate target [5,16,18]. Consequently, in a tropical environment, where the daily insensible fluid loss is about 2000 mL, the daily need for the fistula patient is about 4000 mL. An intravenous infusion is given for the first 24 to 48 h. Once oral intake is tolerated, the patients are instructed to drink water liberally, usually from jars kept at their bedside. 3.1.5. Urine output monitoring The need for close urine output monitoring cannot be overemphasized. It serves as an early indicator of a catheter blockage, of ureteric ligation, or of impaired renal secretion. The frequency of urine output monitoring differs from one facility to another in Nigeria. The persistent passage of clots warrants an irrigation of the bladder with a citrated solution. Whenever urine outflow is decreased or has ceased, the patient is examined to exclude any of the following causes, in this sequence: external compression of the catheter; catheter kinks; catheter blockage from clots or sediment; ureteric obstruction (from ligation or edema); or diminished
S81 urine secretion. The directions compiled in Table 1 can serve as a guide for distinguishing the causes and rectifying the problem. 3.1.6. Antimicrobial use Whereas some surgeons do not use antimicrobial agents unless there is a clinical infection [3,5,9], others use them prophylactically [3,5,9,10,13,15]. At teaching hospitals, the common practice is to perform a routine preoperative urine culture to determine bacterial sensitivity and the appropriate antimicrobial agent to administer. The prophylactic treatment is continued during the postoperative period. In the postoperative period, urine cultures are usually repeated every 2 to 3 days, the final culture being of the tip of the removed catheter. Until a large-scale study is performed on microbial urinary tract patterns in fistula patients, the prophylactic use of affordable broad-spectrum antimicrobial agents (such as cotrimoxazole and nitrofurantoin) may have to be adopted for the duration of the catheterization period in large-scale fistula care protocols. 3.1.7. Patient ambulation The principle that early ambulation stems thrombo-embolic complications and pressure sores after pelvic surgery applies to fistula patients, especially when the repair was done transabdominally. The practice is customized to suit the specific needs of patients, who ambulate as early as the next day if they underwent repair for a simple fistula. Those who had transabdominal surgery for bladder neck and/or urethral reconstruction wait longer [4,7,8,10], but these time intervals are experiential. 3.1.8. Vulvo-vaginal toileting This care is considered necessary. Nurses trained in the care of women with OFs use irrigation techniques to clean the vulva and perineum of blood, menstrual effluent, and any other discharge or debris with warm water or a diluted antiseptic solution each day and after bowel movements.
3.2. Late postoperative care 3.2.1. Determination of repair outcome From the patient's point of view, the success of her fistula repair is determined by the restoration of her urinary continence; from the surgeon's point of view, however, the definition of success is much less precise. Although, from the reports, the rate of success ranges between 72% and 92%, there is no universal criterion for declaring success. For some surgeons success is the confirmation that a fistula is closed and for others it is the restoration of complete continence. With the latter criterion the surgery would be categorized as a failure if a patient experienced postrepair stress incontinence, whereas with the former criterion the surgery would be categorized as a success. It is necessary to harmonize criteria to facilitate meaningful comparisons of treatment outcomes. The patient-centered criterion of continence restoration should be the one universally adopted when fistula treatments are evaluated. When the intended period of continuous bladder drainage is over, the catheter is removed and the patient examined to assess the outcome of the surgical repair. About 2 h after
S82 Table 1
O.S. Shittu et al. Guidelines for identifying and remedying postoperative urine outflow problems
Guideline sequence no.
Likely cause of reduced urine outflow
Observable features
Recommended action
1
External compression of catheter system Catheter kinks
• The patient lies on the catheter or drainage tube
• Redirecting the drainage system to pass over the patient's thighs
• Examination of the entire drainage system for any acute angulations (this is more likely with the small-sized catheters) • External factors excluded, but urine outflow not resumed
• Ensuring that no curvature of the drainage system is less than 120°.
2
3
4
Internal catheter blockage
Ureteric obstruction
• Suprapubic percussion suggests urine within bladder but gentle pressure does not move urine into catheter • Surgical repair that involved the trigone or any of the ureters • Loin pain • Vomiting • Persistent fever
5
Diminished renal secretion of urine
• • • • •
Abdominal distention (Increased creatinine level) Circulatory shock Increased creatinine Increased urea
Using aseptic means, sucking out suspected blockage with a 50-mL syringe connected to the catheter; if this fails, gently instilling a few mL of saline solution and resuming the procedure. • Once patency is restored, irrigating the bladder with a saline or sodium citrate solution • Referring the patient in the absence of facilities for imaging and/or laparotomy • Renal tract imaging: ultrasonography, intravenous urogram, CT scan or MRI (if available) • Strong clinical or radiologic suspicion mandates 2nd laparatomy to identify and free obstruction • (Prevention by routine catheterization of ureters if repair is proximal to them)
• Resuscitation • Dialysis (or referral for dialysis)
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.
removing the catheter, the vestibule is inspected for normality and the introitus for urine leakage and stress incontinence. If there is introital leakage, the outcome is reassessed following recatheterization for a further 7 to 10 days. The repair is declared successful in patients found to have no leakage or stress incontinence. The patients are then given bladder training to improve bladder capacity and voiding function. They initially void urine at hourly intervals, and the interval is progressively extended until a convenient schedule is attained [16]. On the other hand, the repair is declared only partially successful in patients left with stress incontinence after successful fistula closure. Regardless of whether the success of the repair was partial or complete, the patients are counseled on a wide range of topics regarding their future reproductive health [5,7,10,19]. Emphasis is placed on the following: Coitus should not resume for 3 months; unless a pregnancy is desired, contraceptives should be used when coitus is resumed; antenatal care should be sought as early as a pregnancy is suspected and medical history told to the clinic attendants; and any subsequent delivery should be by cesarean section—certainly no home delivery should ever be considered again. At this stage, the patient is discharged to her relatives if they are willing and supportive; otherwise, she is transferred to a rehabilitation center for further care.
3.2.2. Rehabilitation In Nigeria, all fistula centers and a few teaching hospitals (including the facilities where both lead authors work) have active rehabilitation programs where women are able to acquire elementary education and practical skills such as cooking, tailoring, knitting, and other craft-making that will empower them to earn their own living when they return home [12,20]. Social workers attached to these centers help the women renew their ties with their immediate relatives, and some women even return with their husbands. If the Millennium Development Goals are to be achieved, eliminating the poverty, illiteracy, and social isolation of these women needs to be more vigorously addressed through the provision of such services at every fistula care site.
4. Care of clinical conditions associated with OFs The overwhelming distress experienced by women with continual urinary incontinence often relegates coexisting conditions to the background until the fistula is repaired. These include obstetric palsy, secondary amenorrhea, and sexual dysfunction. Since the care of women with OFs should aim at restoring their reproductive health as well as their urinary continence, these conditions deserve intervention.
A review of postoperative care for obstetric fistulas in Nigeria
4.1. Obstetric palsy More than 15% of women with OFs have footdrop, which, like fistulas, arises from prolonged obstructed labor. Most cases of footdrop are unilateral [21,22]. Presently, only teaching hospitals are equipped with the facilities necessary for electrotherapy and proper physical rehabilitation. Even at these centers the shoe calipers and foot elevators needed for passive treatment are generally unavailable; and when they are available, few patients can afford using them. It is necessary to establish physiotherapy services at fistula centers where the bulk of the patients are seen, and other sites where fistula care is given will need to refer their patients.
4.2. Secondary amenorrhea Up to two-thirds of women with OFs also have secondary amenorrhea [7,10,21]. Investigating and treating secondary amenorrhea is beyond the scope of the services available at the fistula centers; and although some of the teaching hospitals are equipped to investigate such possible underlying causes as hypothalamic dysfunction, panhypopituitarism, and uterine synechiae, few patients are able to afford the treatment. Referral arrangements between fistula centers and the closest teaching hospitals will facilitate care for the more affluent patients.
4.3. Sexual dysfunction Whereas in the southern part of Nigeria most of the women with OFs can count on the support of their husbands [3,7,13,15], their northern counterparts are often divorced or separated [8,10,19,23]. In either situation, complaints of coital difficulties emerge after the mandatory 3-month postoperative period of abstinence. Gynatresia is the leading cause of such complaint, as it is present in about 10% of cases following fistula repair [7,8,10,24]. The surgeons skilled in vaginal plastic surgery are all employed by the teaching hospitals [18]; all that can be done at the other fistula treatment facilities is counsel the women and recommend the use of lubricants during sexual intercourse. Fortunately, intercourse with lubrication has been shown to be a superior therapy in the long term.
5. Conclusion The prevalence of OFs in Nigeria is among the highest in the world, and the situation will worsen unless the standards of obstetric care are improved and the rate of fistula repair greatly accelerated. Conducting a more detailed and nationwide survey to assess with workable precision OF prevalence in Nigeria will be an essential first step toward the meaningful planning of any nationwide intervention. Establishing more fistula centers and organizing more fistula campaigns are necessary to harness the enormous surgical expertise presently underutilized at the country's teaching hospitals. The “hightech,” expensive, and unaffordable postoperative protocol currently offered at the teaching hospitals needs to be scaled down in favor of the minimum but safe standard of postoperative care just proposed. The latter was designed to give
S83 not a few, but a multitude of women with fistulas a new chance at enjoying a normal reproductive health. It is needless to emphasize that increased funding is necessary for the provision of resources that will make a difference in the lives of these indigent and socially dislocated women, who may not otherwise benefit from the worldwide efforts aimed at achieving the Millennium Development Goals by 2015. Conflict of interest None. The authors have no financial or personal relationship with any of the persons or organizations that have prompted or encouraged the compilation of this work. Role of the funding source None.
References [1] United Nations Population Fund (UNFPA). Obstetric Fistula in Brief. www.endfistula.org/fistula_brief.htm, 2006. Accessed May 19, 2007. [2] United Nations Population Fund (UNFPA). Nigerian ‘Fistula Fortnight’. www.endfistula.org/fortnight, 2006. Accessed May 19, 2007. [3] United Nations Population Fund (UNFPA) and EngenderHealth. Obstetric fistula needs assessment: findings from nine African countries. New York, NY: UNFPA; 2003. p. 57–76. www.unfpa. org/profile/nigeria.cfm. Accessed May 19, 2007. [4] Lister UG. Obstructed labour: a series of 320 cases occurring over a 4-year period in a hospital in southern Nigeria. J Obstet Gynecol Br Emp 1960;67:188–95. [5] Ejembi CL, editor. The vesico-vaginal fistula scourge: a preventable social tragedy. Proceedings of the National Workshop on Vesico-Vaginal Fistula. Lagos, Nigeria: National Task Force on Vesico-Vaginal Fistula; 1995. [6] Tahzib F. Epidermiological determinants of vesico-vaginal fistulas. Br J Obstet Gynecol 1983;90:1291–3. [7] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(4):189–94. [8] Ghatak DP. A study of urinary fistulae in Sokoto, Nigeria. J Indian Med Assoc 1992;90(11):285–7. [9] Waaldijk K. Immediate indwelling bladder catheterization at post partum urine leakage: personal experience of 1,200 patients. Trop Doct 1997;27:227–8. [10] Wall LL, Kershima JA. The obstetric vesico-vaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011–9. [11] Federal Ministry of Health and the United Nations Population Fund (UNFPA). National Strategic Framework and Plan for VVF Eradication in Nigeria: 2005–2010. New York, NY: UNFPA; November 2005. [12] Shittu O, Ifenne D, Hord C. A hospital in Nigeria reinvents its reproductive health care system. In: Haberland N, Measham D, editors. Responding to Cairo: Case Studies of Changing practice in Reproductive Health and Family Planning. New York, NY: Population Council; 2002. p. 223–35. [13] Gharoro EP, Abedi HO. Vesico-vaginal fistula in Benin City, Nigeria. Int J Gynecol Obstet 1999;64:313–4. [14] Waaldijk K. Step-by-step surgery of vesico-vaginal fistulas. Edinburgh UN: Campion Press; 1994.
S84 [15] Iloabachie GC. 260 cases of juxtacervical fistula. East Afr Med J 1992;69:188–90. [16] Ekwempu CC. Fistulae. In: Agboola A, editor. Textbook of Obstetrics and Gynaecology for Medical Students, vol. 1. Lagos, Nigeria: University Services Educational Ltd; 1988. p. 46–59. [17] Sims JM. On the treatment of vesico-vaginal fistula. Am J Med Sci 1852;23:59. [18] Danso KA. Genital tract fistula. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Gynaecology in the Tropics. Accra, Ghana: Graphic Packaging Ltd; 2005. p. 174–81. [19] Harrison KA. Obstetric fistula: one social calamity too many. Br J Obstet Gynecol 1983;90:385–6.
O.S. Shittu et al. [20] Harrison KA. The importance of educated healthy women in Africa. Lancet 1997;349(9052):644–7. [21] Lewis Wall L. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of Northern Nigeria. Stud Fam Plann 1998;29(4):341–59. [22] Waaldijk K, Eklins TE. The obstetric fistula and peroneal nerve injury: an analysis of 947 consecutive patients. Int Urogynecol J Pelvic Floor Dysfunct 1994;5:12–4. [23] Murphy M. Social consequences of vesico-vaginal fistula in northern Nigeria. J Biosoc Sci 1981;13:139–50. [24] Ojengbede OA, Anifowose IO, Nylander PP. Coital problems of the urinary system in obstetrics urinary fistula. Trop J Obstet Gynaecol 1992;10(2):32–5.