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Obstetric fistulas: A clinical review
International Journal of Gynecology and Obstetrics (2007) 99, S40–S46
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
Obstetric fistulas: A clinical review A.A. Creanga a,⁎, R.R. Genadry b a
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA b Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
KEYWORDS Obstetric fistula; Obstructed labor; Recto-vaginal fistula; Vesico-vaginal fistula
Abstract A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repair’s effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The close embryologic development and anatomic proximity of the urinary and genital organs predispose them to associated injuries during surgical or radiation treatment and during traumatic deliveries. As a result, in women, fistulas may form between the urethra and vagina, the bladder and vagina, even the bladder and uterus, and they may also involve the rectum. A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged ⁎ Corresponding author. Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. Rm W4513, Baltimore, MD 21205, USA. Tel.: +1 410 502 7265; fax: +1 410 955 0792. E-mail address: [email protected] (A.A. Creanga).
obstructed labor coupled with a lack of medical attention. Obstetric fistulas are thus preventable. No reliable data are available on the true incidence of these fistulas worldwide. A high incidence is found in Africa and parts of Asia, but the risk of developing the condition exists wherever there is insufficient or unreliable emergency obstetric care. Very little has been published on obstetric fistulas and especially on their management. The need for more information on prevention and repair of obstetric fistulas is obvious. The objective of this article is to review the existent clinical and epidemiologic knowledge pertaining to obstetric fistulas, and identify issues that require immediate attention from both clinicians and policy makers. Two systematic reviews of the literature on obstetric fistulas were carried out. One looked at the clinical aspects associated with obstetric fistulas, including pathophysiology,
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.2007.06.021
Obstetric fistulas: A clinical review diagnosis, and the various surgical approaches to treatment as well as preoperative and postoperative care. The other looked at the epidemiologic aspects of obstetric fistulas. Overall, the review identified published studies containing any of the topics above mentioned. In the review of the literature on the epidemiology of the condition, all epidemiologic studies reporting on genitourinary fistulas were identified (the methodology is detailed in the article by Stanton and colleagues published in this IJGO supplement), and we retained for discussion in the present article only those meeting the following criteria. First, more than 80% of the cases reported on, needed to be obstetric fistulas. Second, data on the 5 socio-medical factors considered to have a high significance for clinicians needed to be present (i.e., age; parity; duration of labor; place of delivery and/or whether the delivery was attended by skilled or unskilled personnel; and the proportion of cesarean deliveries performed to release obstructed labor). We found only 5 studies that included data on these 5 factors; 7 other studies reported data on 4 of the factors, and an additional 7 reported data on only 3.
2. Pathophysiology The conditions favoring the development of an obstetric fistula have been discussed by many authors [1–3]. It has been hypothesized that women with fistulas are likely to have experienced labor before reaching full physical maturity because they were very young, suffered from poor nutrition, or had skeletal dysmaturity at the time of their first delivery. In a high proportion of women with obstetric fistulas the bladder neck or vault is involved, and these fistulas are probably due to cephalopelvic disproportion [4]. In areas of the world where female genital mutilation is common, the deliberately narrowed vaginal introitus may also be a cause of labor obstruction. Wherever labor obstruction, lack of transportation, scarcity of health facilities, or socio-cultural traditions impeding access to health care coincide, obstetric fistulas occur. In most cases, obstetric fistulas result from the pressure exerted by the presenting part of the fetus during a labor that sometimes lasts for several days [2,5–7]. The level at which fetal descent is arrested determines the site of injury in the lower urinary tract. As the pressure reduces blood supply to the soft tissues of the pelvis, extensive vascular injury leads to tissue necrosis, and then to the formation of an often large fistula, with scarring and reduced vascularity in the tissues adjacent to the defect [1]. As a result, most women with obstetric fistulas have injuries involving multiple organ systems. Arrowsmith et al. [1] characterized these injuries as part of a syndrome that they called the obstetric labor injury complex, which can involve the urologic, gynecologic, gastrointestinal, neurologic, and musculoskeletal systems. The authors compare obstetric fistulas to field injuries, which often result in large areas of ischemic tissue. For example a damaged urethra represents a technical challenge for surgeons, as only small amounts of viable tissue may be available for the construction of a neourethra [1]. Widespread destruction of the vagina and extensive scarring is associated with an increased risk of operative failure and/or postoperative stress incontinence [1,8]. Cervical injury is often encountered in women with fistulas, and prolonged obstructed labor may result in the complete loss of the cervix. The com-
S41 bination of vaginal scarring, cervical destruction, and, frequently, amenorrhea may lead to secondary infertility.
3. Epidemiology Many clinic-based studies have examined the roles of age, parity, and labor circumstances in the occurrence of obstetric fistulas, but the lack of standardized methods of data collection, evaluation, and reporting limits their value. For example, a woman’s age may be reported for the time of fistula occurrence or for the time of admission for repair; delivery location ignores the fact that the woman may have labored for days at home alone or with an unskilled attendant before she was delivered elsewhere; and self-reported duration of labor relies on the self-assessment of the start of active labor, which may not be precisely known and may differ among women. If, from the various reports, the age of women with obstetric fistulas ranges from 9 to 65 years, a vast majority of studies report a mean or median age, together with the percentage of patients younger than 16, 18, or 20 years (Table 1). In the 5 studies discussed in the present review—by Hilton and Ward [5], Ibrahim et al. [6], Wall et al. [2], Tahzib [7], and Kelly and Kwast [9]—the reported age was more often the age at the time of fistula repair. The percentage of primiparas with fistulas varied from 31.4% in the study of 2484 cases by Hilton and Ward [5] to 81.0% in the study of 31 cases by Ibrahim et al. [6]. Labor duration ranged from about 2.5 days [2,5] to 4 days [6]. The percentage of women with fistulas who were delivered at home ranged from 16.0% [6] to 64.4% [7]. While Kelly and Kwast [9] found that almost 61.0% of the women in their study were unattended or attended by an unskilled provider during the delivery that caused their fistulas, reports on the presence or absence of a professional during delivery are rare in the literature on obstetric fistulas. Yet, it is during labor that medical attention is most likely to prevent fistula formation. Among the 5 studies selected for this review, the percentage of cesarean deliveries performed to end an obstructed labor that caused a fistula varies from 6.7% of the 1443 women in Tahzib’s series [7] to 40.3% of the 932 women in Wall’s series [2]. The reported place of delivery and the percentage of women delivered by cesarean section are of significant importance. As noted, the percentage of women with fistulas whose deliveries took place at home, unattended or attended by an unskilled provider, varies greatly between studies but can be more than 60%. The present review found that between 7% and 40% of women seeking fistula repair were delivered by cesarean section, but obviously not in time to avoid the formation of a fistula. A lack of skilled medical personnel, health facilities, roads, and means of transportation delay the provision of appropriate obstetric care. And even when emergency obstetric care is available, financial and social barriers can prevent women from accessing it. Although obstetric fistulas are commonly seen as complications mainly of the first pregnancies, because physical immaturity is thought to be primarily responsible for obstetric fistula formation, in a large 1996 review of the literature on the epidemiology of obstetric fistulas Arrowsmith et al. [1] mentioned that 11.7% of patients treated at Addis Ababa Fistula Hospital had had 6 or more children. The mean age at fistula formation was 18.9 years (range, 12–50 years) and the mean age at which the women presented for treatment was 24.2 years (range, 12–76 years) [1].
S42
A.A. Creanga, R.R. Genadry
Table 1
Socio-medical risk factors associated with obstetric fistulas a
Author(s) (year)
No. of cases
Hilton and Ward (1998) Tahzib (1983)
2484
92.2
1443
83.8
Wall et al. (2004) Kelly and Kwast (1993)
932
96.5
309
97.4
Ibrahim et al. (2000)
31
100.0
a b
Obstetric causes, %
Mean age, years (patients younger than 16, 18 or 20 years, %)
Mean duration of labor, days
Primiparas (mean parity), %
Place of delivery, %
Cesarean delivery, %
28.0 (13.0 b 16, 32.0 b 20) 21.0 (32.9 b 16, 54.8 b 20) 27.0 b
2.5
31.4 (3.5)
34.0
3.0
52.0 (1.6)
2.4
45.8
22.4 (7.0 b 16, 42.0 b 20)
3.9
62.7
(60.0, 13–15) 90.0 b 18)
4.0
81.0
Home, 27.0 Hospital, 73.0 Home, 64.4 Hospital, 6.4 Home, 23.5 Hospital, 76.5 Home, alone or with an unskilled attendant, 60.8 Home, 16.0 Hospital, 84.0
6.7 40.3 7.3
13.0
The study by Kelly and Kwast reports data from Ethiopia whereas the other 4 studies report data from Nigeria. The median age was reported.
In comparison with the findings from African studies, the vast majority of which are from Ethiopia and Nigeria, Ahmad et al. [10] reported a higher age and a higher parity for women with fistulas in Pakistan, and a higher rate of fistulas in women who experienced repeated deliveries than in primiparas. Specifically in this study, less than 2.5% of the women with fistulas were younger than 16 years, and only about 14% were primiparas, whereas the corresponding rates were 32% and 52%, respectively, in a study that Hilton conducted in Nigeria [5]. Considering the clinical urgency associated with fistula formation and treatment, we must stress the need for accessible and affordable obstetric care; for skilled medical personnel able not only to attend to women giving birth but also to perform cesarean deliveries or, at least, refer women in a timely manner; and for surgeons trained to repair obstetric fistulas as rapidly as possible to prevent the negative social consequences of obstetric fistulas.
4. Diagnosis Characteristically, women with fistulas present with continual urinary and/or fecal incontinence, or only at night. If leakage is not obvious on initial examination, methylene blue can help identify the site or sites. Under sedation or anesthesia, tissue condition and mobility are assessed, as well as the feasibility of a vaginal repair. The latter assessment is particularly important in women who already underwent attempts at fistula repair.
5. Classification To date there is no standardized classification system for obstetric fistulas. Various authors have focused on different characteristics of fistulas and emphasized important elements. This lack of standardization precludes comparative analyses of surgical treatment and outcome across studies, and such analyses are needed to identify the best management of women affected with fistulas. Of the 25 classification systems this review identified for genitourinary fistulas, 7 for vesico-
vaginal fistulas and 1 for recto-vaginal fistulas are described in Table 2. These are the most recent and most cited systems. Over the decades, authors have proposed factors to consider for the creation of a classification for genitourinary fistulas that would be easy to learn and apply, among these are, the type, location, number, and size (length and width of the fistula); involvement of other organs; degree of vaginal scarring; attachment of the fistula to the pelvic wall; condition of the urethral sphincter and permeability of the internal orifice of the urethra; location of ureteral orifices and their relation to the edges of the fistula; and presence of complications such as a recto-vaginal fistula and inflammatory lesions of the pelvis, vagina, vulva, or peritoneum. The 2 most recent classification systems for vesicovaginal fistulas were proposed by Waaldijk in 1995 [11] and Goh in 2004 [12]. Waaldijk considers the involvement of the continence mechanism and the degree of damage of the urethra, whereas Goh uses fixed points of reference and divides vesico-vaginal fistulas into 4 classes. The classes are based on the distance of the distal edge of the fistula to the external urinary meatus, and are further subdivided according to size, extent of scarring, vaginal length and/or capacity, or any other particular consideration [12].
6. Management Data suggest that the first repair attempt is likely to be the most successful [13,14]. Although there are reports of successful conservative management with prolonged bladder drainage, mature obstetric fistulas require formal operative repairs.
6.1. Timing of surgical repair The importance of timing for surgical repair has long been emphasized because of its association with the quality of the tissues in need of repair. Authors used to recommend an interval of at least 3 to 6 months between injury and repair; in recent years, however, immediate repair has been advocated to prevent the ostracism often experienced by
Obstetric fistulas: A clinical review Table 2 Year
S43
Classification systems proposed for obstetric fistulas Author
Classification Vesico-vaginal fistulas
1972
Lawson
1992
Gueye
1994
Elkins
1995
Waaldijk
2004
Browning
2004
Goh
1. Juxtaurethral 2. Vault 3. Midvaginal 4. Juxtacervical 1. Simple: far from the ureters, urethra intact 2. Complex: partial or total loss of the urethra 3. Complicated: total loss of the urethra, with or without a recto-vaginal fistula 1. Vesico-cervical 2. Juxtacervical 3. Midvaginal vesico-vaginal 4. Suburethral vesico-vaginal 5. Urethro-vaginal Type I: Does not involve the urethral closing mechanism Type IIAa: Involves the urethral closing mechanism, without (sub)total urethral involvement and without circumferential defect Type IIAb: Involves the urethral closing mechanism, without (sub)total urethral involvement and with circumferential defect Type IIBa: Involves the urethral closing mechanism, with (sub)total urethral involvement and without circumferential defect Type IIBb: Involves the urethral closing mechanism, with (sub)total urethral involvement and with circumferential defect Type III: Involves the ureter; other exceptional fistulas 1. Simple: Minimal vaginal scarring and good bladder volume 2. Complex: Severe vaginal scarring and/or reduced bladder volume needing some degree of vaginoplasty or even reconstruction of the vagina Type 1: Distal edge N 3.5 cm from external urinary meatus Type 2: Distal edge 2.5–3.5 cm from external urinary meatus Type 3: Distal edge 1.5 to b2.5 cm from external urinary meatus Type 4: Distal edge b 1.5 cm from external urinary meatus (a) Size b 1.5 cm in the largest diameter (b) Size, 1.5–3 cm in the largest diameter (c) Size N 3 cm in the largest diameter i. None or only mild fibrosis (around the fistula and/or vagina), and/or vaginal length N 6 cm with normal capacity ii. Moderate or severe fibrosis (around the fistula and/or vagina), and/or reduced vaginal length and/or capacity iii. Special consideration, e.g., postradiation, ureteric involvement, circumferential fistula, or previous repair Recto-vaginal fistulas
2004
Goh
Type 1: Distal edge of fistula N 3.5 cm from hymen Type 2: Distal edge of fistula N 3.5 cm from hymen Type 3: Distal edge of fistula N 3.5 cm from hymen Type 4: Distal edge of fistula N 3.5 cm from hymen (a) Size b 1.5 cm in the largest diameter (b) Size, 1.5–3 cm in the largest diameter (c) Size N 3 cm in the largest diameter i. No or mild fibrosis around the fistula and/or vagina ii. Moderate or severe fibrosis iii. Special consideration, e.g., postradiation, inflammatory disease, malignancy, or previous repair
women with obstetric fistulas. Waaldijk [15] prospectively treated 170 women with a fistula of less than 3 months’ duration to determine the effectiveness of immediate management by catheter and/or early closure. Closure was obtained in 156 women, of whom 93.6% became continent,
4.5% became minimally or mildly incontinent, and 1.9% remained severely incontinent. However, in developing countries, women are often malnourished and anemic, have intestinal parasites or other debilitating conditions. This is why many authors stress the
S44 importance of screening the women for schistosomiasis, tuberculosis, lymphogranuloma, and any other condition requiring prompt treatment prior to fistula repair. Furthermore, contracture of the hip or unilateral or bilateral footdrop may be present in women with fistulas, who also may adopt the fetal position because they are too weak to move. When bladder stones were present, Ahmad et al. postponed the repair for 6 weeks [10]. Additionally, prolonged physiotherapy may be required to allow proper access to the vagina during surgical repair. Antibiotic prophylaxis deserves careful consideration. A randomized controlled trial of women undergoing vesico-vaginal fistula repair was conducted in West Africa [16]. The participants in the prophylaxis group received 500 mg of ampicillin intraoperatively whereas the controls received no antibiotics. The use of antibiotics did not reduce the odds of repair failure (odds ratio, 2.1; 95% confidence interval, 0.75–6.1) or of objective incontinence (odds ratio, 1.9; 95% confidence interval, 0.72–5.1), but women in the prophylaxis group received fewer doses of antibiotics postoperatively and had fewer urinary infections on the 10th day after surgery [16].
6.2. Surgical approaches to fistula repair The literature reports 3 main approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal, but laparoscopy may soon offer alternative approaches. 6.2.1. The vaginal route The vaginal route seems to be associated with less blood loss and pain, fewer operative complications, and shorter hospital stay, allowing for rapid recovery, but it may be associated with vaginal shortening and scarring. The vaginal approach is contraindicated when the vaginal epithelium around the fistula is severely indurated; the bladder has a small capacity and is poorly compliant; vaginal stenosis is present; other pelvic structures are involved; or when the repair requires ureteral reimplantation. A layered closure is the preferred method, whether a vascular flap or urethral reconstruction is needed or not. 6.2.2. The abdominal route The abdominal route is frequently preferred for complex fistulas. Absolute indications include a small-capacity or poorly compliant bladder requiring simultaneous bladder augmentation; the involvement of other abdominal viscera in addition to the bladder; ureteral orifices requiring ureteral reimplantation; high fistulas that are inadequately exposed; vaginal stenosis or adverse musculoskeletal conditions [17]. An associated pelvic pathology or the presence of multiple fistulas may also require an abdominal approach. Abdominal approaches may be extraperitoneal or intraperitoneal. When bladder augmentation is required for complicated fistulas, the bowel segments used are anastomosed to the bladder. The disadvantages associated with this approach are mostly related to increased costs and a higher rate of postoperative complications.
A.A. Creanga, R.R. Genadry layer in the repair, fill dead space, and bring a new blood supply to the area. The tissues used include labial fat and bulbocavernosus muscle in a procedure known as the Martius graft. Other procedures can use a gracilis muscle graft, an omental pedicle graft, a peritoneal flap graft, a pedicled flap of the vaginal wall, and a free bladder mucosal graft. Rangnekar et al. [18] retrospectively evaluated the outcomes of fistula repair procedures in Mumbai, India. The Martius graft was employed in 21 of a total of 46 cases of obstetric fistulas, 12 urethro-vaginal and 34 vesico-vaginal. Overall, 95% of the fistulas treated with the graft were cured, compared with 72% of those treated with a simple anatomic repair.
7. Postoperative care Recovery varies with the extent of the repair. Authors agree that the bladder should be continuously and completely drained for at least 10 days postoperatively, and up to 2 to 3 weeks. Adequate postoperative drainage of the bladder via a urethral or suprapubic catheter, or both, is recommended. Carr and Webster [17] prefer to use only a suprapubic bladder drain, which, if appropriately positioned, reduces bladder spasms and patient discomfort, and thus prevents premature catheter removal. Women are advised not to resume sexual activity for 3 to 4 months to give the tissues sufficient time to heal [14].
8. Surgical outcomes Because there is no standardized definition of success following obstetric fistula repair, the reporting of surgical outcomes varies by author. Most authors, however, report as success the surgical closure of the fistula at the time of hospital discharge, without further evaluation of the effect of the procedure on continence or patient’s subsequent quality of life. In his review, Kelly [3] reported a success rate of 58% to 90% based on the surgical closure of obstetric fistulas, and more than a decade later Cron [19] considered that 85% of vesico-vaginal fistulas could be repaired successfully at the first attempt, and that closure rates were similar with the transvaginal or the transabdominal route. Various authors agree that primary repair failure is more common when the fistula is large, especially when it involves the urethra and/ or rectum in a circumferential fashion. In 1995, Rathee and Nanda [20] related the success rate of fistula closure to the degree of fibrosis present at the fistula site, and noted that the closure rate for fistulas with no fibrosis was 100%, compared to 16.7% for fistulas with marked fibrosis. The results of fistula surgery are influenced by a variety of factors including fistula site and size, and the degree of scarring. Additionally, Kelly [14] mentions the number of previous repair attempts, the severity of the lesions, the overall health of the patient, the availability of health facilities, and the experience and expertise of the surgeon as important factors for a successful surgical closure of obstetric fistulas.
9. Postoperative complications 6.2.3. The combined transabdominal/transvaginal route A combined route may be indicated in some cases. Several techniques have been described to perform fistula repair at different sites. Interposed tissue serves to create an additional
The most common postoperative complications of obstetric fistulas are presented in Table 3. Despite the high success rates reported for fistula closure, persistent urinary incontinence
Obstetric fistulas: A clinical review Table 3
Postoperative complications of fistula surgery
Amenorrhea Anuria (total loss of urination) Atresia Bladder stones Gynatresia (occlusion of some part of the genital tract, especially of the vagina; Asherman syndrome) Incontinence (urinary or fecal) Leg weakness Reduced bladder capacity Superficial wound infection Ureteric injury Urinary retention Urinary tract infection
following surgery occurs in a large proportion of women. Postoperative incontinence is more common after urethral reconstruction for total destruction of the urethra, repair of a urethro-vaginal fistula, or repair of a fistula involving the bladder neck [1]. Waaldijk [21] notes that the critical urethra length for continence seems to be between 1.5 and 2 cm, and that with a length of 1.5 cm or less a woman has little chance of becoming continent once the fistula is surgically closed. Based on his experience at the Fistula Hospital in Addis Ababa, Ethiopia, Browning [22] found that women with low vaginal fistulas could be divided into 2 groups: those with simple fistulas, who have minimal vaginal scarring and an appropriate bladder volume; and those with more complex fistulas, who present with severe vaginal scarring and/or reduced bladder volume. These characteristics appear to influence the presence or absence of residual incontinence postoperatively. Of 318 women with simple fistulas in Browning’s study, 50% remained urinary incontinent in the immediate postoperative period whereas all of the women with complex fistulas did so [22]. The term gynatresia refers to foreshortened and stenotic vaginas following fistula repair. In 1994, Elkins [23] reported gynatresia following the repair of 8 of the 16 large fistulas (N 4 cm) surgically treated in a series of 100 women, and in a study published in 2004, Ijaiya and Aboyeji observed gynatresia from vaginal fibrosis in 2.9% of the women surgically treated at their hospital over 10 years [24]. Hilton and Ward [5] noted that normal menstruation may return rapidly after successful surgical repair, but that it may also be delayed for several years or never return. In their review, the mean time to presentation for surgical repair for women who had resumed menstruating was 51 months, compared with 23.4 months for those who had not [5]. The authors hypothesized that fistula formation had a suppressive effect on the hypothalamus, which tended to resolve spontaneously after 2 years even if the fistula remained untreated. On the other hand, in a 1978 Nigerian study of 66 women who were amenorrheic for several months to 15 years before successful fistula repair, 55 were menstruating again within 6 months of the repair [25]. Many authors emphasize that women who underwent fistula repair should always be delivered by cesarean section. However, in a report by Kelly [14] on 33 women who became pregnant within 1 year of fistula repair, 12 were delivered vaginally without damage to the repair. The criteria Kelley
S45 used for attempting vaginal delivery included a nonrecurring cause for the fistula, the use of an interposition graft in the repair, and skilled labor supervision.
10. In the presence of recto-vaginal fistulas Vesico-vaginal fistulas alone are far more common than recto-vaginal fistulas alone or combined vesico-vaginal and recto-vaginal fistulas. In 1992 Kelly [26] reported on 716 women whom he treated for fistulas (not all of obstetric origin), 578 in Africa and 138 in Britain. In 78% of the women the fistulas were vesico-vaginal, in 17% they were combined vesico-vaginal and recto-vaginal, and in 4% they were recto-vaginal. In general, repair is less successful for recto-vaginal than for vesico-vaginal fistulas. However, the rate of successful surgical closure is the same for recto-vaginal fistulas alone and for rectovaginal fistulas combined with vesico-vaginal fistulas [1]. An anatomical classification has been developed to guide selection for the most appropriate surgical procedure for recto-vaginal fistula repair [27]. When they involve the upper third of the vagina, routinely performing diverting colostomies might improve the success rate of repair. However, colostomies are not easily accepted culturally, and procuring colostomy bags and related supplies would make this option impractical in the developing world. Although women may experience persistent stress incontinence after the successful closure of a vesico-vaginal fistula, it is not frequently reported that women with a successfully closed recto-vaginal fistula continue to experience fecal loss because of a defective anal sphincter [1].
11. Conclusion Data on obstetric fistulas are scarce. A standardized terminology, classification, and system for reporting data pertaining to the surgical management of obstetric fistulas and its outcomes, are urgently needed. Better differentiation between simple and complex fistulas would indicate both the severity of the lesions and the degree of surgical care and expertise required for repair, and result in improved patient care. The need for emergency obstetric care, skilled medical personnel, and trained fistula surgeons merit its place on the agenda of policy makers in developing countries, especially in countries where obstructed labor and obstetric fistulas are known to be prevalent. Role of the funding source None. Conflict of interest None.
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S46 [2] Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190(4):1011–9. [3] Kelly J. Fistulae of obstetric origin. Midwifery 1991;7(2):71–3. [4] Murray C, Goh JT, Fynes M, Craey MP. Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula. BJOG 2002;109(7):828–32. [5] 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. [6] Ibrahim T, Sadiq AU, Daniel SO. Characteristics of VVF patients as seen at the specialist hospital Sokoto, Nigeria. West Afr J Med 2000;19(1):59–63. [7] Tahzib F. Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynecol 1983;90(5):387–91. [8] Margolis T, Mercer LJ. Vesicovaginal fistula [review]. Obstet Gynecol Surv 1994;49(12):840–7. [9] Kelly J, Kwast BE. Epidemiologic study of vesico-vaginal fistulas in Ethiopia. Int Urogynecol J 1993;4:278–81. [10] Ahmad S, Nishtar A, Hafeez GA, Khan Z. Management of vesicovaginal fistulas in women. Int J Gynecol Obstet 2005;88 (1):71–5. [11] Waaldijk K. Surgical classification of obstetric fistulas. Int J Gynecol Obstet 1995;49(2):161–3. [12] Goh JT. A new classification for female genital tract fistula. Aust N Z J Obstet Gynecol 2004;44(6):502–4. [13] Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003;48(3):295–304. [14] Kelly J. Vesicovaginal fistulae. Br J Urol 1979;51(3):208–10. [15] Waaldijk K. The immediate surgical management of fresh obstetric fistulas with catheter and/or early closure. Int J Gynecol Obstet 1994;45(1):11–6.
A.A. Creanga, R.R. Genadry [16] Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. Br J Obstet Gynecol 1998;105(4):397–9. [17] Carr LK, Webster GD. Abdominal repair of vesicovaginal fistula. Urology 1996;48(1):10–1. [18] Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary–vaginal fistulas. J Am Coll Surg 2000;191(3):259–63. [19] Cron J. Lessons from the developing world: obstructed labor and the vesico-vaginal fistula. MedGenMed 2003;5(3):24. [20] Rathee S, Nanda S. Vesicovaginal fistulae: a 12-year study. J Indian Med Assoc 1995;93(3):93–4. [21] Waaldijk K. The immediate management of fresh obstetric fistulas. Am J Obstet Gynecol 2004;191(3):795–9. [22] Browning A. Prevention of residual urinary incontinence following successful repair of obstetric vesico-vaginal fistula using a fibro-muscular sling. BJOG 2004;111(4):357–61. [23] Elkins TE. Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol 1994;170(4):1108–18 [Discussion: 1118–1120]. [24] Ijaiya MA, Aboyeji PA. Obstetric urogenital fistula: the Ilorin experience, Nigeria. West Afr J Med 2004;23(1):7–9. [25] Evoh NJ, Akinla O. Reproductive performance after the repair of obstetric vesico-vaginal fistulae. Ann Clin Res 1978;10 (6):303–6. [26] Kelly J. Vesico-vaginal and recto-vaginal fistulae. J R Soc Med 1992;85(5):257–8. [27] Rosenshein NB, Genadry RR, Woodruff JD. An anatomic classification of rectovaginal septal defects. Am J Obstet Gynecol 1980;137:439–42.
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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
Obstetric fistulas: A clinical review A.A. Creanga a,⁎, R.R. Genadry b a
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA b Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
KEYWORDS Obstetric fistula; Obstructed labor; Recto-vaginal fistula; Vesico-vaginal fistula
Abstract A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repair’s effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The close embryologic development and anatomic proximity of the urinary and genital organs predispose them to associated injuries during surgical or radiation treatment and during traumatic deliveries. As a result, in women, fistulas may form between the urethra and vagina, the bladder and vagina, even the bladder and uterus, and they may also involve the rectum. A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged ⁎ Corresponding author. Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. Rm W4513, Baltimore, MD 21205, USA. Tel.: +1 410 502 7265; fax: +1 410 955 0792. E-mail address: [email protected] (A.A. Creanga).
obstructed labor coupled with a lack of medical attention. Obstetric fistulas are thus preventable. No reliable data are available on the true incidence of these fistulas worldwide. A high incidence is found in Africa and parts of Asia, but the risk of developing the condition exists wherever there is insufficient or unreliable emergency obstetric care. Very little has been published on obstetric fistulas and especially on their management. The need for more information on prevention and repair of obstetric fistulas is obvious. The objective of this article is to review the existent clinical and epidemiologic knowledge pertaining to obstetric fistulas, and identify issues that require immediate attention from both clinicians and policy makers. Two systematic reviews of the literature on obstetric fistulas were carried out. One looked at the clinical aspects associated with obstetric fistulas, including pathophysiology,
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.2007.06.021
Obstetric fistulas: A clinical review diagnosis, and the various surgical approaches to treatment as well as preoperative and postoperative care. The other looked at the epidemiologic aspects of obstetric fistulas. Overall, the review identified published studies containing any of the topics above mentioned. In the review of the literature on the epidemiology of the condition, all epidemiologic studies reporting on genitourinary fistulas were identified (the methodology is detailed in the article by Stanton and colleagues published in this IJGO supplement), and we retained for discussion in the present article only those meeting the following criteria. First, more than 80% of the cases reported on, needed to be obstetric fistulas. Second, data on the 5 socio-medical factors considered to have a high significance for clinicians needed to be present (i.e., age; parity; duration of labor; place of delivery and/or whether the delivery was attended by skilled or unskilled personnel; and the proportion of cesarean deliveries performed to release obstructed labor). We found only 5 studies that included data on these 5 factors; 7 other studies reported data on 4 of the factors, and an additional 7 reported data on only 3.
2. Pathophysiology The conditions favoring the development of an obstetric fistula have been discussed by many authors [1–3]. It has been hypothesized that women with fistulas are likely to have experienced labor before reaching full physical maturity because they were very young, suffered from poor nutrition, or had skeletal dysmaturity at the time of their first delivery. In a high proportion of women with obstetric fistulas the bladder neck or vault is involved, and these fistulas are probably due to cephalopelvic disproportion [4]. In areas of the world where female genital mutilation is common, the deliberately narrowed vaginal introitus may also be a cause of labor obstruction. Wherever labor obstruction, lack of transportation, scarcity of health facilities, or socio-cultural traditions impeding access to health care coincide, obstetric fistulas occur. In most cases, obstetric fistulas result from the pressure exerted by the presenting part of the fetus during a labor that sometimes lasts for several days [2,5–7]. The level at which fetal descent is arrested determines the site of injury in the lower urinary tract. As the pressure reduces blood supply to the soft tissues of the pelvis, extensive vascular injury leads to tissue necrosis, and then to the formation of an often large fistula, with scarring and reduced vascularity in the tissues adjacent to the defect [1]. As a result, most women with obstetric fistulas have injuries involving multiple organ systems. Arrowsmith et al. [1] characterized these injuries as part of a syndrome that they called the obstetric labor injury complex, which can involve the urologic, gynecologic, gastrointestinal, neurologic, and musculoskeletal systems. The authors compare obstetric fistulas to field injuries, which often result in large areas of ischemic tissue. For example a damaged urethra represents a technical challenge for surgeons, as only small amounts of viable tissue may be available for the construction of a neourethra [1]. Widespread destruction of the vagina and extensive scarring is associated with an increased risk of operative failure and/or postoperative stress incontinence [1,8]. Cervical injury is often encountered in women with fistulas, and prolonged obstructed labor may result in the complete loss of the cervix. The com-
S41 bination of vaginal scarring, cervical destruction, and, frequently, amenorrhea may lead to secondary infertility.
3. Epidemiology Many clinic-based studies have examined the roles of age, parity, and labor circumstances in the occurrence of obstetric fistulas, but the lack of standardized methods of data collection, evaluation, and reporting limits their value. For example, a woman’s age may be reported for the time of fistula occurrence or for the time of admission for repair; delivery location ignores the fact that the woman may have labored for days at home alone or with an unskilled attendant before she was delivered elsewhere; and self-reported duration of labor relies on the self-assessment of the start of active labor, which may not be precisely known and may differ among women. If, from the various reports, the age of women with obstetric fistulas ranges from 9 to 65 years, a vast majority of studies report a mean or median age, together with the percentage of patients younger than 16, 18, or 20 years (Table 1). In the 5 studies discussed in the present review—by Hilton and Ward [5], Ibrahim et al. [6], Wall et al. [2], Tahzib [7], and Kelly and Kwast [9]—the reported age was more often the age at the time of fistula repair. The percentage of primiparas with fistulas varied from 31.4% in the study of 2484 cases by Hilton and Ward [5] to 81.0% in the study of 31 cases by Ibrahim et al. [6]. Labor duration ranged from about 2.5 days [2,5] to 4 days [6]. The percentage of women with fistulas who were delivered at home ranged from 16.0% [6] to 64.4% [7]. While Kelly and Kwast [9] found that almost 61.0% of the women in their study were unattended or attended by an unskilled provider during the delivery that caused their fistulas, reports on the presence or absence of a professional during delivery are rare in the literature on obstetric fistulas. Yet, it is during labor that medical attention is most likely to prevent fistula formation. Among the 5 studies selected for this review, the percentage of cesarean deliveries performed to end an obstructed labor that caused a fistula varies from 6.7% of the 1443 women in Tahzib’s series [7] to 40.3% of the 932 women in Wall’s series [2]. The reported place of delivery and the percentage of women delivered by cesarean section are of significant importance. As noted, the percentage of women with fistulas whose deliveries took place at home, unattended or attended by an unskilled provider, varies greatly between studies but can be more than 60%. The present review found that between 7% and 40% of women seeking fistula repair were delivered by cesarean section, but obviously not in time to avoid the formation of a fistula. A lack of skilled medical personnel, health facilities, roads, and means of transportation delay the provision of appropriate obstetric care. And even when emergency obstetric care is available, financial and social barriers can prevent women from accessing it. Although obstetric fistulas are commonly seen as complications mainly of the first pregnancies, because physical immaturity is thought to be primarily responsible for obstetric fistula formation, in a large 1996 review of the literature on the epidemiology of obstetric fistulas Arrowsmith et al. [1] mentioned that 11.7% of patients treated at Addis Ababa Fistula Hospital had had 6 or more children. The mean age at fistula formation was 18.9 years (range, 12–50 years) and the mean age at which the women presented for treatment was 24.2 years (range, 12–76 years) [1].
S42
A.A. Creanga, R.R. Genadry
Table 1
Socio-medical risk factors associated with obstetric fistulas a
Author(s) (year)
No. of cases
Hilton and Ward (1998) Tahzib (1983)
2484
92.2
1443
83.8
Wall et al. (2004) Kelly and Kwast (1993)
932
96.5
309
97.4
Ibrahim et al. (2000)
31
100.0
a b
Obstetric causes, %
Mean age, years (patients younger than 16, 18 or 20 years, %)
Mean duration of labor, days
Primiparas (mean parity), %
Place of delivery, %
Cesarean delivery, %
28.0 (13.0 b 16, 32.0 b 20) 21.0 (32.9 b 16, 54.8 b 20) 27.0 b
2.5
31.4 (3.5)
34.0
3.0
52.0 (1.6)
2.4
45.8
22.4 (7.0 b 16, 42.0 b 20)
3.9
62.7
(60.0, 13–15) 90.0 b 18)
4.0
81.0
Home, 27.0 Hospital, 73.0 Home, 64.4 Hospital, 6.4 Home, 23.5 Hospital, 76.5 Home, alone or with an unskilled attendant, 60.8 Home, 16.0 Hospital, 84.0
6.7 40.3 7.3
13.0
The study by Kelly and Kwast reports data from Ethiopia whereas the other 4 studies report data from Nigeria. The median age was reported.
In comparison with the findings from African studies, the vast majority of which are from Ethiopia and Nigeria, Ahmad et al. [10] reported a higher age and a higher parity for women with fistulas in Pakistan, and a higher rate of fistulas in women who experienced repeated deliveries than in primiparas. Specifically in this study, less than 2.5% of the women with fistulas were younger than 16 years, and only about 14% were primiparas, whereas the corresponding rates were 32% and 52%, respectively, in a study that Hilton conducted in Nigeria [5]. Considering the clinical urgency associated with fistula formation and treatment, we must stress the need for accessible and affordable obstetric care; for skilled medical personnel able not only to attend to women giving birth but also to perform cesarean deliveries or, at least, refer women in a timely manner; and for surgeons trained to repair obstetric fistulas as rapidly as possible to prevent the negative social consequences of obstetric fistulas.
4. Diagnosis Characteristically, women with fistulas present with continual urinary and/or fecal incontinence, or only at night. If leakage is not obvious on initial examination, methylene blue can help identify the site or sites. Under sedation or anesthesia, tissue condition and mobility are assessed, as well as the feasibility of a vaginal repair. The latter assessment is particularly important in women who already underwent attempts at fistula repair.
5. Classification To date there is no standardized classification system for obstetric fistulas. Various authors have focused on different characteristics of fistulas and emphasized important elements. This lack of standardization precludes comparative analyses of surgical treatment and outcome across studies, and such analyses are needed to identify the best management of women affected with fistulas. Of the 25 classification systems this review identified for genitourinary fistulas, 7 for vesico-
vaginal fistulas and 1 for recto-vaginal fistulas are described in Table 2. These are the most recent and most cited systems. Over the decades, authors have proposed factors to consider for the creation of a classification for genitourinary fistulas that would be easy to learn and apply, among these are, the type, location, number, and size (length and width of the fistula); involvement of other organs; degree of vaginal scarring; attachment of the fistula to the pelvic wall; condition of the urethral sphincter and permeability of the internal orifice of the urethra; location of ureteral orifices and their relation to the edges of the fistula; and presence of complications such as a recto-vaginal fistula and inflammatory lesions of the pelvis, vagina, vulva, or peritoneum. The 2 most recent classification systems for vesicovaginal fistulas were proposed by Waaldijk in 1995 [11] and Goh in 2004 [12]. Waaldijk considers the involvement of the continence mechanism and the degree of damage of the urethra, whereas Goh uses fixed points of reference and divides vesico-vaginal fistulas into 4 classes. The classes are based on the distance of the distal edge of the fistula to the external urinary meatus, and are further subdivided according to size, extent of scarring, vaginal length and/or capacity, or any other particular consideration [12].
6. Management Data suggest that the first repair attempt is likely to be the most successful [13,14]. Although there are reports of successful conservative management with prolonged bladder drainage, mature obstetric fistulas require formal operative repairs.
6.1. Timing of surgical repair The importance of timing for surgical repair has long been emphasized because of its association with the quality of the tissues in need of repair. Authors used to recommend an interval of at least 3 to 6 months between injury and repair; in recent years, however, immediate repair has been advocated to prevent the ostracism often experienced by
Obstetric fistulas: A clinical review Table 2 Year
S43
Classification systems proposed for obstetric fistulas Author
Classification Vesico-vaginal fistulas
1972
Lawson
1992
Gueye
1994
Elkins
1995
Waaldijk
2004
Browning
2004
Goh
1. Juxtaurethral 2. Vault 3. Midvaginal 4. Juxtacervical 1. Simple: far from the ureters, urethra intact 2. Complex: partial or total loss of the urethra 3. Complicated: total loss of the urethra, with or without a recto-vaginal fistula 1. Vesico-cervical 2. Juxtacervical 3. Midvaginal vesico-vaginal 4. Suburethral vesico-vaginal 5. Urethro-vaginal Type I: Does not involve the urethral closing mechanism Type IIAa: Involves the urethral closing mechanism, without (sub)total urethral involvement and without circumferential defect Type IIAb: Involves the urethral closing mechanism, without (sub)total urethral involvement and with circumferential defect Type IIBa: Involves the urethral closing mechanism, with (sub)total urethral involvement and without circumferential defect Type IIBb: Involves the urethral closing mechanism, with (sub)total urethral involvement and with circumferential defect Type III: Involves the ureter; other exceptional fistulas 1. Simple: Minimal vaginal scarring and good bladder volume 2. Complex: Severe vaginal scarring and/or reduced bladder volume needing some degree of vaginoplasty or even reconstruction of the vagina Type 1: Distal edge N 3.5 cm from external urinary meatus Type 2: Distal edge 2.5–3.5 cm from external urinary meatus Type 3: Distal edge 1.5 to b2.5 cm from external urinary meatus Type 4: Distal edge b 1.5 cm from external urinary meatus (a) Size b 1.5 cm in the largest diameter (b) Size, 1.5–3 cm in the largest diameter (c) Size N 3 cm in the largest diameter i. None or only mild fibrosis (around the fistula and/or vagina), and/or vaginal length N 6 cm with normal capacity ii. Moderate or severe fibrosis (around the fistula and/or vagina), and/or reduced vaginal length and/or capacity iii. Special consideration, e.g., postradiation, ureteric involvement, circumferential fistula, or previous repair Recto-vaginal fistulas
2004
Goh
Type 1: Distal edge of fistula N 3.5 cm from hymen Type 2: Distal edge of fistula N 3.5 cm from hymen Type 3: Distal edge of fistula N 3.5 cm from hymen Type 4: Distal edge of fistula N 3.5 cm from hymen (a) Size b 1.5 cm in the largest diameter (b) Size, 1.5–3 cm in the largest diameter (c) Size N 3 cm in the largest diameter i. No or mild fibrosis around the fistula and/or vagina ii. Moderate or severe fibrosis iii. Special consideration, e.g., postradiation, inflammatory disease, malignancy, or previous repair
women with obstetric fistulas. Waaldijk [15] prospectively treated 170 women with a fistula of less than 3 months’ duration to determine the effectiveness of immediate management by catheter and/or early closure. Closure was obtained in 156 women, of whom 93.6% became continent,
4.5% became minimally or mildly incontinent, and 1.9% remained severely incontinent. However, in developing countries, women are often malnourished and anemic, have intestinal parasites or other debilitating conditions. This is why many authors stress the
S44 importance of screening the women for schistosomiasis, tuberculosis, lymphogranuloma, and any other condition requiring prompt treatment prior to fistula repair. Furthermore, contracture of the hip or unilateral or bilateral footdrop may be present in women with fistulas, who also may adopt the fetal position because they are too weak to move. When bladder stones were present, Ahmad et al. postponed the repair for 6 weeks [10]. Additionally, prolonged physiotherapy may be required to allow proper access to the vagina during surgical repair. Antibiotic prophylaxis deserves careful consideration. A randomized controlled trial of women undergoing vesico-vaginal fistula repair was conducted in West Africa [16]. The participants in the prophylaxis group received 500 mg of ampicillin intraoperatively whereas the controls received no antibiotics. The use of antibiotics did not reduce the odds of repair failure (odds ratio, 2.1; 95% confidence interval, 0.75–6.1) or of objective incontinence (odds ratio, 1.9; 95% confidence interval, 0.72–5.1), but women in the prophylaxis group received fewer doses of antibiotics postoperatively and had fewer urinary infections on the 10th day after surgery [16].
6.2. Surgical approaches to fistula repair The literature reports 3 main approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal, but laparoscopy may soon offer alternative approaches. 6.2.1. The vaginal route The vaginal route seems to be associated with less blood loss and pain, fewer operative complications, and shorter hospital stay, allowing for rapid recovery, but it may be associated with vaginal shortening and scarring. The vaginal approach is contraindicated when the vaginal epithelium around the fistula is severely indurated; the bladder has a small capacity and is poorly compliant; vaginal stenosis is present; other pelvic structures are involved; or when the repair requires ureteral reimplantation. A layered closure is the preferred method, whether a vascular flap or urethral reconstruction is needed or not. 6.2.2. The abdominal route The abdominal route is frequently preferred for complex fistulas. Absolute indications include a small-capacity or poorly compliant bladder requiring simultaneous bladder augmentation; the involvement of other abdominal viscera in addition to the bladder; ureteral orifices requiring ureteral reimplantation; high fistulas that are inadequately exposed; vaginal stenosis or adverse musculoskeletal conditions [17]. An associated pelvic pathology or the presence of multiple fistulas may also require an abdominal approach. Abdominal approaches may be extraperitoneal or intraperitoneal. When bladder augmentation is required for complicated fistulas, the bowel segments used are anastomosed to the bladder. The disadvantages associated with this approach are mostly related to increased costs and a higher rate of postoperative complications.
A.A. Creanga, R.R. Genadry layer in the repair, fill dead space, and bring a new blood supply to the area. The tissues used include labial fat and bulbocavernosus muscle in a procedure known as the Martius graft. Other procedures can use a gracilis muscle graft, an omental pedicle graft, a peritoneal flap graft, a pedicled flap of the vaginal wall, and a free bladder mucosal graft. Rangnekar et al. [18] retrospectively evaluated the outcomes of fistula repair procedures in Mumbai, India. The Martius graft was employed in 21 of a total of 46 cases of obstetric fistulas, 12 urethro-vaginal and 34 vesico-vaginal. Overall, 95% of the fistulas treated with the graft were cured, compared with 72% of those treated with a simple anatomic repair.
7. Postoperative care Recovery varies with the extent of the repair. Authors agree that the bladder should be continuously and completely drained for at least 10 days postoperatively, and up to 2 to 3 weeks. Adequate postoperative drainage of the bladder via a urethral or suprapubic catheter, or both, is recommended. Carr and Webster [17] prefer to use only a suprapubic bladder drain, which, if appropriately positioned, reduces bladder spasms and patient discomfort, and thus prevents premature catheter removal. Women are advised not to resume sexual activity for 3 to 4 months to give the tissues sufficient time to heal [14].
8. Surgical outcomes Because there is no standardized definition of success following obstetric fistula repair, the reporting of surgical outcomes varies by author. Most authors, however, report as success the surgical closure of the fistula at the time of hospital discharge, without further evaluation of the effect of the procedure on continence or patient’s subsequent quality of life. In his review, Kelly [3] reported a success rate of 58% to 90% based on the surgical closure of obstetric fistulas, and more than a decade later Cron [19] considered that 85% of vesico-vaginal fistulas could be repaired successfully at the first attempt, and that closure rates were similar with the transvaginal or the transabdominal route. Various authors agree that primary repair failure is more common when the fistula is large, especially when it involves the urethra and/ or rectum in a circumferential fashion. In 1995, Rathee and Nanda [20] related the success rate of fistula closure to the degree of fibrosis present at the fistula site, and noted that the closure rate for fistulas with no fibrosis was 100%, compared to 16.7% for fistulas with marked fibrosis. The results of fistula surgery are influenced by a variety of factors including fistula site and size, and the degree of scarring. Additionally, Kelly [14] mentions the number of previous repair attempts, the severity of the lesions, the overall health of the patient, the availability of health facilities, and the experience and expertise of the surgeon as important factors for a successful surgical closure of obstetric fistulas.
9. Postoperative complications 6.2.3. The combined transabdominal/transvaginal route A combined route may be indicated in some cases. Several techniques have been described to perform fistula repair at different sites. Interposed tissue serves to create an additional
The most common postoperative complications of obstetric fistulas are presented in Table 3. Despite the high success rates reported for fistula closure, persistent urinary incontinence
Obstetric fistulas: A clinical review Table 3
Postoperative complications of fistula surgery
Amenorrhea Anuria (total loss of urination) Atresia Bladder stones Gynatresia (occlusion of some part of the genital tract, especially of the vagina; Asherman syndrome) Incontinence (urinary or fecal) Leg weakness Reduced bladder capacity Superficial wound infection Ureteric injury Urinary retention Urinary tract infection
following surgery occurs in a large proportion of women. Postoperative incontinence is more common after urethral reconstruction for total destruction of the urethra, repair of a urethro-vaginal fistula, or repair of a fistula involving the bladder neck [1]. Waaldijk [21] notes that the critical urethra length for continence seems to be between 1.5 and 2 cm, and that with a length of 1.5 cm or less a woman has little chance of becoming continent once the fistula is surgically closed. Based on his experience at the Fistula Hospital in Addis Ababa, Ethiopia, Browning [22] found that women with low vaginal fistulas could be divided into 2 groups: those with simple fistulas, who have minimal vaginal scarring and an appropriate bladder volume; and those with more complex fistulas, who present with severe vaginal scarring and/or reduced bladder volume. These characteristics appear to influence the presence or absence of residual incontinence postoperatively. Of 318 women with simple fistulas in Browning’s study, 50% remained urinary incontinent in the immediate postoperative period whereas all of the women with complex fistulas did so [22]. The term gynatresia refers to foreshortened and stenotic vaginas following fistula repair. In 1994, Elkins [23] reported gynatresia following the repair of 8 of the 16 large fistulas (N 4 cm) surgically treated in a series of 100 women, and in a study published in 2004, Ijaiya and Aboyeji observed gynatresia from vaginal fibrosis in 2.9% of the women surgically treated at their hospital over 10 years [24]. Hilton and Ward [5] noted that normal menstruation may return rapidly after successful surgical repair, but that it may also be delayed for several years or never return. In their review, the mean time to presentation for surgical repair for women who had resumed menstruating was 51 months, compared with 23.4 months for those who had not [5]. The authors hypothesized that fistula formation had a suppressive effect on the hypothalamus, which tended to resolve spontaneously after 2 years even if the fistula remained untreated. On the other hand, in a 1978 Nigerian study of 66 women who were amenorrheic for several months to 15 years before successful fistula repair, 55 were menstruating again within 6 months of the repair [25]. Many authors emphasize that women who underwent fistula repair should always be delivered by cesarean section. However, in a report by Kelly [14] on 33 women who became pregnant within 1 year of fistula repair, 12 were delivered vaginally without damage to the repair. The criteria Kelley
S45 used for attempting vaginal delivery included a nonrecurring cause for the fistula, the use of an interposition graft in the repair, and skilled labor supervision.
10. In the presence of recto-vaginal fistulas Vesico-vaginal fistulas alone are far more common than recto-vaginal fistulas alone or combined vesico-vaginal and recto-vaginal fistulas. In 1992 Kelly [26] reported on 716 women whom he treated for fistulas (not all of obstetric origin), 578 in Africa and 138 in Britain. In 78% of the women the fistulas were vesico-vaginal, in 17% they were combined vesico-vaginal and recto-vaginal, and in 4% they were recto-vaginal. In general, repair is less successful for recto-vaginal than for vesico-vaginal fistulas. However, the rate of successful surgical closure is the same for recto-vaginal fistulas alone and for rectovaginal fistulas combined with vesico-vaginal fistulas [1]. An anatomical classification has been developed to guide selection for the most appropriate surgical procedure for recto-vaginal fistula repair [27]. When they involve the upper third of the vagina, routinely performing diverting colostomies might improve the success rate of repair. However, colostomies are not easily accepted culturally, and procuring colostomy bags and related supplies would make this option impractical in the developing world. Although women may experience persistent stress incontinence after the successful closure of a vesico-vaginal fistula, it is not frequently reported that women with a successfully closed recto-vaginal fistula continue to experience fecal loss because of a defective anal sphincter [1].
11. Conclusion Data on obstetric fistulas are scarce. A standardized terminology, classification, and system for reporting data pertaining to the surgical management of obstetric fistulas and its outcomes, are urgently needed. Better differentiation between simple and complex fistulas would indicate both the severity of the lesions and the degree of surgical care and expertise required for repair, and result in improved patient care. The need for emergency obstetric care, skilled medical personnel, and trained fistula surgeons merit its place on the agenda of policy makers in developing countries, especially in countries where obstructed labor and obstetric fistulas are known to be prevalent. Role of the funding source None. Conflict of interest None.
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