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Vaginal and Recto Vaginal Fistulas

Traditionally fistulas occur in the developing world in association with obstetric injury. In the developed world, fistulas usually occur as a complication of pelvic surgery, radiotherapy or foreign body injury. As antenatal care is so advanced in these countries, obstetric trauma is not a common cause of fistulas in the developed world.

Fistulas are holes that are created between the vaginal wall and the bladder (vesicovaginal fistula or VVF), the urethra (urethra-vaginal fistula), the ureter (uretero-vaginal fistula) and the neck of the womb (juxta-cervical fistula). They can also be formed between the vaginal wall and the rectum (rectovaginal fistula or RVF). Fistulas have severe physical and social consequences and are one of the most degrading abnormalities resulting from pregnancy and childbirth. As these holes are caused by trauma suffered during childbirth, the term Obstetric fistula is commonly used as an umbrella term.

Approximately 80% of fistula cases reported in the developing world, including Nigeria, are due to unrelieved obstructed labour during childbirth. Obstructed labour is related to the custom of early marriage in many countries, though this is not always the case. Early marriage invariably leads to early sexual contact and subsequent pregnancy at a time when a young girl is not adequately physically developed to permit the passage of a baby with relative ease. This can lead to a prolonged and obstructed labour and pelvic floor damage leading to the misery of fistula. The same phenomenon also occurs in women whose growth has been stunted as a result of poor nutrition or malnourishment.

Consequences of Fistula

The immediate physical consequences of VVF are urinary incontinence and / or faecal incontinence due to RVF. If the nerves to the lower limbs are damaged, women may suffer from paralysis of parts of the lower half of the body, such as foot drop.

As well as the physical consequences, the social consequences for those who suffer from fistula are also severe. Many victims of obstructed labour, in whom fistulas subsequently occur, will also have given birth to a stillborn baby, thus leaving the woman childless. In some areas, a high percentage of fistulas occur during the first pregnancy.

Prevention and treatment of Obstetric Fistula

The incidence of obstetric fistula decreased significantly at the end of the 19th century in western countries when caesarean section became widely available. Access to modern obstetric care is limited for much of the developing world, and availability of a timely caesarean section is virtually impossible.

Prevention of fistulas requires skilled attendants at birth and a swift surgical intervention if obstructed labour occurs. The pressure of the foetal head during obstructed labour causes ischemia (reduced blood flow) to the pelvic organs, and a spectrum of injuries follow as a consequence. These include vesico-vaginal (VVF), recto-vaginal (RVF) and urethro-vaginal (UVF) fistulas.

The main treatment for all types of fistulas remains surgical repair. The success and recovery rate from an operation to correct simple fistula is very high – almost 90%. However, the success of the repair is not only dependant on good surgery, but also on excellent nursing care and the prevention of complications. When complications arise, patients can end up with extensive surgery often requiring urinary or colo-rectal by-pass surgery. This essentially involves repairing a hole in the bladder or rectum and can usually take place through the vagina without the need for major incision. The operation is delicate and specially trained surgeons and support staff are required.

In some cases, women who have also suffered severe nerve damage may require prolonged physical therapy. Unfortunately, for some women, the damage is beyond repair and continual care is required. New surgical techniques are being pioneered to improve results and address more severe tissue damage.

Approaches towards eliminating Fistula

The majority of patients with fistula are from rural areas, where there are low literacy levels and a lack of physical and economic access to medical care. Furthermore, long distances to medical facilities combined with high cost of care, and poor nutrition make women more vulnerable to VVF. Since many expectant mothers do not attend antenatal clinics, exposure to high risk conditions, medical and obstetric complications which endanger the life or harm the health of the mother and her baby, will not be detected early enough for precautionary measures to be taken.

In the short term, better use of existing obstetric services and increased provision of effective health services in rural areas will lower the incidence of fistula. Ultimately, improving the education and economic empowerment of young women will remove the conditions that lead to the occurrence of fistula. Such improvements would lead women to seek safer obstetric practices, including the use of family planning, delayed childbearing, and prenatal and antenatal care during pregnancy. In women with a formal education, the maternal mortality rate is one quarter of that in women with no formal education.

Further Help

If you are concerned about your bladder problem and it is starting to affect your day to day life make an appointment to see your doctor, continence nurse or specialist physiotherapist. A continence nurse and specialist physiotherapist are healthcare professionals who specialise in bladder and bowel problems.