Genital fistula, GF

Notes

## Basic introduction

  • A fistula is an abnormal connection between two hollow spaces such as blood vessels and intestines.
  • GF is the physical linkage between either genital tract and urinary bladder (Vesicovaginal Fistula, VVF) or genital tract and/or the rectum (rectovaginal fistula, RVF)
  • In VVF, there is a continuous involuntary discharge of urine into the vaginal vault.
  • World Health Organisation refers to fistulae “as the single most devastating morbidity of neglected child birth”

## Statistics

  • The global annual incidence of GF: 50,000-100,000 women (mainly due to obstructed labor)
  • The number of young women living with untreated obstetric fistula in Asia and sub-Saharan Africa: about > 2 million
  • Facts on GF in Kenya: prevalence of 3-4 per 1,000 deliveries; the annual incidence is 3,000; only 7.5% cases of GF are able to access medical care; Kenyatta National Hospital (KNH) carries out about 200 fistula operations annually; Kenya has only 10 fistula surgeons.

## Causes of GF

  • Pelvic abscess
  • Obstetric injury (especially in obstructed labor), where unborn child tightly presses against the pelvis, cutting off blood flow to the vesicovaginal wall and leading to necrosis of the affected tissues and formation of a hole.
  • Malignancies
  • Instrumental delivery
  • Operative injuries e.g. during Caesarian section
  • Radiotherapy of pelvic region
  • Violent cases of rape
  • Lack of access to maternity care
  • Poverty (leading to malnutrition thus stunted growth)
  • Early marriage and childbirth
  • Short stature
  • Illiteracy
Symptoms
  • Urinary incontinence
  • Fecal incontinence
  • Both urinary and fecal incontinence
  • Profound effect on the patient's emotional well-being
Diagnosis
  • Clinical review
  • Diagnosis is done under anesthesia (using Sim’s speculum)
Differential
  • Not applicable
Prevention
  • Professional obstetric care
  • Delaying the age of first pregnancy
  • The cessation of harmful traditional practices such as FGM
Reference

1. AbouZahr C. Global burden of maternal death and disability. Br Med Bull. 2003;67:1–11. doi: 10.1093/bmb/ldg015

2. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

3. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

4. Roka ZG, Akech M, Wanzala P, Omolo J, Gitta S, Waiswa P. Factors associated with obstetric fistulae occurrence among patients attending selected hospitals in Kenya, 2010: a case control study. BMC Pregnancy and Childbirth. 2013;13:56. doi:10.1186/1471-2393-13-56.

5. 10 facts on obstetric fistula. 2017. http://www.who.int/features/factfiles/obstetric_fistula/en/. Access on 20th January 2016.

Management
  • VVF are repaired either transvaginal or laparoscopically. Complications associated with VVF surgery include recurrent formation of the fistula, injury to ureter, bowel, or intestines, and shortening of a vagina.
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