Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia

Introduction and objective

Little is known about the extent to which women in low- and middle-income countries suffer with urological and urogynaecological complications of childbirth. This study measured the prevalence of obstetric fistula and symptomatic pelvic organ prolapse (POP) in east and north Ethiopia.

Methods

We randomly selected 23,023 women of reproductive age (15–49 years) from 113 villages in East Harraghe, South Gondar and West Gojjam, Ethiopia. Trained local health workers administered a validated face-to-face survey and a team of researchers verified data by readministering a random selection (5 %) of the survey. All suspected fistulae were followed up to confirm a clinical diagnosis.

Results

Mean age was 29.5 [standard deviation (SD) 8.05] years. Only 22 % of women were knowledgeable about the symptoms of fistula. The prevalence of all obstetric fistulae was 6:10,000 reproductive-aged women [95 % confidence interval (CI) 3–8], of untreated fistula 2:10,000 (95 % CI 0–4) and of symptomatic POP 100:10,000 (95 % CI 86–114).

Conclusion

The prevalence of obstetric fistula in these rural zones of Ethiopia is relatively low and reflects a substantial reduction from previous reports. Significant numbers of women suffer with symptomatic POP, for which surgical and nonsurgical treatments would be beneficial.

Brief summary

Obstetric fistula in north and east Ethiopia is relatively low; however, the many women with symptomatic pelvic organ prolapse could benefit from treatment.

     

Mental health screening in women with severe pelvic organ prolapse,chronic fourth-degree obstetric tear and genital tract fistula in western Uganda

Introduction and hypothesis

High levels of mental health dysfunction have been identified in women with genital tract fistula. The aim of this study was to use the General Health Questionnaire-28 (GHQ-28) to screen women in western Uganda with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula for risk of mental health dysfunction.

Methods

Women undergoing surgery for severe pelvic organ prolapse, chronic fourth-degree obstetric tear, and genital tract fistula were interviewed using the GHQ-28 to screen for the risk of mental health dysfunction.

Results

A total of 125 women completed the GHQ-28, including 22 with pelvic organ prolapse, 47 with fourth-degree obstetric tear, 21 with genital tract fistula, and 35 controls. Nearly all women with these serious gynaecological conditions were positive for the risk of mental health dysfunction. In the domain assessing symptoms of severe depression, women with fourth-degree obstetric tear and genital tract fistula scored higher than women with pelvic organ prolapse.

Conclusions

A significant risk of mental health dysfunction was identified in women with severe pelvic organ prolapse and chronic fourth-degree obstetric tear. These rates are similar to the high rates of mental health dysfunction in women with genital tract fistula. Identification and management of mental health dysfunction in women with these conditions should be a priority.

     

Impact of surgery on quality of life of women with obstetrical fistula: a qualitative study in Burkina Faso

Introduction and hypothesis

Obstetric fistula, caused by traumatic delivery and patient lack of access to obstetric care, is an important public health concern in developing countries, particularly in Sub-Saharan Africa. This research focuses on the experience of women living with obstetric fistula in Burkina Faso as well as their reintegration into community after surgery.

Methods

This project was funded by the Mères du Monde en Santé (MMS) Foundation and conducted in collaboration with the Boromo Hospital. A qualitative approach based on grounded theory and using the principles of participative action research (PAR) was used with semidirected interviews prior to surgery and follow-up interviews 1–2 years after surgery directly in the women’s village of origin. Thirty-nine participants were recruited between 2012 and 2015.

Results

The results point to circumstances leading to obstetric fistula development: poverty, gender inequality in terms of decision making, healthcare-system deficiencies, and lack of services for referral and treatment of this condition. Our results reinforce the knowledge about the social and psychological repercussions of fistula by exploring the concepts of gossips, shame and self-exclusion as powerful mechanisms of exclusion, but they also show that social support was conserved for several women through their journey with this disease. There was complete social rehabilitation within the community after surgery; however, persistent barriers in term of anxiety regarding obstetric future and economic insecurity were present.

Conclusions

Early recruitment for surgery and prevention are the main objectives when attempting to reduce the impact of obstetric fistula and facilitate patient reintegration. Improvements in local and governmental public health policies are required.

     

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya

Introduction and hypothesis

More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears.

Methods

Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya.

Results

One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation.

Conclusion

These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

     

Genital tract fistula: a case series from a tertiary centre in South Africa

Introduction and hypothesis

We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit.

Methods

This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05).

Results

The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications.

Conclusions

A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.

     

Critical Care in a Tertiary Hospital in Malawi

Background

The provision of critical care services is essential to healthcare systems and increasingly a global health focus, but many hospitals in sub-Saharan Africa are unable to meet this need. Intensive care unit (ICU) mortality in this region is high, but studies describing the provision of critical care services are scarce.

Methods

This was a retrospective cohort study of all patients admitted to the ICU at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, between September 1, 2013, and October 17, 2014. We summarized demographics, clinical characteristics, and outcomes, and analyzed factors associated with mortality.

Results

Of 390 patients admitted to ICU during the study, 44.9 % of patients were male, and the median age was 22 years (IQR 6–35) years. Although most patients (73.1 %) were admitted with surgical diagnoses, the highest mortality was among patients admitted with sepsis (59.3 %), or obstetric (44.7 %) or medical (40.0 %) diagnoses. Overall ICU mortality was high (23.6 %).

Conclusions

There is a shortage of data describing critical care in low-resource settings, particularly in sub-Saharan Africa. Surgical disease comprises the majority of ICU utilization in this study site, but medical and obstetric illness carried higher ICU mortality. These data may guide strategies for improving critical care in the region.

     

Urinary diversion for patients with inoperable obstetric vesicovaginal fistula: the Jos,Nigeria experience

Introduction

Repair of obstetric urinary fistula may result in successful fistula closure, but often incontinence persists. Our goal was to review our experience with continent urinary diversion in our patients with inoperable vesicovaginal fistula (VVF).

Methods

The database of patients who underwent urinary diversion at ECWA Evangel VVF Centre in Jos, Nigeria, between 1996 and 2012, was reviewed. Complications and surgical outcomes were noted. The earlier patients (1996–2002) and the later patients (2003–2012) were compared.

Results

Urinary diversions were performed on 118 patients. Compared with the earlier patients, the later patients more often underwent modified Mainz II diversions, had similar complication rates, but had better outcomes. The use of ureteric catheters intraoperatively and the performance of modified Mainz II pouch were associated with a better outcome. Overall perioperative mortality was 2.5 %.

Conclusions

Urinary diversion is feasible in a low-resource setting. Use of modified Mainz II pouch diversion and intraoperative ureteric catheters were associated with a better outcome. Urinary diversion should be undertaken only after the careful counseling of each patient, and by an experienced surgeon.

     

Fistelreifung: Vorhersage durch intraoperative Flussmessung

Background

The autogenous arteriovenous fistula (AVF) is the access of choice for hemodialysis therapy. Its timely and successful creation is particularly important to avoid hemodialysis catheters; however, according to the literature primary failure occurs in 20–50?% of newly created AVF.

Objective

To identify factors influencing AVF maturation and thus identify predictors of successful fistula creation.

Methods

We report on a prospective cohort study of 41 patients undergoing the first upper extremity AVF placement. Primary endpoint of the study was successful fistula maturation after 6 weeks and several constitutional, demographic, hemodynamic and technical factors were investigated.

Results

The most significant predictive parameter for fistula maturation was flow volume measured in the access vein during surgery. The receiver operating characteristic (ROC) curve analysis showed a cut-off value of 170 ml/min for the blood flow volume with the best possible sensitivity (85?%) and maximum specificity (80?%) for prediction of fistula failure within 6 weeks.

Conclusion

Intraoperative transit time flow measurement is easy to perform and can be used anytime to reliably predict successful AVF maturation.

     

Pubovesical sling for residual incontinence after successful vesicovaginal fistula closure: a new approach to an old procedure

Introduction and hypothesis

For decades, the pubovesical (PV) sling has been in the armamentarium of the fistula surgeon for treating persistent urinary incontinence after successful fistula closure. We report our early experience with slings, and then also introduce a new “tight” PV sling technique for management of post-fistula urethral leak. Our hypothesis is that performance of tight slings might result in improved continence for women with persistent urinary incontinence after obstetric fistula closure.

Methods

Data from 120 patients in whom some type of sling procedure had been performed between 1996 and 2012 were extracted and labeled as “early slings.” Beginning in October 2014, more complete data were recorded and a more uniform approach was undertaken in 40 patients. Data were extracted from their charts and recorded as “tight slings.” This information was analyzed using Chi-squared analysis.

Results

Tight slings were more successful in patients who had less severe fibrosis and who had a shorter time since initial injury. Thirty percent of women who underwent tight slings had improved continence at follow-up.

Conclusion

Persistent urinary incontinence despite successful surgical closure of obstetrical fistula remains a difficult problem. Tight slings may be warranted in an attempt to avoid urinary diversion.

     

Are obstetric outcomes affected by female genital mutilation?

Introduction and hypothesis

Female genital mutilation (FGM) has been associated with adverse obstetric and neonatal outcomes, such as postpartum haemorrhage (PPH), perineal trauma, genital fistulae, obstructed labour and stillbirth. The prevalence of FGM has increased in the UK over the last decade. There are currently no studies available that have explored the obstetric impact of FGM in the UK. The aim of our study was to investigate the obstetric and neonatal outcomes of women with FGM when compared with the general population.

Methods

We conducted a retrospective case–control study of consecutive pregnant women with FGM over a 5-year period between 1 January 2009 and 31 December 2013. Each woman with FGM was matched for age, ethnicity, parity and gestation with subsequent patients without FGM (control cohort) over the same 5-year period. Outcomes assessed were mode of delivery, duration of labour, estimated blood loss, analgaesia, perineal trauma and foetal outcomes.

Results

A total of 242 eligible women (121 FGM, 121 control) were identified for the study. There was a significant increase in the use of episiotomy in the FGM group (p = 0.009) and a significant increase in minor PPH in the control group during caesarean sections (p = 0.0001). There were no differences in all other obstetric and neonatal parameters.

Conclusions

In our unit, FGM was not associated with an increased incidence of adverse obstetric and foetal morbidity or mortality.

     

Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center

Introduction and hypothesis

The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure.

Methods

The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as “easy,” “of intermediate complexity,” or “difficult” based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression.

Results

The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success (“closed and dry”) was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for “easy” cases, 68% for “intermediate” cases, and 57% success for “difficult” cases. Success decreased with increasing numbers of previous attempts at surgical repair.

Conclusions

These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.

     

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation

Background

A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes.

Methods

We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications.

Results

36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula.

Conclusions

Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.

     

Repair of a vesicouterine fistula following cesarean section

Introduction and hypothesis

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

     

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

Presentation and management of rectovaginal fistulas after delivery

Introduction

Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries.

Methods

Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively.

Results

Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients.

Conclusion

The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient’s wishes

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique

Introduction and hypothesis

The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique.

Methods

In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers.

Results

The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula.

Conclusions

For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

     

Outcome of Surgery for Coloduodenal Fistula in Crohn’s Disease

Background

This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn’s disease and explore the effect of preoperative optimization on surgical outcome.

Methods

This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn’s disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected.

Results

Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n?=?25) had decreased postoperative major (24.0 vs. 87.5 %, P?=?0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P?=?0.008) complications compared to patients with emergent/semi-emergent surgery (n?=?8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P?=?0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P?=?0.031) compared with those with spontaneous duodenum-colonic fistula.

Conclusion

Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn’s disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.