Social Implications of Obstetric Fistula: An Integrative Review

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub‐Saharan Africa.     

Common Genitourinary Infections

Vulvovaginal pain, itching, and burning are a triad of symptoms for which women frequently seek health care. Often accompanied by vaginal discharge and dysuria, these symptoms account for as many as 5 million office visits a year. Proper assessment and management of these symptoms by nurses, nurse practitioners, and nurse midwives can help to substantially improve a woman's quality of life and help prevent long-term problems. Several differing syndromes or infections can be the cause of these symptoms. The most common causes are discussed, and a plan for management and prevention is presented.     

Genitourinary problems in adolescence

Urinary tract abnormalities in adolescent girls can range from previously unrecognized anatomic problems to metabolic diseases (which may lead to stone formation) to voiding patterns that can produce urinary incontinence. This paper reviews the various abnormalities and describes their pathophysiology so that practitioners can increase their understanding of these entities and improve their diagnostic acumen.     

FATHER AND CHILDBIRTH: An Anthropological Perspective*

In a cross-cultural discussion of the participation of the father in the birth of his child, couvade, is discussed as a specific example of such participation. The current trend in the United States in favor of “natural childbirth” and the use of psychoprophylaxis is discussed. The paper lends support to the social, psychological, and physical value of the father's participation in childbirth.     

Genitourinary Infection in Older Women

As they age, women become increasingly susceptible to all infectious processes. Compounding increased susceptibility are the aging process and chronic and coexisting diseases that can mask or confound an infectious process. Infections in older women may present atypically, which hinders diagnosis and treatment. The presentation, treatment, and nursing care involved in treating elderly women with urinary tract infections and vulvovaginitis are discussed.     

Guideline No. 422b: Menopause and Genitourinary Health

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1The effects of estrogen deficiency on urogenital tissues include signs and symptoms of vulvovaginal atrophy, urinary urgency, dysuria, and recurrent urinary tract infection (high).
• 2Genitourinary syndrome of menopause is common and impairs quality of life, sexual function, and partner relationships (high).
• 3Without treatment, this syndrome will evolve chronically in most women and progress to functional and structural urogenital tissue changes that can be difficult to reverse even with treatment (high).

RECOMMENDATIONS

• 1Women entering menopause should be educated about the progressive impact of estrogen deficiency on urogenital health and the many options available for symptom relief (strong, high).
• 2Menopausal women should be comprehensively screened for genitourinary syndrome of menopause symptoms on an ongoing basis, as symptoms can present insidiously and become bothersome long after the menopausal transition (strong, high).
• 3First-line management options for genitourinary syndrome of menopause may include vaginal lubricants and/or vaginal moisturizers, particularly if patient concerns are limited to vaginal dryness or dyspareunia (strong, high).
• 4Second-line therapy for genitourinary syndrome of menopause is vaginal estrogen, administered either as a cream, tablet, or sustained-release ring (strong, high). Clinically significant systemic hormone absorption does not occur with low-dose therapy, so concomitant progestogen therapy is not needed (strong, high).
• 5Other second-line pharmacotherapy for atrophic vaginal symptoms includes the oral selective estrogen receptor modulator, ospemifene, and vaginal dehydroepiandrosterone ovules (strong, high).
• 6Long-term use of intravaginal laser therapy to manage genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should be conducted only within the protocols of well-executed clinical trials designed to establish its safety and efficacy (strong, very low).

     

Genitourinary mycobacteria in infertile Egyptian men

Forty infertile patients with a preliminary diagnosis of genitourinary tuberculosis were selected for our study when they presented with one or more of the following: (1) personal or family history of tuberculosis, (2) sterile pyuria, (3) voiding urinary symptoms, (4) abnormality in the epididymis, (5) hemospermia, and (6) clinically unexplained obligoathenospermia. Direct smear examination by Ziehl-Neelsen stain for 24-hour urine and freshly ejaculated semen for 3 days as well as culture of midstream urine and semen were done on egg media. Urine smear was positive (+)ive in 20 patients (50%), culture was (+)ive in 23 (57.5%), whereas for semen smear was (+)ive in 3 (7.3%) and culture was (+)ive in 5 (20%). Tuberculous mycobacteria were detected in 5 of 23 cases (21.7%). Nontuberculous mycobacteria were detected in 18 of 23 cases (78.3%). Mycobacterium smegmatis was the most common mycobacterium isolated. There was improvement of the seminal picture, though not significant, after therapy.     

PRIMARY CARE FOR WOMEN: Assessment and Management of Genitourinary Tract Disorders

This article reviews the basic anatomy and physiology of the genitourinary system and disorders commonly encountered in the primary care setting. The role of the nurse-midwife in the assessment and treatment or referral of complaints of dysuria, hematuria, and incontinence is discussed. The treatment of nonpregnant women with cystitis is addressed; symptoms associated with pelvic relaxation are discussed, and a management scheme for teaching effective pelvic floor exercises is presented.     

Indian Perspective on Clinical Aspects,Usage, and Guidelines of Folic Acid

Folic acid (pteroylmonoglutamic acid) is the stable, fully oxidized form of folate which is used in food fortification and supplements. Keen interest has been generated in folic acid due to its suggested role in prevention of various disorders. Strong evidence from clinical trials indicates preventive effect of folic acid on both occurrence and recurrence of neural tube defects. It also plays a significant role in mitigating the risk of cardiovascular disorders through homocysteine regulation. In addition, the beneficial effect of folic acid in various types of cancers, neurological disorders, conditions affecting pregnancy, and other clinical conditions has been reported in literature. Various guidelines reinforce the need for women to obtain adequate amount of folic acid either through food fortification or supplements. In India, national guidelines on the proper dose of folic acid to pregnant women are not available. Given its significant beneficial effects on health, awareness should be spread among communities on the usage and benefits of folic acid.     

Obstetric Fistula: Living With Incontinence and Shame

Over 2 million women worldwide have an obstetric fistula, with the majority of cases occurring in resource-poor countries. Afflicted women tend to be young, primiparous, impoverished, and have little or no access to medical care. Incontinent of urine and/or stool, these women become ostracized and shunned by their community. Most obstetric fistulas are surgically correctible, although surgical outcomes have been poorly studied. Programs that improve nutrition, delay the age of marriage, improve family planning, and increase access to maternal and obstetric care are necessary to prevent obstetric fistula.Key words: Obstetric fistula, Obstructed labor, Vesicovaginal fistulaObstetric fistula (OF) has virtually been eliminated in industrialized nations, yet continues to plague women in resource-poor countries. The condition is entirely preventable; prolonged obstructed labor is estimated to account for 76% to 97% of OF (and is also a major cause of maternal mortality). The condition results when the descending fetus is unable to pass through the mother’s pelvis. The fetal head enters the vagina, but the shoulders cannot pass through the bony pelvis (Figure 1). Without access to medical care to relieve the obstruction, the woman may remain in labor for days. The fetal head compresses the vaginal tissue and widespread ischemic damage of the soft tissue occurs. Once fetal death from asphyxiation occurs, the dead fetus is expelled. The necrotic tissue sloughs off, leaving a hole between the vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) (Figure 2). The woman develops incontinence of urine and/or stool, and is affected by multiple devastating medical and psychosocial sequalae.Open in a separate windowFigure 1Obstructed labor. Illustration from A Sett of Anatomical Tables, With Explanations, and An Abridgment, of the Practice of Midwifery, by William Smellie, printed in 1754.Open in a separate windowFigure 2Simple vesicovaginal fistula. A metal catheter through urethra is visible through destructed bladder. Copyright? Worldwide Fistula Fund, used by permission.     

Robotic Vesicovaginal Fistula Repair

Study ObjectiveTo illustrate a technique of robotic vesicovaginal fistula repair in a patient with a previous history of pelvic radiation therapy and multiple abdominal surgeries.DesignStepwise demonstration of the technique with narrated video footage.SettingThis 59-year-old woman presented with vesicovaginal fistula. She had a history of rectosigmoidectomy followed by pelvic radiotherapy for stage III colon cancer 23 years earlier and subsequent robotic hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II mixed cell endometrial carcinoma, which required surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence.InterventionsWe performed a robotic approach to vesicovaginal fistula with several key steps to repair the fistula and maintain the integrity of the abdominopelvic structures: (1) careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum; (2) cystotomy with vaginal probe guidance; (3) fistulectomy by monopolar scissors after ureteral orifice visualization; (4) dissection of the retropubic space of Retzius, relieving bladder tension; (5) transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in 2 layers with minimal tension; and (6) transurethral instillation of methylene blue into the bladder.ConclusionsTraditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording 3-dimensional visualization and stabilization of instruments, allowing wrist-like movements.