The epidemiology of genitourinary fistulae in Kumasi,Ghana, 1977–1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91.5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157 449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity. Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.EDITORIAL COMMENT: This is an interesting article with respect to its elucidation of the etiology of various fistulae, both obstetric and gynecologic. In addition, the elevated numbers of fistulae in multiparous patients (in this series over 50% of the cases) draws attention to this problem population. Indeed, nearly a quarter of these patients were women who had had 5 or more children. All this points to the importance of early intervention with respect to the conduct of labor in patients with a potential for prolonged obstructed labor. Also of interest is the high number of ureterovaginal fistulae associated with abdominal hysterectomy for uterine fibroid. This emphasizes the importance of surgical technique to avoid damage to the upper urinary tract during gynecological surgery. Devitalization of the ureter from damage to its blood supply or direct damage to the ureter are responsible for this problem. These factors should be either avoided or appropriately identified and corrected at the time of surgery.