Obstetric Fistulae

1. Obstetric Fistulae/gynaetresia Dr Loto O.M

2. Definition A fistula is defined as a pathological communication between two epithelial surfaces. Obstetric fistulae are fistulae developed in the course of pregnancy and childbirth. Common types seen in obstetrics are vesico-vaginal fistula (VVF), rectovaginal fistula (RVF), Ureterovaginal fistula (UVF)

3. Vesico-Vaginal fistula Commonest type of obstetric fistula in Nigeria. More common in the northwest, northeast, northcentral, southeast and south south geopolitical zones. Aetiology-prolonged obstructed labor (CPD), ruptured uterus, caesarean hysterectomy, operative vaginal delivery (forceps, destructive operation), symphysiotomy, CS, Gishri cut

4. Non obstetric causes-pelvic floor repair, vaginal hysterectomy, genital and bladder cancers, irradiation, congenital, coital injuries,pelvic fractures, caustic agents.

5. Pathology Pressure necrosis Ischaemia-necrosis-sloughing off btw 3 to 10 days-urinary incontinence. RVF- compression of rectovaginal septum btw the fetal skull and sacral promontory.

6. Anatomic classification Juxta urethral Mid vaginal Juxta cervical Large fistula Circumfrential juxta urethral Vault fistula

7. RVF High RVF (upper half of vagina) Low RVF (lower half ) 3rd degree perineal tear. Large (greater than half of post wall

8. Other clasification Small fistula less than 2cm Medium 2-3 cm Large 4-5 cm Extensive greater than 6cm

9. Clinical presentation Hx of prolonged obstructed labor rsulting in stillbirth/CS/OPVD Total incontinence 3-10 days later There may be associated feacal incontinence (RVF) Weakness in the lower limbs.

10. Pt is unkempt, smells of urine, miserable looking. May have cs scar Vulva is wet, vulvar excoriation( ammoniacal dermatitis) May have vaginal stenosis from scarring, so do digital exam before speculum.

11. Investigations FBC, Hiv screening, E & U, CR, renal uss, cystoscopy, pippette specimen urine for mcs.

12. Differential diagnosis Stress incontinence Urge incontinence Ureterovaginal fistula(UVF) Overflow incontinence.

13. 3 swab test Use to diferentiate btw UVF, VVF and stress incontinence Place 3 swab in the vagina Instill 100ml methylene blue into bladder Move around for 10-15 min Lower swab wet & blue-SI, upper swab wet & blue-VVF, upper swab wet but not blue-UVF.

14. Mgt VVF repair Psychological support Physiotherapy If follow obstructed labor wait for 3 mths to allow slough to separate, inflamation to subside and new tissue plane to form. If due to cs injury, repair immediately. Optimise patient before repair.

15. Post op mgt Catheterise for 10-14 days Monitor urinary output hourly 6 litres of fluid per day. Antibiotics Analgesics All future delivery should be by CS

16. Complications Haemorrhage Infection Clot retention Catheter blockage Occlusion of ureters

17. Prevention Good nutrition for girls Avoid early mariage Adequate ANC/ emergency obstetric care Education of populace Family planning-reduce parity

18. RVF May coexist with VVF Repair vvf first High fistula-colostomy first

19. Preoperative mgt Bowel preparation- neomycin 1 g, low residue diet 3 days b4 operation, rectal wash out night before.

20. Postoperative mgt Low residue diet for 5days Liquid paraffin Deliver subsequent babies by CS

21. Gynaetresia Narrowing or occlusion of the vagina May be congenital or acquired Acquired is more common in the tropics. Incidence 7 per 1000. peak age 20-30 years. Commonest cause here is chemical vaginitis from caustic pessaries May follow vvf/rvf repair, FGM,colporrhaphy, irradition

22. Clinical presentation Dyspareunia Apreunia Vaginal stenosis/ occlusion

23. Management Vaginoplasty- one stage, mc Indole- Read,williams. Simple dilatation

24. prevention Community based education to discourage harmful practices.