Obstetric Fistula

What is Obstetric Fistula?

Obstetric fistula, or vaginal fistula, is an abnormal communication between the vagina and either the bladder anteriorly or the lower digestive tract posteriorly. It is a complication of childbirth and occurs due to prolonged childbirth (1^✔).

When a woman has an obstructed labor and is not given help, the labor could last for up to even 5 to 7 days. This creates a lot of pressure on the vagina, urethra and rectum. The compression can cut off the blood supply to the baby and to the mother's soft tissues, proving to be fatal to the baby, and causing death to the mother's tissues as well. This results in the formation of an abnormal communication between the vagina and bladder, or vagina and rectum. The condition results in incontinence, the constant and uncontrolled flow of urine or feces, or both (2^✔).

Depending on the location of the fistula, obstetric fistula can be classified as:

• Vesicovaginal Fistula: Fistula that connects the urinary bladder and vagina (3^✔).
• Rectovaginal Fistula: Fistula that connects the rectum and vagina (4^✔).

Obstetric fistula is a preventable and treatable condition. Basic medical care for a pregnant woman with immediate attention to any labor pains can help prevent injury and fistula formation during labor. Obstetric fistula is treated with surgery.

What are the Causes of Obstetric Fistula?

Obstetric fistula is usually a problem of underdeveloped countries and is commonly caused to due prolonged, unattended labor. Other possible causes of vaginal fistula include (5^✔) :

• Poorly performed abortions
• Use of episiotomy and forceps during labor
• Pelvic fracture, resulting in a difficult labor
• Cervical cancer therapy with radiation
• Inflammatory bowel disease like ulcerative colitis, Crohn's disease

• Sexual abuse or rape
• Trauma during surgery of vagina, perineum, anus or rectum

There are several indirect risk factors that can end up in causing the obstetric fistula.

• Poverty: Most of the impoverished countries can lack adequate medical infrastructure. They lack of proper medical professionals, medical care and infrastructure to take care of a woman in labor.
• Malnutrition: Lack of proper nutrition to the mother makes her vulnerable to diseases. Stunted growth during the growing years of the woman is the result of malnutrition and is associated with underdeveloped pelvic bones. The weak and underdeveloped bones can increase the risk of difficult labor and consequently of obstetric fistula.
• Lack of Information: Lack of information about maternal health, family pressures about waiting for a normal labor and other complications that may arise during home-births can contribute to the risk factors of developing obstetric fistula (1^✔).
• Early Marriages and Childbirth: In under-developed countries like Sub-Saharan Africa, many girls are married off as soon as they attain menarche. This is due to the socio-economic factors where the girls are "sold" in marriage for a price. This leads to early childbirth when the girl's tissues are not ready to take in the pressure. The tragic part is that once these girls develop obstetric fistula, they are shunned by the family and society (1^✔).
• Status of Women in Under-Developed and Developing Countries: Women in certain societies are dominated by their husband and in-laws who decide about the maternal care to be provided. Some even believe that women are supposed to suffer in childbirth and refuse to go for cesarean section even if it is strongly indicated.

What are the Symptoms and Signs of Obstetric Fistula?

A vaginal fistula or obstetric fistula is usually painless. But it results in uncontrollable passing of the urine or feces, causing a lot of embarrassment.

• In case of vesicovaginal fistula, urine keeps leaking out of the vagina (6^✔).
• In case of rectovaginal fistula, a foul smelling discharge leaks out. Gas may also be discharged (4^✔).

Other symptoms include:

• Infection and inflammation of the genital area resulting in irritation or pain
• Intense pain during sexual activity

Complications of Obstetric Fistula

Some of the serious complications that occur along with obstetric fistula include (5^✔):

• Severe ulcerations of the vaginal tract
• Kidney damage
• Infection of the fistula turning it into an abscess
• Paralysis of the lower limbs caused by nerve damage
• Amenorrhea, or absence of menstruation

Obstetric fistula has a more severe impact on the social, economic and psychological aspects, apart from the physical symptoms. Affected women are often ostracized from the community due to the smell or continuous leakage of urine.

How to Diagnose Obstetric Fistula?

The symptoms of the obstetric fistula are the basis of diagnosis.

• Physical examination is done to look at the vaginal walls (3^✔).
• A dye is used in the vagina to find the site of leakage (3^✔).
• Infection of the vagina is confirmed with local swabs and blood and urine tests.

• An X-ray or MRI scan can help in identifying the extent of tissue damage (7^✔).
• Endoscopy is done to find out the type of fistula and its size (8^✔).

How do you treat Obstetric Fistula?

Treatment of obstetric fistula depends on the ability of the tissue to heal. It also depends on the size and location of the fistula.

About 80% of women can be cured by simple vaginal surgery (9^✔). Topical or oral medicines are given for the wounds to heal before surgical intervention.

Based on the extent of the damage and size and location of the fistula, various types of vaginal surgery may be done.

• Single-layered technique, using non-absorbable suture
• Flap-splitting technique (10^✔)
• Urethral reconstruction or catheterization
• Saucerization technique
• Using grafts

The surgery may be done directly via the vagina, via the bladder or through the abdomen. A combination of abdomino-vaginal repair may also be chosen depending upon the existing fistula.

Colostomy (an opening created between the intestine and the skin on the abdomen) is done first in case of a large rectovaginal fistula to divert the intestinal contents so that the fistula is kept clean for surgery. Once the surgical wound heals, the colostomy is closed.

Prevention of Obstetric Fistula

Obstetric fistula is a preventable tragedy. It affects millions of women and girls, more so in Sub-Saharan Africa and South Asia. Maternal medical care and expertise and adequate infrastructure can largely contribute towards prevention of obstetric fistula.

The United Nations Population Fund has launched a global campaign against obstetric fistula (11^✔). The campaign aims at preventing and treating fistulas, as well as rehabilitating survivors.

Skilled medical care providers can identify women and girls at risk for obstetric fistula and educate them about the prevention and action to be taken. Effective surgical repair, to be done at low cost or free of cost, has to be made available to the areas where the prevalence of obstetric fistula is high.

Health Tips

• While planning a pregnancy, get the necessary medical checkup done.
• Learn the way your pregnancy is proceeding and if any risk factors during the prenatal, perinatal (childbirth) and postnatal problems and complications.
• See that you get a balanced meal and proper nutrition during the prenatal period.

• Talk to your doctor if there were any complications during the birth of a previous child.
• Ask your doctor for any particular exercises, like Kegels, to make the pelvic muscles stronger and flexible.
• Maintain proper hygiene, especially in the genital area to avoid any infections and inflammations.

References:

1. Obstetric Fistula - (http://www.opfistula.org/fistula/)
2. What Is Fistula? - (https://www.fistulafoundation.org/what-is-fistula/)
3. 10 facts on obstetric fistula - (https://www.who.int/features/factfiles/obstetric_fistula/en/)
4. Obstetric Fistula: Living With Incontinence and Shame - (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621054/)
5. Obstetric fistula - (https://en.wikipedia.org/wiki/Obstetric_fistula)
6. Fast Facts - (https://www.fistulafoundation.org/what-is-fistula/fast-facts-faq/)

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