Obstetric Fistula

Original Editor - Rosie Swift Top Contributors - Rosie Swift and Kim Jackson

Description[edit | edit source]

  • Obstetric fistula is an abnormal opening between a woman’s genital tract and her urinary tract or rectum causing urinary and faecal incontinence, ongoing genital infections, anaemia and neurological symptoms of the lower limb.[1]
  • It is most commonly caused by prolonged obstructed labour. The child is often stillborn and there is a risk to future fertility if cervical damage has occurred.[2]
  • Unsurprisingly, this highly stigmatizing condition has a significant impact on mental health as well as social and conjugal relations.[3]
  • It is estimated that each year between 50 000 to 100 000 women worldwide are affected by obstetric fistula and that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.[4]

Aetiology[edit | edit source]

  • Most common cause: Prolonged, obstructed labour (lasting for up to 5 days)[2]
  • Social causes that contribute to obstructed labour include: lack of access to maternal health services; poverty; lack of education; role of women in decision making; early marriage; harmful traditional practices such as Female Genital Mutilation; lack of access to and uptake of family planning resulting in the planned spacing of childbearing
  • Obstructed labour could be avoided by:
  1. delaying the age of first pregnancy, so that the pelvic ring is fully developed meaning there is more room for the foetal head to pass through the pelvic canal
  2. cessation of harmful traditional practices
  3. timely access to maternal and obstetric care; these include the three delays of 1) making the decision to access medical care 2) making the journey to the nearest medical care facility 3) once at a medical care centre, receiving treatment from an appropriately skilled practitioner[4]
  • Other (less common) causes in low-resource setting include: sexual abuse and rape; the complications of unsafe abortions; and surgical trauma (most commonly, injury to the bladder at caesarean section) [5]
  • Other (less common) causes in high-resource setting include: Crohn’s disease; gynaecological cancer and infection.; and as an unintended consequence of medical interventions such as colorectal anastomosis, anorectal operations, or radiation therapy (uncommon in low-resource settings)[6]

Clinically Relevant Anatomy[edit | edit source]

Female reproductive system

Obstetric fistula involves the renal system, the female reproductive system and, in obstructed labour, the neurological system and consequently the musculoskeletal system of the lower limbs[5]. The fistula involves an abnormal opening between the vagina and the bladder (a vesicle-vaginal fistula or VVF) or the vagina and the rectum (a recto-vaginal fistula RVF).

Renal damage:

  • bladder - tissue loss from necrosis causes reduced volume and reduced bladder compliance
  • urethra - fibrosis of the urethra causing urine incontinence
  • ureters - substantial damage to the bladder neck may affect the ureteral orifices
  • kidneys - due to possible ascending infection

Genital tract injuries include:

  • vagina - fibrosis and vaginal stenosis may lead to infertility
  • cervix and possibly the uterus - cervical injury may lead to pelvic inflammatory disease and cervical incompetence
Lumbo-Sacral Plexus

Neurological injuries include:

  • Lumbo-sacral plexus - this suffers compression during the obstruction, resulting in lower limb neurological deficiencies, such as altered sensation, muscle weakness and contractures
  • Peroneal nerve compression - caused by prolonged squatting during labour and result in foot drop
  • Nerves in the bladder - if injured can cause neurogenic bladder

Musculoskeletal injuries:

  • Foot drop and resulting contractures
  • Muscle weakness resulting from nerve injury and de-conditioning
  • Dysfunctional pelvic floor muscle group, including the levator ani muscle, the coccygeus, and connective tissue.

Mechanism of Injury[edit | edit source]

Obstetric Fistula resulting from obstructed labour is caused by the necrosis of the surrounding tissue in the birth canal due to pressure of the baby’s head against the pelvis. The reduced flow of blood to the soft tissues surrounding the bladder, vagina and rectum results in necrosis of the tissue. If the mother survives, this kind of labour often ends when the fetus dies and gradually decomposes enough to slide out of the vagina. The injured pelvic tissue also rots away, leaving a hole, or a fistula, between adjacent organs[7].

Compression to the lumbo-sacral plexus can result in nerve injury affecting sensation and muscle power of the lower limbs. If there is a delay between onset of injury and treatment intervention, secondary musculoskeletal injuries such as contractures and extensive muscle weakness can result.

Clinical Presentation[edit | edit source]

  • Urinary and/or Faecal incontinence[1]
  • Ongoing genital infections[1]
  • Anaemia[1]
  • Neurological symptoms affecting the lower limb causing foot drop, altered gait, significant muscle weakness[1]
  • Low mood/psychological distress

Diagnostic Procedures[edit | edit source]

Diagnosis is based on taking a careful history, where the patient complains of constant urine leakage, the onset of which was directly after labour and/or delivery or pelvic trauma. The history should include details of the labour, how it was managed, the position of the foetus, the mode of delivery, the outcome for the baby, details of the urinary or faecal incontinence, problems with mobility, any relevant past medical history, and a social history including any issues that may have arisen as a result of the fistula[7]

The physical examination should include a visual inspection looking for signs of urinary dermatitis, ulceration, skin or urine infection, faecal soiling and genital cutting. A vaginal speculum examination may be performed, during which the site, number and size of fistulas should be documented, along with whether there is any urethral involvement, vaginal scarring or presence of recto-vaginal fistula. Tests involving methylene blue dye or phenazopyridine hydrochloride which stains the urine orange, may be used to help identify the location of the fistula[7].

The fistula are then classified according to certain criteria based on the degree of anticipated difficulty of repair, determining them to be either 'simple/ good prognosis' or 'complicated/ uncertain prognosis'[7].

The physical examination should also encompass psychological assessment and appropriate support should be offered.

Outcome Measures[edit | edit source]

Management / Interventions
[edit | edit source]

  • Surgery: surgery can be a simple process but surgeons need special training to carry out repairs. Specialised fistula hospitals exist in areas of high prevalence i.e. Ethiopia, Sierra Leone, DRC
  • Supportive nursing care, pre- and post-operatively care: this includes catheter management and education
  • Physical rehabilitation: to address nerve injury; musculoskeletal issues; gait disturbance and pelvic floor deficiency[2]
  • Education, to incorporate: the cause of the injuries and incontinence, the treatment and the rehabilitation required[7]
  • Psychological support: individual and group support should be offered where possible[7]

Physiotherapy Management[edit | edit source]

  • Structured tailored exercise programme (passive, active-assisted stretching), active-assisted range of movement exercises and active range of movement
  • Manual therapies, such as desensitisation massage
  • Gait re-education and use of appropriate walking aids
  • Contracture management
  • Orthotics such as ankle foot orthosis, resting splints to encourage dorsiflexion range of movement
  • Pelvic floor muscle rehabilitation (exercises)
  • Bladder re-education programme

[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 Muleta M, Hamlin C, Fantahun M, Kennedy R and Tafesse B. Health and Social Problems Encountered by Treated and Untreated Obstetric Fistula Patients in Rural Ethiopia. Journal of Obstetrics and Gynaecology Canada. 2008.30(1). pp. 44-50. 30(1). pp. 44-50. Available from https://pubmed.ncbi.nlm.nih.gov/18198067/ [Accessed 22 Nov 2021]
  2. 2.0 2.1 2.2 Lombard L, St. Jorre J, Geddes R, El Ayadi A and Grant L. Rehabilitation experiences after obstetric fistula repair: systematic review of qualitative studies. Tropical medicine and International health. 2015 20(5). pp. 554-568. Available from https://pubmed.ncbi.nlm.nih.gov/25640771/ [Accessed 21 Nov 2021]
  3. Desalliers J, Pare ME, Kouraogo S and Corcos J. Impact of surgery on quality of life of women with obstetric fistula: a qualitative study in Burkina Faso. International Urogynecological Journal. 2017. 28(7). pp.1091- 1100. Available from https://pubmed.ncbi.nlm.nih.gov/28025680/ [Accessed 21 Nov 2021]
  4. 4.0 4.1 World health Organisation. Obstetric Fistula [online]. 2021. Available from: https://www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula [Accessed 18 Nov 2021]
  5. 5.0 5.1 Wall LL, Arrowsmith SD, Briggs ND, Lassey A. Urinary Incontinence in the developing world: The obstetric fistula. Proceedings of the Second International Consultation on Urinary incontinence, Paris 2001:1-67. Available from https://www.gfmer.ch/fistula/pdf/Obstetric-fistula-2015.pdf. [Accessed 21 Nov 2021]
  6. Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL Steele SR. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the Colon & Rectum. 2016 59:12. Available from: https://fascrs.org/ascrs/media/files/downloads/Clinical%20Practice%20Guidelines/clinical_practice_guideline_for_the_management_of_anorectal_abscess_fistula-in-ano_and_rectovaginal_fistula.pdf [Accessed 20 Nov 2021]
  7. 7.0 7.1 7.2 7.3 7.4 7.5 Lewis G, de Bernis L. Obstetric Fistula: guiding principles for clinical management and programme development. Prepared for World Health Organisation.2006. Available from: https://apps.who.int/iris/handle/10665/43343 [Accessed 20 Nov 2021]