Obstetric Fistula: Difference between revisions
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== Description == | == Description == | ||
* 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<ref>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.</ref>. | * 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<ref name=":2">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.</ref>. | ||
* It is most commonly caused by prolonged obstructed labour (although it sometime results from sexual abuse or as an unintended result of obstetric surgery). The child is often stillborn and there is a risk to future fertility if cervical damage has occurred<ref>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.</ref>. | * It is most commonly caused by prolonged obstructed labour (although it sometime results from sexual abuse or as an unintended result of obstetric surgery). The child is often stillborn and there is a risk to future fertility if cervical damage has occurred<ref>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.</ref>. | ||
* Unsurprisingly, this highly stigmatizing condition has a significant impact on mental health as well as social and conjugal relations<ref>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.</ref>. | * Unsurprisingly, this highly stigmatizing condition has a significant impact on mental health as well as social and conjugal relations<ref>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.</ref>. | ||
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* vagina - fibrosis and vaginal stenosis may lead to infertility | * 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 | * cervix and possibly the uterus - cervical injury may lead to pelvic inflammatory disease and cervical incompetence | ||
[[File:Sacral Plexus.png|thumb|Lumbo-Sacral Plexus]] | |||
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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<ref name=":0" />. | 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<ref name=":0" />. | ||
Compression to the lumbo-sacral plexus can result in nerve injury affecting sensation and muscle power of the lower limbs | Compression to the lumbo-sacral plexus can result in [[Nerve Injury Rehabilitation|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 == | == Clinical Presentation == | ||
* Urinary and/or Faecal incontinence<ref name=":2" /> | |||
* Ongoing genital infections<ref name=":2" /> | |||
* Anaemia<ref name=":2" /> | |||
* Neurological symptoms affecting the lower limb causing foot drop, altered gait, significant muscle weakness<ref name=":2" /> | |||
== Diagnostic Procedures | == Diagnostic Procedures == | ||
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 unitary 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<ref name=":0" /> | |||
The physical examination should include direct observation of urine passing from the vagina and a vaginal speculum examination may be performed, during which the site and number of fistulas should be documented. Tests involving Methylene blue dye or phenazopyridine hydrochloride which stains the urine orange, may be used to help identify the location of the fistula<ref name=":0" />. | |||
The fistula will then be classified according to [WHO classification]:<br> | |||
== Outcome Measures == | == Outcome Measures == | ||
Revision as of 07:42, 20 November 2021
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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 (although it sometime results from sexual abuse or as an unintended result of obstetric surgery). 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)[5]
- 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:
- delaying the age of first pregnancy, so that the pelvic ring is fully developed meaning there is more room for the feral head to pass through the pelvic canal
- cessation of harmful traditional practices
- 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). [6]
- 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)[7]
Clinically Relevant Anatomy[edit | edit source]
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[6]. 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
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 injuries can cause neurogenic bladder.
Mechanism of Injury / Pathological Process[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[4].
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]
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 unitary 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[4]
The physical examination should include direct observation of urine passing from the vagina and a vaginal speculum examination may be performed, during which the site and number of fistulas should be documented. Tests involving Methylene blue dye or phenazopyridine hydrochloride which stains the urine orange, may be used to help identify the location of the fistula[4].
The fistula will then be classified according to [WHO classification]:
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Management / Interventions
[edit | edit source]
Surgery - simple but need training. Special fistula hospitals. Most doctors in low resource settings lack the training or resources to identify and repair fistula
Physical rehabilitation
Education
Psychological support
Physiotherapy Management[edit | edit source]
Pre-op
Post-op
Resources
[edit | edit source]
Obstetric Fistula E-learning course - https://www.gfmer.ch/fistula/Obstetric-fistula-2015.htm
References[edit | edit source]
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 4.0 4.1 4.2 4.3 4.4 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
- ↑ 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.
- ↑ 6.0 6.1 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.
- ↑ 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]
