This is one of the stories from the September 2012 issue of International News. Andrew Browning, the Director of the Selian Fistula Project in Arusha, Tanzania, discusses the problem of residual incontinence following obstetric vesicovaginal surgery.
Use the table below to access other stories in this issue.
Obstetric vesicovaginal fistula surgery presents many challenges. The injury usually occurs in resource-poor areas and is thus managed in hospitals that are themselves poorly resourced. The pathology is complex and extensive, affecting any, and sometimes all, parts of the lower urinary tract. The long obstructed labour and resulting ischaemia throughout the pelvis can destroy all the normal mechanisms for urinary continence.
It is one thing to be able to close the defect and try to restore normal anatomy, but it is quite another thing altogether to obtain a functional closure, ensuring normal continence. There are varied reports about the extent of incontinence after fistula surgery, from 8%1 to more widely accepted figures of 18–33%,2 even up to 47% in an unpublished survey performed in the Addis Ababa Fistula Hospital in 2003. As with all things, it depends on how closely you look for the problem. In the early work by Kelly and Kwast,1 the figure was the number of women returning to the hospital with continuing incontinence despite a closed fistula. It is likely that many women would have remained at home with mild incontinence. The figures of 18–33% had a standard way of looking for incontinence including a basic set of structured questions ranging from ‘are you wet with cough or heavy activity?’ to ‘are you leaking urine involuntarily when lying?’.2 A cough examination with a full bladder was used to confirm the diagnosis.
The exact nature of the incontinence is often complex and only a handful of studies have investigated the nature of the pathology. One study3 of 22 women with severe incontinence following fistula closure underwent urodynamic assessment: 41% had genuine stress incontinence (GSI); 14% had GSI and poor compliance; 41% had GSI and detrusor overactivity, and 4% had voiding disorder and overflow incontinence.
The prognostic factors associated with incontinence after fistula surgery have been shown in observational studies and include:4
- If the urethra is involved in the defect; the strongest determining risk factor with an odds ratio of 8.4. The urethra is involved in some way in up to 63% of cases (unpublished series, Browning, Barhirdar, Ethiopia).
- If there is significant vaginal scarring, such that a small Sims speculum cannot be inserted into the vagina without relaxing incisions.
- The larger the fistula.
- If there is a reduced bladder volume, more so if less than 100ml.
During the first operation, at the time of fistula repair, a simple method can be used to try and reduce the rate of continuing incontinence after repair. For all urethral fistulae larger than 4mm, a sling of pubococcygeal muscle (or scar tissue if the sling had been destroyed by the long labour) placed beneath the urethra can reduce the incontinence rate in these women from 33% to 18%. This has been shown in a retrospective analysis2 but has yet to be proven prospectively.
Continuing incontinence after surgery poses an enormous problem for the woman. If the continuing incontinence is severe, such that the woman is still leaking when walking and lying, she will have difficulty reintegrating into her normal life, will suffer depression and will think that not much was actually achieved during the operation.5,6
There are a number of ways to manage the patient and try to improve her condition and quality of life. The simplest is to teach her pelvic floor exercises. If the incontinence is mild, leaking only on coughing or mild exercise, 50% of women will be cured after six months of this conservative management, although there is some doubt whether the exercises are actually carried out as claimed! If the incontinence is more severe, with leaking while walking, sitting and lying, only 18% will be improved at six months.6 For this latter group a urethral plug is a good option if it is available (see image). It not only keeps the patient dry but if the patient has a small bladder the continual obstruction can help her bladder expand. Anecdotally, we have seen bladder volumes increase from 100ml or less to up to 300ml by using a urethral plug for six months.
The standard practice at Barhirdar Fistula Centre in Ethiopia was to ask patients to come back at six months for follow-up. If a woman was still incontinent and a recurrent fistula had been excluded, an incontinence procedure was undertaken. The principle of this was to lengthen the urethra as the average length of the urethra was 1.4cm in this patient group. This was done by severe plication of the remaining urethra and the bladder base along with a sling of pubococcygeal muscle. The average urethral length after the operation was 3cm and again this is maintained in the majority at six months’ follow-up.
The cure rate from this operation is around 70% and largely maintained at six months’ follow-up. Longer-term follow-up is not yet available. The remaining 30% of women would be evenly divided to 15% improved severity of incontinence and 15% no change in incontinence. Most of these women would be dry when using the urethral plug and with this be able to live a relatively normal life.
The women still suffering with continuing incontinence after fistula repair also pose a long-term management problem. Most of these women are still young, in their twenties, and they face another 30 or 40 years, maybe longer, with this problem and might be dependent on a device such as a urethral plug for all this time. Later in life there is undoubtedly a potential for recurrence of incontinence making further management more troublesome. It is sobering to remember that this long-term suffering could have been easily prevented if the woman had been able to get to a hospital for a timely and safe delivery.
Andrew Browning, Director of the Selian Fistula Project, Arusha, Tanzania
1. Kelly J, Kwast BE. Epidemiological study of vesico-vaginal fistulas in Ethiopia. Int Urol J 1993;4:278–81.
2. Browning A. A new method for preventing residual urinary incontinence after successful closure of vesico-vaginal fistula. BJOG 2004;111:357–61.
3. Carey MP, Goh JT, Fynes MM, Murray CJ. Stress urinary incontinence after delayed primary closure of genitourinary fistula: a technique for surgical management. Am J Obstet Gynecol 2002;186:948–53.
4. Browning A. Risk factors for developing residual incontinence after vesicovaginal fistula repair. BJOG 2006;113:482–5.
5. Browning A, Fentahun W, Goh JTW. The impact of surgical treatment on the mental health of women with obstetric fistula. BJOG 2007;114:1439–41.
6. Browning A, Menber B. Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment. BJOG 2008;115:1564–9.