This is one of the stories from the September 2012 issue of International News. Michael Bishop is a retired consultant urologist who has had a long career working in fistula care in countries such as Uganda, Sudan and more recently Nepal. In this article he gives an overview of the problem of obstetric fistulae.
Use the table below to access the other stories in this issue.
Obstetric injury is one minor component of maternal mortality but both are surrogate markers for the quality of antenatal and intrapartum care and reflect the ability and willingness of an administration to provide socialised health care.1,2 It is one simple factor among many others defining national status as the developing world. Historically, the recognition that obstetric fistulae were caused by social deprivation was acknowledged and reflected tangibly in the closure of the New York Fistula Hospital less than 100 years after its opening. Such a specialised facility was no longer required, with a dramatic fall in maternal mortality rates reflecting public health improvements resulting from increasing industrialisation and prosperity.
Obstetric fistulae are caused mainly by ischaemia of adjacent pelvic organs resulting from obstructed labour from delay in provision of facilities for operative delivery. Other contributory factors in developing countries include harmful cultural influences, poverty, ignorance, illiteracy and low esteem in which women are still held. Specifically when labour does not progress, traditional birth attendants may waste critical time, even if it is recognised that western style facilities are required. Transport may be poor or non-existent and the health centre to which the woman is taken may have no resident medical staff or equipment. This in turn reflects on such issues as emigration of medical staff, corruption and maladministration.
The emergence of national leadership committed to good governance and with a will to provide sustainable developments in education and community health can deliver improvements in maternal care. This has been shown in analyses of national trends but more dramatically in reports of local initiatives.3
Unfortunately there is a major problem of confidence in data provided from official sources on maternal mortality and obstetric fistulae in particular. With the proximity of the 2015 deadline for assessing achievement against the Millennium Development Goals (MDGs), specifically MDG 5, official pressure to publish positive outcomes is likely to be intense. But the process from data collection to analysis is flawed. This is hardly surprising in countries where comprehensive registration of births and deaths is non-existent. Even if a determined effort is made to document various aspects of maternal health in a defined segment of the population, this will be disrupted by political turmoil and war, both of which are likely to lead to escalation in incidence of maternal death and fistulae. At a local level, the accuracy of data collection is also likely to be limited by a reluctance to admit to the problem, which for many is a cause for shame and exclusion from society. Invariably, official government estimates of incidence and prevalence of fistulae underestimates the problem. A more accurate impression may come when a local population becomes aware of a facility offering successful fistula repair and the service is broadcast by local media supported by community education programmes originating in the health facility. This is particularly well exemplified where a new service is established, for example, in Nepal.
Fistula surgery is bedevilled with problems of classification and assessment of outcome. Several systems are available for grading of the fistula according to the likelihood of success with closure and a reasonable functional result in the hands of a competent surgeon.4,5 The relatively poor prognostic implication of involvement of the urethra and closure mechanism is acknowledged but they are difficult to use and the objective classification of a fistula often needs to be qualified by additional description.
Outcome is particularly difficult to assess in a population of patients who are often itinerant or live far away from the fistula centre. Often the surgeon will have returned home before the catheter is removed. Ideally, just before this is done, a dye test should be performed to assure at least early evidence of closure but this is by no means the rule in every unit. Until recently, closure tended to be the marker of success in fistula surgery. Several publications by acknowledged experts have provided useful benchmarks of surgical expertise and short-term results.6 However, perhaps with increasing involvement of urologists and urogynaecologists, there is growing recognition that stress incontinence is a common problem leading to a poor outcome. Other consequences of the ischaemic process may also have been underestimated: necrosis of the bladder wall will be self-evident but more subtle functional changes caused by loss of detrusor compliance and injury to parasympathetic innervation may be more difficult to detect. For obvious reasons there are few data available on the long-term symptomatic results of fistula repair and fewer still of objective outcomes in terms of even simple urodynamic assessment. Surgical success in terms of closure of the fistula have been achieved in up to 91% of cases of mixed complexity, with up to 25% having significant incontinence of urine. The majority had genuine stress incontinence but a proportion had detrusor overactivity and presumably the majority of this group had poor compliance. More surprisingly perhaps, a significant proportion of those with detrusor overactivity, either isolated or mixed with stress incontinence, responded to anticholinergic therapy.
It must be acknowledged that there is a delayed failure rate or, in other words, loss of continence despite the fact that the patient may have left hospital with good urinary control. This may be in part due to increasing stress incontinence but also to late breakdown of the repair. No doubt a multiplicity of factors is involved extending from vaginal trauma from early sexual activity to overfilling of the bladder despite advice to the patient to void regularly within the confines of a small-capacity bladder. Sadly, subsequent ill-advised attempted vaginal delivery, which may again be prolonged, can lead to breakdown of a vulnerable repair.
In the future it is possible that better follow-up data may be obtained. In other branches of health care in developing countries, for example, moderation of antituberculous therapy by Stop TB Strategy with the use of mobile phones has been of considerable help in encouraging compliance with treatment and obtaining follow-up data.
The longer a fistula unit is established, the greater the likelihood that simpler fistulae will be treated in peripheral hospitals in the network, by surgeons with less experience or confidence, but ability to recognise a fistula beyond their capabilities and to refer the patient to the central unit. Increasingly, the work of the base hospital will concentrate on the more difficult cases requiring multiple attempts at repair, operations for stress incontinence and urethral reconstruction. These generally have less satisfactory outcomes. The treatment of stress incontinence is discussed further in another article (see ‘The problem of continuing urinary incontinence after obstetric vesicovaginal surgery’) but it hardly needs emphasising that there is little comparison between treating sphincter weakness in Europe and the USA where it is largely due to extrinsic causes and attempting to correct loss of function in a short, rigid tube, which is the end result of urethral damage and repair in the setting of obstetric fistulae.
The specialist hospital will also have to focus on the ‘terminal’ patient who remains severely incontinent after multiple attempts at fistula closure and/or unsuccessful stress incontinence surgery. She can either be discharged as an emotional, physical and psychological wreck and arguably in a worse situation than when she first entered the system, or urinary diversion can be considered. The issue is extremely controversial. It is very questionable whether an ileal conduit should ever be performed where long-term stomal problems need to be managed and appliances provided on a regular basis. On the other hand, a modified ureterosigmoid diversion has been shown to be very effective in providing a satisfactory functional result, at least in the short term A counter argument has been that there will ultimately be a high risk of development of colonic tumours but more seriously perhaps, there is little opportunity to monitor the patient for serum electrolyte abnormalities and progressive chronic metabolic acidosis.
Finally, fistula surgery should be no exception to the principle of recognising the need for continuing audit and research with due consideration for the application of and discussion of ethical issues. It should surely be self-evident that a surgeon from the West should operate to the same rigorous standards in a developing country even though his or her work will be less likely subject to critical scrutiny than back home. It is to be hoped that the recently established International Society of Fistula Surgeons will set standards, encourage membership and submission of research papers, unify practice and coordinate the work of the multitude of organisations involved in fistula care.
1. Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011–9.
2. United Nations Population Fund, EngenderHealth. Obstetric Needs Assessment Report: Findings from Nine African Countries. New York: UNFPA, EngenderHealth; 2003.
3. Rwamasirabo E. VVF Prevention Programme in Rwanda. Presentation to 27th Annual European Association of Urology Congress, 24–28 February 2012, Paris.
4. Goh JTW, Browning A, Berhan B, Chang A. Predicting risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system. Int Urogynaecol J 2008;19:1659–62.
5. Waaldijk K. Step by Step Surgery of Vesico-Vaginal Fistulas. Edinburgh: Campion; 1994.
6. Raasen TJ, Verdaasdonk EGG, Vierhout ME. Prospective results after first time surgery for obstetric fistulas in East African women. Int Urogynaecol J 2008;19:73–9.