Classification of Obstetric Fistulae

• Vesicouterine fistula (VUF): Between bladder and uterus.
• Vesicovaginal fistula (VVF): Between bladder and vagina.
• Urethrovaginal fistula (UVF): Between urethra and vagina.
• Rectovaginal fistula (RVF): Between rectum and vagina.
• Ureterovaginal fistula: Between ureters and vagina.

Etiologies

• Obstructed labor (>80%).
• Lack of access to emergency obstetric care.
• Iatrogenic causes:
• Caesarean section.
• Assisted vaginal deliveries.
• Total and subtotal abdominal hysterectomies.
• Other causes:
• Radiation.
• Granulomatous diseases (e.g., tuberculosis).

Risk Factors for Obstetric Fistula

• Lack of access to medical facilities, obstetric care, and emergency caesarean section.
• Lack of adequately trained, skilled medical staff.
• Lack of medical supplies and equipment.
• Poverty.
• Malnutrition.
• Early marriages.
• Lack of formal education.
• Cultural beliefs and traditions (e.g., Female Genital Mutilation – FGM).

Diagnosis

• History: Constant leakage of urine from the vagina, History of obstructed labor,  Instrumental delivery.

• Physical Examination:  Ammonia smell, Excoriation of vulva skin, Recurrent cystitis.

• Investigations: Full Blood Count (FBC), Urinalysis, Serum urea, creatinine, electrolytes.

• Sim’s position: 3 swab test with methylene blue.

Complications of Fistula

• Recurrent fistula.
• Recurrent vaginal and urinary infections.
• Vaginal stenosis.
• Hygiene problems.
• Bladder symptoms.
• Sexual problems.
• Reduced bladder capacity.

Management

Conservative

• Applicable for simple fistula <1 cm.
• Diagnosed within 7 days of occurrence.
• Foley’s urethral catheter.

Surgical

• Repair after 3 months of occurrence.
• Preoperative preparation:
• Nutrition.
• Infection control.
• Dermatitis management.
• Urine acidification.
• Psychological preparation.

Principles of Surgery:

• Wide tissue mobilization.
• Adequate exposure.
• Haemostasis.
• Aseptic technique.

Postoperative Care

• Keep catheter in situ for 14 days.
• Principle of 3 Ds:
• Take fluids.
• Bed dry.
• Catheter draining.

Advice at Discharge

• Delay sexual intercourse for 3 months.
• Pass urine frequently.
• Defer pregnancy for one year.
• Deliver in a hospital.

Prevention of Fistula

Primary Prevention

• Girl child education.
• Women empowerment.
• Collaboration with religious and cultural leaders.

Secondary Prevention

• Avoid obstructed and prolonged labor using a partograph.
• Caesarean section in indicated cases.
• Avoid difficult forceps and destructive deliveries.
• Keep catheter in situ for 7 to 14 days in obstructed labor and bladder repair.

Tertiary Prevention

• Early detection and repair.
• Rehabilitation and integration into the community.
• Family support.
• Delivery in the hospital.