Vesico-Vaginal Fistula: The Need for Safe Motherhood Practices in IndiaDr. S. Kataria Obstructed labor remains the most important cause of vesico-vaginal fistulas in developing countries. Absent or untrained birth attendants, reduced pelvic dimensions (caused by early childbearing, chronic disease, malnutrition, and rickets), uncorrected inefficient uterine action, malpresentation, hydrocephalus, and introital stenosis secondary to tribal circumcision all contribute to obstructed labor. Prolonged impaction of the presenting fetal part against a distended edematous bladder eventually leads to pressure necrosis and fistula formation. Considerable necrosis, sloughing, tissue loss, and cicatrisation characterize obstetrical fistulas. In modern obstetrics, most of these conditions do not exist; however, genitourinary fistulas still occur rarely. The social consequences of ostracism take an enormous toll on affected women; divorce is common, and depression and suicide may follow. Many women are unaware that the condition is treatable, and are prevented from learning about appropriate care by severe social isolation as a result of their incontinence. In the first half of the twentieth century, obstetricians in India considered Vesico-Vaginal Fistula (VVF) as a hopeless condition. A Dutchman, H Van Roonhuyse, whose contribution was far in advance of his time in 1663, made the first real surgical contribution to its repair. George Hayward of Boston described the important technical point of separating the vagina from the bladder in 1839. Jobert de Lauballe stressed the tension-free suture line of the bladder wall and the vaginal mucosa in 1845. Wutzer of Bonn reported 11 of 35 as cured in 1852. He was first to use suprapubic drainage. Trendelenburg described the transvesicle approach in 1890. Maisonneuve and Mackenrodt described a technique, which approaches the modern technique to a considerable extent. In 1988, Zacharin published an interesting review of the history of obstetric vesico-vaginal fistula. The second half of the twentieth century has seen better days and better operative results in India, as well as abroad. ETIOLOGY Vesico-vaginal fistulae result chiefly from obstetric injuries. Other etiological factors in the formation of VVF are gynecological surgery, extension of carcinoma of cervix and radiotherapy. There is yet another small group of miscellaneous causes which mostly including injury in this region. The western world and affluent nations have been able to eliminate the obstetric injury resulting in VVF and have already seen its exit. In fact, Grady Memorial Hospital in Atlanta reports 150,000 deliveries in 25 years with no incidence of obstetric fistulae. Theirs is a predominantly black and indigent population. (2) Johns Hopkins Hospital reported the incidence of fistulae as follows between 1933 and 1953: Since then, there has been a further decrease in the incidence with better operative techniques, both gynecological as well obstetric. At the Mayo Clinic, 24,883 patients underwent gynecological surgery. Only one developed VVF in primary radical hysterectomy. The overall incidence of post-hysterectomy VVF has been reported as 0.5 to 1% in other institutions. These injuries will continue to plague Africa and Asia for some time. The medical world here is trying its best to reach desirable levels of efficiency. The General Hospital of Chandigarh, India (500 beds with 200 obstetric beds) conducted 5000-10,000 deliveries per year from 1965 to 1984. No obstetric fistulae occurred in these cases. In the same 19 year period, they also performed 10,440 gynecological surgeries without any resulting fistulae. This hospital does not treat carcinoma patients. Between 1965 to 1984, this hospital received 102 cases of vesico-vaginal fistulae and urinary incontinence connected with injuries to the urethra, vagina and bladder. They were as follows: i) OBS - small V.V.F. less than 1 cm 39 38% ii) OBS - large V.V.F. more than 1 cm & less than 3 cm 27 26% iii) OBS - multiple fistulae, more than 3 cm & less than 4 cm associated with either additional VVF, one or two R.V.F. or extensive damage in this region. 32 31% iv) Gyn. - post-hysterectomy 1 1% v) Misc. - post-coital or other injuries 3 3% Total 102 OBS (obstetrics) 96% GYN (gynecology) 1% Misc (miscellaneous) 3% Thirty-two of these cases had multiple fistulae: either two VVFs in one patient; or VVF accompanied by 1 or 2 recto-vaginal fistula; or extensive 3rd degree tear of the perineum; or VVF with RVF and 3rd degree perineum tear. Urban hospitals of India have achieved reasonable standards of medical care in the past 50 years. It is unfortunate that rural areas have yet to develop health services with acceptable standards, so that preventable injuries could be eliminated. MANAGEMENT Most of the patients reported for surgery long after their injury. Others who reported earlier than 3 months were advised to wait for 3 months so that treatment of infection and anemia could be given and investigations could be undertaken for better evaluation of optimum time for surgery. Post-hysterectomy VVF was referred from outside this hospital and was operated within 6 weeks after hysterectomy for reasons of anxiety on the part of the patient. All patients who reported for treatment, except 3, were operated and local re-constructive surgery gave excellent results. Ureteral catheters were inserted in all patients for safety. All fistulae were closed per vaginum. Schuchardt's incision and adequate traction achieved adequate exposure. Simple ureteral catheters and urinary bags undertook bladder drainage. In no case was suprapubic drainage applied. All cases of multiple fistulae were operated at the same time, in view of the fact that leaking fistulae of one organ may not hamper the healing process of the other. 99 of 103 cases were operated with 100% success rate at the first surgical attempt. There was no ureteral incontinence either after surgery. Post-operative management was undertaken with utmost care for strict asepsis and included 6 hourly dressings, sterile bed sheets, and continuous bladder drainage for 10 to 14 days. All cases healed well with perfect continence. Three cases had the entire anterior vaginal wall missing with much scarring. It was a considered opinion that no local surgery would benefit, and they were referred to an appropriate institution, where ileal loop surgery was feasible. Hopefully, medical service condition in India will improve in the 21st century with better bed/population ratio, as well as better doctor/population ratio, so desirable medical standards are made available in the Indian continent. References: Editor's Note: Safe Motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth. In 1987, when the Global Safe Motherhood Initiative was launched, representatives from a range of international agencies and governments committed themselves to the goal of reducing maternal deaths and morbidity. The Power of Partnership between the governments and NGOs should be encouraged to make a difference. This will help to plan long-term projects and programs at the national levels in women's health care. For more information on Safe Motherhood Initiatives, we suggest and highly recommend our readers to visit the web site: |