The Burden of Vesico-Vaginal Fistula In North Central NigerIa

Abstract

Background: Vesico Vaginal Fistula (VVF), as seen in this environment, is a major cause of severe morbidity and potential mortality, which can result in marital disruption, rejection and, eventual destitution.

Aims and Objectives

To determine the socio-demographic characteristics, fistula features, and evaluate the intervention measures in Jos, North Central Nigeria.

Setting

This study was carried out at the VVF Centre, ECWA Evangel Hospital, Jos, North Central Nigeria.

Design of the study

Descriptive retrospective study.

Materials and Methods

The patients’ records from January 1 to December 31, 2007 were retrieved and analyzed for the demographics, clinical features, management and outcome using EPI Info version 3.4.3, 2008.

Results

A total of 314 patients were treated. The patients aged between 12 to 60 years (SD 6.19) with a mean parity of 3.7. Seventy percent (70%) of the patients were married and living with their husbands, while 65% of the patients were illiterate farmers. Christians and Muslims patients made up 60% and 40% respectively. Juxta-cervical (26%) and juxta-urethral fistulae (26%) were the commonest types, with obstructed labour being the causative factor in 82% of the patients. Ninety three percent of the repairs were repaired via the vaginal approach. The success rate at repair was 69%. Post-operative complications occurred in 16% of the patients.

Conclusion

Vesico- vaginal fistula is a problem in this environment, occurring mainly amongst the illiterate farmers after prolonged obstructed labour. Public enlightenment and appropriate ante-natal care and delivery would reduce the incidence.

Introduction

Vesico-vaginal fistula (VVF) of obstetric aetiology was first reported in the literature by the physicians of ancient Egypt about 2050 BC.1,2,3 This dehumanizing condition has continued to inflict high morbidity in young mothers in the rural populations in the developing countries of the world even till date5.

The exact magnitude of VVF worldwide is unknown. However, the World Health Organization (WHO) estimated that over 20 million women are living with this condition, with 50,000 to 100,000 new cases per annum.2,6,7 The incidence in West Africa is estimated to be 3 to 4 per 1000 deliveries.2 This is attributed to poverty, illiteracy, ignorance and poor obstetric services.4,5,6 Zacharin puts it right: “In an unequal world, woman with fistula are the most unequal among the unequal”.8

In Nigeria alone, 800,000 to 1,000,000 women are estimated to be awaiting repair.5 As in most third world countries, most women acquire it while performing their legitimate obstetric function.9,10,11,12,13

The situation in the developed world is now different. Advances in obstetric care have made the various sequelae of obstructed labour nearly obsolete. 3,5,6.

VVF from prolonged obstructed labour occurs as a result of ischaemic necrosis of entrapped soft tissues between the fetal skull and the maternal pelvis which subsequently sloughs off leaving a defect between the epithelial surface of the urinary bladder and that of the vagina and occasionally involving the rectum as well.13,14,15 Although the obvious injuries of clinical interest are to the vagina, urinary bladder and/or rectum, they constitute only a fraction in the range of the devastating injuries produced by obstructed labour.

Radiation treatment for pelvic cancers can lead to fistula formation as reported in 1.4% to 5.2% of post-radiation hysterectomies.13, 14

Focal injuries to the genitourinary tract during hysterectomy, and caesarean section can cause VVF. Additional causes of vesico-vaginal fistulae are congenital abnormalities, infection, trauma and foreign bodies but these are relatively rare.1

Many classification systems exist for VVF. One of such is that described by Lawson, who classified genitourinary fistulae into juxta-urethral, mid-vaginal, juxta-cervical, large, vault, and combined (with coexisting recto-vaginal fistula).16,17 . Fistulae can also be classified based on size into small, medium, large, and extensive.17 Elkins in his review, grouped fistulae into five categories i.e. vesico-cervical, juxta-cervical, mid-vaginal, sub urethral and urethra-vaginal fistulae.18 Waaldijk proposed three types of fistulae; type I (not involving the urethral closure mechanism), type II (involving the urethral closing mechanism) and type III (involving the ureter and other exceptional fistulae).12 As useful as they are in communicating the appearance of a given fistula, no information is given to capture the prognosis for successful outcome or difficulty of repair. These drawbacks have led to the call for a classification that is evidence based putting these factors into consideration.11,12

Various conservative and non-invasive treatments for VVF exist but most are of doubtful significance.13 Surgical correction remains the primary method of repairing VVF with good success rates17,19 Generally, the success rate of 69% to 95% at first repair is encouraging 20.

This study is designed to determine the socio-demographic characteristics and features of the fistulae, as well as to evaluate the intervention measures at a Fistula Centre in Jos, Nigeria.

Reports

MATERIALS AND METHODS

This study was a descriptive retrospective study carried out at the Bingham University Teaching Hospital (Formerly called ECWA Evangel Hospital) VVF Centre, Jos, North Central Nigeria, from 1^stJanuary to 31^st December 2007. Approval was obtained from the hospital ethical committee. Data were collected from the patients’ folders, records from the operating theatre, as well as the wards. Information obtained from these sources included age, parity, marital status, educational status, occupation. Others included the fistula characteristics like duration of the fistula, probable cause, type of fistula, outcome of repair, and post operative complication, The data were entered into a proforma on EPI info analyzed using EPI Info version 3.4.3.

RESULTS

During this period of study, a total of 314 patients with VVF were managed. The patients were within the age range of 12 to 60 years, with a mean age of 29 years (SD 6.19). The mean parity was 3.7. Seventy percent (70%) of the patients were married and living with their husbands. Of those who had urinary diversion, 4 (30.7%) were living with their husbands, 2 (15.3%) divorced, while the marital status of 7 (54%) was not stated. Most (65%) of the patients had no formal education and were mainly farmers in 55% of cases (Table 1). Sixty percent (60%) of the patients were Christians 40% were Muslims while less than 1% practiced traditional religion. Forty-eight (48%) percent of the patients delayed for over a year, while 5.7% waited for more than 20 years before presentation at the hospital. Juxta-cervical (26%) and juxta-urethral fistulae (26%) were the commonest types with obstructed labour as the causative factor in 82% of the patients. Ninety three percent (93%) of the repairs were done per vaginam. Five percent (13) were repaired per abdomen to enable urinary diversions into the large bowel (Mainz’s pouch) as shown in Table 2.

Spinal anaesthesia was used in 84% of the patients, general anaesthesia in 6%. . The success rate at repair was 68%. Post-operative complications occurred in 16% of the patients.

Conclusions

In conclusion, vesico- vaginal fistula is a problem in this environment, occurring mainly amongst the illiterate farmers after prolonged obstructed labour. Public enlightenment and appropriate ante-natal care and delivery would reduce the incidence.

Discussion

This study showed that the patients seen in this Centre come from many parts of Nigeria, and not restricted to the North Central region of Nigeria. This is not surprising as it is a referral Centre for other hospitals. Most of these patients (60 %) were Christians, in contrast to the findings in Sokoto where Hausa/Fulani Moslems predominated21 with mean age at presentation of 29 years, which is similar to the 34 years, reported from Eastern Nigeria22. Most (54%) of the patients presented with vesico-vaginal fistulae in their second pregnancy, which suggested that poor intra-partum care, rather than immature pelvis was responsible for the disease.

The low socio–economic status of the patients in this study was typical of findings in other developing countries of the world1,2,3,4,5,6. They were mostly farmers with 67%% having no formal education and only 1% had tertiary education. This may explain the high prevalence and delay in presentation with only less than 40% presenting within 1 year of injury and others delay for over 10 years 13% of cases.

Juxta-cervical and Juxta-urethral fistulae were the commonest which was similar to the findings in eastern Nigeria.22

Prolonged obstructed labour remained the commonest cause in 82% of cases, as it is in other developing countries. Twenty four percent (24%) of these patients still developed genital fistula despite caesarean section for prolonged obstructed labour, indicating late caesarian section would not prevent the development of VVF. Gishiri cut, which is a traditional incision practiced in Northern Nigeria, contributed 2% of the cases of the fistulae compared to 6 % in Maiduguri24 and 13% in some parts of Northern Nigeria9. This is in contrast to the picture in the developed world where more than 50% are caused by gynecological surgeries2,3,4,5,6,7.

Majority of the repairs were done through the vaginal route because of its relative technical ease, low morbidity and shorter operating time6. However, 5% of the patients had urinary diversions into the large bowel as prior attempts at repair elsewhere had failed. It is noteworthy that 4 of these patients were still married and were living with their husbands.

Successful closure with restoration of continence was achieved in 68% of the patients, which is similar to the accepted success rate range of 69 – 95%3. Fourteen percent (14%) of patients still had urinary incontinence despite successful closure of the fistula at surgery. This is similar to findings of 10 to 16 % in other studies.36 This usually results in disappointment to both the surgeon and the patient. Applying slings intra-operatively at repair reduce the incidence of this complication.28

There is no doubt that the prevalence of vesico-vaginal fistula is still high. It has been estimated that it will take over 30 years to clear the back log of existing fistulae in Nigeria if the repair continuous at the present rate.30 Hence, there is need to aggressively train appropriate health personnel, and establish more centers in the country where VVF can be repaired successfully.

Cure goes beyond achieving continence only. Rehabilitation and psychotherapy with skills acquisition will go a long way in addressing some of the patients’ socio-economic challenges, which are contributory to causing the fistulae.

Prevention should be the ultimate goal if this disability and dehumanizing condition is to be eliminated. This could be achieved through education of the girl child, as well as the provision of available, accessible, and affordable quality obstetric care in every part of this country to prevent prolonged obstructed labour – the major cause of VVF.

Improved childhood nutrition and infection control to ensure adequate physical growth in pelvic size would prevent obstructed labour later in life.36 Women empowerment, basic universal formal education, avoidance of early marriage, contraception as well as elimination of poverty will go a long way in eradicating this menace in our society.36

Table 1: Patients’ Sociodemographic Features

Variable	Frequency	%
Age (Years)
11-15	7	2
16-20	47	15
21-25	71	23
26-30	65	21
31-35	44	14
36-40	34	11
41-45	11	3
46-50	21	7
>50	9	3
Unknown	5	1
Total	314	100
Mean Age =29year: SD= 6.19
Parity
0	3	0
1	103	34
2	24	8
3	30	9
4	24	7
5	28	9
6	25	8
7	11	4
>7	41	13
Not stated	25	8
Total	314	100
Marital Status
Married	218	70
Divorced	35	11
Separated	28	9
Single	5	1
Widowed	9	3
Not stated	19	6
Total	314	100
Educational Status
None	197	63
Arabic	3	1
Primary	61	19
Secondary	17	5
Tertiary	4	1
Not stated	32	11
Total	314	100
Occupation
Farming	170	54
House-wife	52	16
Trader	43	14
Civil servant	4	1
Student	4	1
Tailor	1	1
Others	9	3
Not stated	31	10
Total	314	100
State Of Residence
Adamawa	13	``
Bauchi	25	8
Benue	31	9
Borno	7	2
Cross River	4	1
FCT	4	1
Gombe	23	8
Kaduna	23	8
Kano	13	4
Nassarawa	16	5
Taraba	42	13
Plateau	54	18
Others	31	9
Not Stated	28	10
Total	314	100

Table 2: Fistula Features

Variable Duration Of Fistula Before Presentation	Frequency	Percentage
< 6Months	60	19
6Month-<1 Year	59	19
1-5years	86	27
6-10years	44	14
11-15years	19	6
16-20years	20	6
>20years	4	1
Not stated	22	8
Total	314	100
Cause of Fistula
Obstructed Labour	256	82
Hysterectomy	21	7
Caesarean section	17	5
Instrumental delivery	8	2
Instrumental delivery	8	2
Trauma	1	0
Others	5	2
Total	314	100
Type of Fistula
Juxtacervical	81	26
Juxta-urethral	80	25
Large	51	17
Midvaginal	25	8
Uretero-vaginal	13	4
Vault	12	4
Vesico-uterine	15	5
VVF* + RVF**	9	3
Previous Failed Repair	13	4
Not stated	16	5
Total	314	100
Outcome of Repair
Continent	216	69
Failed repair	52	17
Urethral leak	42	13
Not stated	4	1
Total	314	100
Post Operative Complication
None	262	83
Wound Infection	14	5
UTIǂ	14	5
Pyrexiaα	11	4
Hemorrhageβ	7	1
Others	6	2
Total	314	100
ǂUTI= Urinary Tract Infection*VVF= Vesico-vaginal fistula**RVF= Rectovaginal FistulaαPyrexia = Temperature > 37.4oC after first post operative dayβHaemorrhage = Blood loss > 500ml