Tandem vaginoscopy with colonoscopy: a diagnostic technique for the assessment of colovaginal fistula.

AIM: Colovaginal fistula (CVF) has a negative impact on quality of life. Identifying the fistula track is a critical step in its management. In a subset of patients, localizing the fistula preoperatively can be difficult. The purpose of this report is to describe the technique and results of tandem vaginoscopy with colonoscopy (TVC). METHOD: A retrospective analysis was conducted of all patients referred to a tertiary centre with symptoms suggestive of CVF but no prior successful localization of a fistula. TVC was performed by one colorectal surgeon in the endoscopy suite under intravenous sedation. RESULTS: Between 2003 and 2013, 18 patients (median age 58 years) underwent TVC. CVF was ruled out in three patients. In the remaining 15 patients, TVC documented the fistula in 13. In eight cases a wire was passed through the fistulous track from the vagina to the colon, in three the track was large enough to be traversed with the endoscope and in two a fistulous opening was noted on the vaginal side but passage of a wire to localize the opening on the colonic side was not possible due to extensive scarring. No TVC-related complications were recorded. The sensitivity, specificity, positive predictive value and negative predictive value for TVC in detecting CVF were 86.7%, 100%, 100% and 60%, respectively. CONCLUSION: TVC is a useful technique that can localize the fistulous track in most patients with CVF.

Caring for children with colorectal disease in the context of limited resources.

The management of patients with colorectal disease in the pediatric population is challenging. Such management is all the more challenging when facing the constraints imposed by an environment with limited clinical resources. Three types of colorectal problems are highlighted in this article: anorectal malformations, Hirschsprung's disease, and acquired rectovaginal fistula in the human immunodeficiency virus-positive population. Through the use of illustrative cases, the authors discuss the pitfalls and challenges encountered in the diagnosis, treatment, and appropriate disposition of these patients. The bulk of the experience used to write this article was acquired in low- and middle-income countries in Africa. The authors hope that the lessons learned will help others manage such patients in the context of limited resources, but recognize that challenges will vary from place to place. There is no substitute for local, contextual expertise.

Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline.

It is estimated that more than 2 million women are living with obstetric fistulas (OFs) worldwide, particularly in Africa and Asia, and yet this severe morbidity remains hidden. As a contribution to the global Campaign to End Fistula, the World Health Organization (WHO) published Obstetric fistula: Guiding principles for clinical management and programme development, a manual intended as a practical working document. Its 3 main objectives are to draw attention to the urgency of the OF issue and serve as an advocacy document for prompt action; provide policy makers and health professionals with brief, factual information and principles that will guide them at the national and regional levels as they develop strategies and programs to prevent and treat OFs; and assist health care professionals as they acquire better skills and develop more effective services to care for women treated for fistula repair.

Strengthening public health priority-setting through research on fistula, maternal health, and health inequities.

OBJECTIVE: Findings from 4 studies conducted by the Women's Dignity Project and partners on the subjects of obstetric fistula, maternal mortality and morbidity, and health inequities are presented. METHODS: The studies include qualitative and quantitative research, a survey, and an analysis of secondary data that examine women's experiences of fistula; constraints in service delivery for fistula treatment; factors shaping women's access to delivery care and constraints health workers face in providing care; and health inequities. RESULTS: Findings from the studies are being used to improve fistula prevention and management, strengthen access to and provision of quality maternity care, and redress the health inequities that so adversely affect the poor. CONCLUSION: The studies provide policy makers, program managers, and service providers with evidence and the impetus to re-equilibrate policies, financial and human resources, and services in the interest of those in greatest need: women living in poverty.

Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Social and economic consequences of obstetric fistula: life changed forever?

OBJECTIVES: To summarize the social, economic, emotional, and psychological consequences incurred by women with obstetric fistula; present the results of a meta-analysis for 2 major consequences, divorce/separation and perinatal loss; and report on improvements in health and self-esteem and on the possibility of social reintegration following successful fistula repair. METHODS: We conducted a review of the literature published between 1985 and 2005 on fistula in developing countries. We then performed a meta-analysis for 2 of the major consequences of having a fistula, divorce/separation and perinatal child loss. RESULTS: Studies suggest that surgical treatment usually closes the fistula and improves the physical and mental health of affected women. CONCLUSION: With additional social support and counseling, women may be able to successfully reintegrate socially following fistula repair.