Obstetric fistula and safe spaces: discussions of stigmatised healthcare topics at a fistula centre.

Obstetric fistula can have major psychosocial repercussions for women and their families, which are often hidden as a result of stigmatisation. We investigated how the sexual function of women with vesicovaginal fistula differs before and after fistula repair at the Fistula Care Centre in Lilongwe, Malawi. Structured interviews and physical examinations were conducted with 115 women from the central region of Malawi. The average age of participants was 32 years and the majority lived in rural communities. Patients were more responsive than expected to discussing how genital modification, gender-based violence, marital relationships and traditional medicine impact their sexual function. Of the 115 participants interviewed, 107 (93%) reported stretching their labia and 42 (37%) were coerced into sexual activities before surgery. Before repair, 56 (49%) women reported husbands being unfaithful. 12 (10%) had new cowives after surgery. 38 (33%) used traditional medicine to enhance their sexual function before surgery. We conclude that specialised centres providing care for women, such as a fistula centre, might offer a unique space in which women can more comfortably discuss stigmatised subjects. This suggests that such issues should be incorporated into services where appropriate.

Physical etiology of sexual dysfunction in obstetric fistula patients: A prospective study.

OBJECTIVE: To understand how the physical etiology of sexual dysfunction among women with obstetric fistulas can inform repair. METHODS: A prospective cohort study included women aged 18 years or over presenting at the Fistula Care Center, Bwaila Maternity Hospital, Lilongwe, Malawi, with obstetric vesicovaginal fistula before and after repair. The study took place between January 1, 2018, and December 31, 2018, and involved physical examinations and interviews. The primary outcome was sexual function. RESULTS: 115 were interviewed before and after repair. 44 (40.0%) preoperatively and 14 (12.2%) postoperatively reported sexual dysfunction. 94 women (81.7%) had little or no interest in sexual activity before repair. 55 women (47.8%) had little or no interest in sexual activity after repair. Before surgery, 69 women (60.0%) were not sexually active in the 30 days before coming to the Fistula Care Centre. After surgery, 32 women (27.8%) were not sexually active in the 30 days before returning to the Fistula Care Centre. Of those who were not sexually active in the 30 days before coming to the Fistula Care Centre (n=69), the majority cited their health as a reason before repair (n=45, 65.2%), while the most commonly cited reason after repair was an absent partner (n=23, 35%). CONCLUSION: Given the significant percentage of women with obstetric fistula reporting sexual dysfunction after repair, a more holistic perspective of health outcomes should be considered. Further investment should be made in screening tools and surgical techniques targeting sexual dysfunction.

Rehabilitation and reintegration programming adjunct to female genital fistula surgery: A systematic scoping review.

BACKGROUND: Female genital fistula is associated with significant physical, psychological, and economic consequences; however, a knowledge and practice gap exists around services adjunct to fistula surgery. OBJECTIVES: To examine rehabilitation and reintegration services provided adjunct to genital fistula surgery, map existing programming and outcomes, and identify areas for additional research. SEARCH STRATEGY: We searched the published and grey literature from January 2000 to June 2019. Two reviewers screened articles and extracted data using standardized methods. SELECTION CRITERIA: Research and programmatic articles describing service provision in addition to female genital fistula surgery were included. DATA COLLECTION AND ANALYSIS: Of 3047 published articles and 2623 unpublished documents identified, 26 and 55, respectively, were analyzed. MAIN RESULTS: Programming identified included combinations of health education, physical therapy, social support, psychosocial counseling, and economic empowerment, largely in sub-Saharan Africa. Improvements were noted in physical and psychosocial health. CONCLUSIONS: Existing literature supports holistic fistula care through adjunct reintegration programming. Improving the evidence base requires implementing robust study designs, increasing reporting detail, and standardizing outcomes across studies. Increased financing for holistic fistula care is critical for developing and supporting programming to ensure positive outcomes.

Addressing the fistula treatment gap and rising to the 2030 challenge.

Obstetric fistula is a neglected public health and human rights issue. It occurs almost exclusively in low-resource regions, resulting in permanent urinary and/or fecal incontinence. Although the exact prevalence remains unknown, it starkly outweighs the limited pool of skilled fistula surgeons needed to repair this childbirth injury. Several global movements have, however, enabled the international community to make major strides in recent decades. FIGO's Fistula Surgery Training Initiative, launched in 2012, has made significant gains in building the capacity of local fistula surgeons to steadily close the fistula treatment gap. Training and education are delivered via FIGO and partners' Global Competency-based Fistula Surgery Training Manual and tailored toward the needs and skill level of each trainee surgeon (FIGO Fellow). There are currently 62 Fellows from 22 fistula-affected countries on the training program, who have collectively performed over 10 000 surgical repairs. The initiative also contributes to the UN's Sustainable Development Goals (1, 3, 5, 8, 10, and 17). The UN's ambitious target to end fistula by 2030 will be unobtainable unless sufficient resources are mobilized and affected countries are empowered to develop their own sustainable eradication plans, including access to safe delivery and emergency obstetric services.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea.

OBJECTIVES: Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. METHODS: This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. RESULTS: The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. CONCLUSION: Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.

Clinical procedures and practices used in the perioperative treatment of female genital fistula during a prospective cohort study.

BACKGROUND: Treatment and care for female genital fistula have become increasingly available over the last decade in countries across Africa and South Asia. Before the International Federation of Gynaecology and Obstetrics (FIGO) and partners published a global fistula training manual in 2011 there was no internationally recognized, standardized training curriculum, including perioperative care. The community of fistula care practitioners and advocates lacks data about the prevalence of various perioperative clinical procedures and practices and their potential programmatic implications are lacking. METHODS: Data presented here are from a prospective cohort study conducted between September 2007 and September 2010 at 11 fistula repair facilities supported by Fistula Care in five countries. Clinical procedures and practices used in the routine perioperative management of over 1300 women are described. RESULTS: More than two dozen clinical procedures and practices were tabulated. Some of them were commonly used at all sites (e.g., vaginal route of repair, 95.3% of cases); others were rare (e.g., flaps/grafts, 3.4%) or varied widely depending on site (e.g. for women with urinary fistula, the inter-quartile range for median duration of post-repair bladder catheterization was 14 to 29 days). CONCLUSIONS: These findings show a wide range of clinical procedures and practices with different program implications for safety, efficacy, and cost-effectiveness. The variability indicates the need for further research so as to strengthen the evidence base for fistula treatment in developing countries.

Vesicovaginal fistula due to vaginal herb for primary infertility: could it be devastating?

Vesicovaginal fistula (VVF) is a very commonly encountered urogynaecological entity in developing countries such as India. The most common cause of VVF in developing counties is secondary to obstructive labour. We report a very unusual case of VVF in a young woman that developed due to insertion of an unknown vaginal herb for treatment of primary infertility. Cystoscopy showed a single trigonal fistula measuring 3×2 cm just near the bladder neck. Vaginoscopy revealed cicatrised less capacious vagina and unhealthy vaginal mucosa. She was treated with transvaginal VVF repair using Martius flap interposition which leaked on 10th postoperative day. She underwent re-evaluation and another transvaginal fistula repair for small trigonal residual fistula after 3 months. She is doing well during the follow-up of 2 years. She attained sexual activity after 3 months of surgical repair but could not conceive.

Vesico-vaginal fistula repair as a day case: is it a worthy venture?

Two vesico-vaginal fistula patients who were successfully managed with outpatient care as an alternative approach, to ensure early access to care and integration into their family. The two patients had simple uncomplicated mid-vagina fistulae surgically repaired with local infiltrative anaesthesia. We suggest some selection criteria and clinical guidelines that can facilitate successful treatment by this choice of care.

Vaginally inserted herbs causing vesico-vaginal fistula and vaginal stenosis.

A 32-year-old woman developed a vesico-vaginal fistula and vaginal stenosis following insertion of herbs into her vagina by a traditional doctor to "melt" her uterine myomata. She underwent successful trans-abdominal repair of her fistula and passive dilatation of her vagina was recommended for the vaginal stenosis. The emerging importance of traditional treatments as a cause of vesico-vaginal fistula is highlighted. The role of quality improvement through research and strict regulation to maximise the benefits of traditional treatment and minimise complications is also emphasised.

Vesico-vaginal fistula in a patient with Meyer-Rokitansky-Kuster-Hauser syndrome.

This was a case of Gishiri cut in a patient with Meyer-Rokitansky-Kuster-Hauser syndrome resulting in a vesico-vaginal fistula and urethral loss. This followed an attempt to enlarge and lengthen the vagina to enhance penile penetration. Few cases of MRKH syndrome presenting with complications after an attempt at treatment by traditional birth attendants have been reported. This report is particularly of essence as most urinary fistulae in Nigeria are obstetric fistulae following prolonged obstructed labour.

Corrosive-induced vesicovaginal fistula with procidentia: a rare occurrence.

Vesicovaginal fistula (VVF) has huge physical, psychological and, above all, social implications in a woman's life. It has always been a challenge for the urogynaecologic surgeons to manage VVF. VVF can be caused by unrelieved obstructed labour, pelvic surgery, malignancies, radiation therapy, infection and trauma. Here we report a case of VVF caused by the application of a mixture of chemicals in a female with longstanding pelvic organ prolapse. This occurrence is unique by virtue of aetiology and to the best of our knowledge is only the second of its kind reported till date. We have also explained the operative technique used to combine both the prolapse and the fistula repair into a single operation that achieved excellent functional results.

Local anesthesia: an appropriate technology for simple fistula repair.

OBJECTIVES: To assess the efficacy of local infiltrative anesthesia with lidocaine hydrochloride in patients undergoing the surgical repair of a simple vesico-vaginal fistula. METHODS: The study was carried out with 21 patients undergoing the repair of a simple midvaginal vesico-vaginal fistula. The patients' perception of pain was evaluated intraoperatively. RESULTS: Most patients indicated that the anesthetic agent provided adequate analgesia, and all fistulas were repaired successfully without postoperative complications. CONCLUSION: Repairing simple vesico-vaginal fistulas is feasible with a local infiltrative anesthetic.

The Addis Ababa fistula hospital: an holistic approach to the management of patients with vesicovaginal fistulae.

Ethiopia is amongst the world's poorest countries. It is estimated that approximately 30,000 women have an untreated vesicovaginal fistula, the overwhelming proportion of which are complications of neglected, prolonged or obstructed labour. When unrelieved, the presenting foetal part is impacted against the soft tissues of the pelvis, resulting in a widespread ischaemic injury. This 'field injury' often results in multiple other injuries, in addition to a vesicovaginal fistula. Focusing simply on the 'hole' between the bladder and vagina will ignore many of the other injuries these women have sustained. These include both physical and social problems, stress and urge urinary incontinence, hydronephrosis, renal failure, rectovaginal fistulae, third degree tears, amenorrhea, secondary infertility, vaginal scarring and foot drop. Over 50% will be divorced by their husband and excluded from religious activities, their home, public transport and hospitals. The Fistula Hospital in Addis Ababa in Ethiopia, founded in 1975 and run entirely by charitable donation, is dedicated exclusively to the care of women with obstetric fistulae, and the treatment of other physical and social injuries they have sustained.

Did J. Marion Sims deliberately addict his first fistula patients to opium?

American surgeon J. Marion Sims (1813-83) is regarded by many modern authors as a controversial figure because he carried out a series of experimental surgeries on enslaved African American women between 1846 and 1849 in an attempt to cure them of vesicovaginal fistulas, which they had all developed as a result of prolonged obstructed labor. He operated on one woman, Anarcha Westcott, thirty times before he successfully closed her fistula. Sims performed these fistula repair operations without benefit of anesthesia but gave these women substantial doses of opium afterwards. Several modern writers have alleged that Sims did this in order to addict them to the drug and thereby to enhance his control over them. This article examines the controversy surrounding Sims' use of postoperative opium in these enslaved surgical patients. The evidence suggests that although these women were probably tolerant to the doses of opium that he used, there is no evidence that he deliberately tried to addict them to this drug. Sims' use of postoperative opium appears to have been well supported by the therapeutic practices of his day, and the regimen that he used was enthusiastically supported by many contemporary surgeons.

Management of refractory urinary urge incontinence following urogynecological surgery with sacral neuromodulation.

AIMS: We sought to explore our patient outcomes utilizing sacral neuromodulation in the management of refractory urinary urge incontinence following urogynecological surgical procedures. METHODS: A total of 25 women with urinary urge incontinence following urogynecological surgery were selected for SNS therapy and retrospectively analyzed. All patients completed a comprehensive urological evaluation. Clinical data was recorded to determine outcomes and identify parameters that would be predictive of response to neuromodulation. Outcomes were determined via subjective patient questionnaire and graded as follows: significant response (> or =80% improvement), moderate response (> or =50% and <80% improvement), and poor response (<50% response). RESULTS: Nineteen patients had a previous pubovaginal sling (10 with concomitant pelvic prolapse repair), 3 a previous retropubic suspension, and 3 a transperitoneal vesicovaginal fistula repair. Urethrolysis was performed in 4 patients to alleviate bladder outlet obstruction prior to sacral neuromodulation. Mean patient age was 59.8 years and length of follow-up was 7.2 months. Twenty-two women (88%) had the IPG placed during a Stage 2 procedure. Twenty patients maintained at least a 50% improvement in clinical symptoms at last follow-up and 6 patients were continent. Overall, the number of pads/day improved from 4.2 to 1.1 (P < 0.001). There were no significant differences in response to neuromodulation based upon age, duration of symptoms, type of surgery, or urodynamic parameters. CONCLUSION: Sacral neuromodulation appears to be an effective therapy in patients with refractory urge incontinence following urogynecological surgery. Larger prospective studies with longer follow-up are needed to assess the durability of this therapeutic modality.

Prevention of obstetric urogenital fistulae: some thoughts on a daunting task.

Significant obstetric-related pelvic floor injury is still all too common in many areas of the world. Vesicovaginal fistula formation typically results from obstructed labor in the setting of limited medical resources for the patient. Many people have dedicated their time and even their lives to repairing these types of pelvic floor injuries, which certainly can impact in a positive way on the quality of life of these suffering women. However, it is time to consistently combine surgical repair initiatives with education, training, and prevention strategies, as well as outcomes research in order to improve on these efforts. It is only through committed initiatives with all of these elements that we may be able to ultimately decrease the prevalence of these types of pelvic floor sequelae.