Medicine for Africa - Medical Information Service
ESICOAGINAL 
ISTULA
Definition:
Vesicovaginal Fistula (VVF) is an abnormal fistulous tract that extends from the urinary bladder (‘vesico’) to the vagina, resulting in an involuntary continuous discharge of urine into the vagina (urinary incontinence).
A fistula is a tissue hole that can develop between the urinary bladder and the vagina (VVF) or between the vagina and the rectum (rectovaginal fistula, RVF).
The causes for the development of a VVF include:
-
Childbirth – most cases (up to 80%) of VVF occur when during a prolonged labor the unborn child presses against the pelvis, thus cutting off the blood flow to the vesicovaginal wall, which can result in tissue necrosis (dead tissue) and the development of a hole between the vagina and the urinary bladder. This type of VVF is also called obstetric fistula, and is often seen during unattended and/or prolonged labor, in very young women whose pelvis is still too small for harboring a baby, or in malpresentation of the baby, or due to poor uterine contractions during labor. It can also be the result of a Cesarean section or a difficult forceps delivery.
-
Hysterectomy or other gynecological surgery to the pelvic area – occasionally, a VVF can occur accidentally during surgery in the pelvic area, especially, during extensive tumor surgery in case of a cancer of the cervix or cancer of the uterus, or following myomectomy (the surgical removal of benign smooth muscle tumors called leiomyomas or fibroids). It can also develop secondarily after radiation therapy for cancer treatment. In certain countries of Africa, where female circumcision, also called female genital mutilation, is still performed, a VVF is often a second or third unwanted result of this traditional, yet brutal procedure.
- Violent rape – a VVF can result from a violent act of rape; VVF has become common in certain wars where rape has been used as a weapon against women.
-
Gishiri – ‘salt cut’, a traditional ‘cure’ consisting of a surgical cut into the anterior vaginal wall of a woman who has been diagnosed by a traditional healer to suffer of gishiri disease (a wide range of conditions and symptoms, such as itching of the vulva, amenorrhea [absence of menstruation] and infertility, obstructed labor, anemia, edema, as well as malaria, headaches or fainting attacks, and dyspareunia [painful sexual intercourse]). Mostly practiced in Nigeria and other (West) African countries.
- Angurya – scraping of the vagina and surrounding tissues, in order to remove the clitoris as part of a female circumcision/female genital mutilation.
- Secondary VVF – may be caused by diseases such as:
- some sexually transmitted diseases, such as syphilis or lymphogranuloma venereum, or a history of previous pelvic inflammatory diseases (PID),
- tuberculosis,
- bladder stones or retained foreign bodies within the vagina,
- endometriosis,
- diabetes, or
- an anatomic distortion of the pelvic area.
The development of a VVF has, aside from its physiological problems for the patient, also often severe psychological consequences for the patient, as she is embarrassed about her incontinence, and often shunned by the community due to her impairment.
Symptoms:
The most common symptoms are urinary incontinence/urine leakage from the vagina, often exacerbated by physical activities. In addition, the patient may experience irritation and itching of the vulva and frequent, recurrent urinary tract infections.
Some women may complain of hematuria or non-specific vaginal discharge. Upon a long-standing VVF, the patient may experience concurrent ureteric involvement with symptoms such as fever, chills, flank pain or gastrointestinal symptoms.
The start of the symptoms usually coincides with a traumatic childbirth (within 24 to 48 hours), a surgical procedure in the gynecological area (within 5 to 30 days), or following another kind of trauma (see above – rape, female genital mutilation). Fistulas that develop secondary to radiation therapy may develop any time between 30 days to 30 years after treatment.
The affected woman may emit a smell of urine due to her persistent incontinence, which may make her an unpleasant person to be around and thus, put further strain on her social status in the community, and her psychological self-esteem and well-being.
Diagnosis:
The diagnosis of VVF requires a proper evaluation of the patient’s past medical history in order to identify the accurate cause of the woman’s symptoms, followed by an appropriate and extensive physical examination.
A VVF can be diagnosed by performing a so-called cystoscopy, a flexible or rigid optical tube which is inserted through the urethra into the urinary bladder, in order to examine the interior walls of the bladder. Another, similar kind of procedure is the vaginography, which proceed through the vagina; a radio-opaque solution is being instilled into the vagina while taking x-rays revealing the vesicovaginal or rectovaginal fistula.
VVF is typically classified into two categories – a simple VVF and a complicated VVF – which can aid the treating surgeon in planning on the appropriate treatment prior to surgery:
- Simple VVF – less than 2 to 3 cm in size, located near the vaginal cuff, with a normal vagina and no previous patient history of radiation or malignancy;
- Complicated VVF – patient has a current pelvic malignancy, or has had previous radiation therapy for a malignancy; the fistula is greater than 3 cm, and located distant from the cuff, while the length of the vagina is shortened.
Routine laboratory tests should always include a urinalysis to rule out a coexisting urinary tract infection, as well as the evaluation of the renal function in association with standard blood and electrolyte panels.
Above listed radiological studies are recommended prior to surgery, including an intravenous pyelogram to exclude a concurrent ureterovaginal fistula or ureteral obstruction.
Treatment:
Following medical treatment of any possible or concurrent urinary tract infection, the fistula will ultimately have to be closed surgically. The surgical repair may be performed through the vagina, or may require an incision in the abdomen; if considerable tissue necrosis is present (dead tissue), the surgeon may have to introduce a new blood supply via nearby arteries.
Following surgery, the patient may need to wear a catheter for a short period of time until the surgical repair has completely healed and potential urinary tract infections have been averted by the prescription of antibiotics.
General guidelines on how to approach the treatment of a VVF are:
-
If the fistula is smaller than one (1) cm in size, a conservative therapy could be attempted, if it can be started within one week of the occurrence of the injury, and if it is not associated with a local carcinoma or preceded by radiation.
- Risk factors to a surgical intervention include:
Prevention:
The prevention of VVFs requires strategies to educate the community about cultural, social and physiological factors which have an increased risk potential for fistulas. Physiological immaturity is typically characterized by a small pelvis size, immediately following menarche (the beginning of menstruation/monthly female cycle), thus, it is recommended to prevent childbearing at a very early age of the mother. Obstetric complications are the most common cause of VVF, which include not only early age of pregnancy, but also delayed and obstructed labor (often associated with a pregnancy at an early age).
Helping in the physiological development of young girls/women, proper nutrition and especially nutritional needs for growing women, in order to prevent chronic malnutrition and its subsequent physiological results, is another important preventive measurement against VVF.
It is often important to change family and community attitudes, in order to improve antenatal screening procedures and care, combined with a medically skilled attendance at the time of delivery.
Another major problem consists of preventing VVFs that develop subsequent to violent rape – be it in a patriarchic society where ‘forced sexual intercourse’ appears acceptable, or in the context of (civil) war atrocities when mass raping of local women has become a weapon of psychological warfare. Prevention of rape in the former case scenario requires the education of the entire community on medical, moral and social levels, as well as teaching local women a more determined and self-assured position towards their own life, body and health status. Prevention of the above mentioned war atrocities against women is much more difficult to achieve...
On a personal note – the author believes that the socially 'accepted' oppression of women could well be reversed by promoting both basic and specific education to the communities. In order to prevent war atrocities, however, would require the international political community to not only do their utmost to prevent the outbreak or continuation of such wars, but also require the international judiciary system to take a clear and undeterred stand against such acts of violence, enforcing the prosecution of anyone, no matter what rank or military position he may hold, to take responsibility for his direct, or indirectly implied or supported acts of violence, against human decency.
_____________________________________________________________________________________
DISCLAIMER: The above article is only intended to provide general information regarding this topic. It is not intended and does NOT replace the need to consult a medical or other professional person, if you have or believe to have this disease/disorder. While the article was researched, written and reviewed by medical professionals, and Medicine for Africa, its staff and publisher made every effort to assure accuracy and correctness, it does not claim to be complete, correct or to reflect the very latest stand of medical/scientific knowledge in the disease’s/syndrome’s pathology, diagnostic and/or therapeutic development. Medicine for Africa, its founder, management, staff, writers, reviewers or publishers may NOT be made responsible or legally bound to any information provided above, and cannot be held liable to any conclusions or decisions the reader may draw after reading this article. The reader is explicitly advised to consult a licensed physician and to present his/her specific situation before making any health related decisions.