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W2: Vaginal Fistula; Lesson Learned Workshop Chair: Sherif Mourad, Egypt 26 August 2013 14:00 - 17:00

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W2: Vaginal Fistula; Lesson Learned Workshop Chair: Sherif Mourad, Egypt 26 August 2013 14:00 - 17:00 W2: Vaginal Fistula; Lesson Learned Workshop Chair: Sherif Mourad, Egypt 26 August 2013 14:00 - 17:00 Start End Topic Speakers 14:00 14:15 Introduction and Overview Sherif Mourad 14:15 14:30 Epidemiology of Vaginal Fistulas Sohier Elneil 14:30 14:45 Anatomic Aspects & Aetiology Hassan Shaker 14:45 15:00 Classification of Vaginal Fistulas Edward Stanford 15:00 15:15 Surgery for Low Vaginal Fistulae Dirk De Ridder 15:15 15:30 Discussion All 15:30 16:00 Break None 16:00 16:15 Surgery for High Vaginal Fistula Sohier Elneil 16:15 16:30 Laparoscopic/Robotic Surgery for Vaginal Fistula Hassan Shaker Repair 16:30 16:45 Ureterovaginal, uterovaginal and other rare cases Dirk De Ridder 16:45 17:00 How to Treat Complications of Fistula Repair Sherif Mourad Aims of course/workshop This workshop is very important in showing the audience the real factors after the increased numbers of vaginal fistulae, not only in the developing countries, but among the well developed countries as well. 30/05/2013 Introduction •Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). •VVF is an abnormal fistulous tract extending between the bladder and the vagina. •It allows continuous involuntary discharge of urine into the vaginal vault. Types of Urogenital Fistula • Vesicovaginal fistula • Recto-vaginal fistula • Urethrovaginal fistula • Ureterovaginal fistula • Vesicouterine fistula Countries from which obstetric vesico-vaginal fistulas have been reported (WHO 2003). The prevalence is actually greater than this map indicates. Fistula Etiology in Developing Countries The obstructed labor complex • •Marriage and conception at a young age, often Delay in deciding to seek help – before full pelvic growth has been achieved. Delay in arriving at the health care facility – Delay in receiving adequate care – (Sexual abuse, rape, accidents) • •Chronic malnutrition limits pelvic dimensions, (Traditional practices) • Gishiri cutting, infibulation – increasing the risk of cephalopelvic disproportion and malpresentation. Injuries sustained during operative • interventions Forceps, cesarean section – Most prevalent cause in the Western world – •Few attendances by qualified health care Hysterectomy, gynecological procedures • professionals or having access to medical facilities during childbirth. 1 30/05/2013 30% 26% 25% •Female circumcision and the practice of 20% harmful traditional medical practices such as 14% 15% 12% 12% Gishiri incisions (anterior vaginal wall 10% 10% incisions). 10% 8% 5% 3% 2% 2% 1% •The insertion of caustic substances into the 0% vagina with the intent to treat a gynecologic condition or to help the vagina to return to its nulliparous state. percent Bar chart showing the age at which the women developed obstetric fistula around whole Africa 2007( WHO report) •Prolonged impaction of the fetal presenting part in Developed Countries the pelvis causing widespread tissue edema, hypoxia, necrosis, and sloughing resulting from prolonged •VVFs is mainly due to inadvertent bladder injury during pressure on the soft tissues of the vagina, bladder pelvic surgery (90%). base, and urethra. •Bladder wall injury from electro-cautery or mechanical crushing, and the dissection of the bladder into an incorrect plane, causing avascular necrosis. •The risk of formation of a hematoma or avascular •Complex neuropathic bladder dysfunction and necrosis after a suture is placed through the bladder urethral sphincteric incompetency often result, even if wall can lead to infection, abscess, and subsequent the fistula can be repaired successfully. suture erosion through the bladder wall. The time of clinical presentation depends on the etiology of the VVF: Possible Social Consequences •A VVF secondary to a bladder laceration typically presents immediately. -Stigma and discrimination. •Approximately 90% of genitourinary fistulas associated -Social isolation. with pelvic surgery are symptomatic within 7-30 days -Community/familial rejection. postoperatively. -Divorce or abandonment. •An anterior vaginal wall laceration associated with obstetric fistulas typically (75%) presents in the first 24 -Verbal and Physical Abuse. hours of delivery. -Loss of income, extreme •In contrast, radiation-induced UGFs are associated with poverty. slowly progressive devascularization necrosis and may present 30 days up to many years later. 2 30/05/2013 Marital status after Social effect of V.V.F Marital status of cases after Social effect of the V.V.F cases in Zambia , 2005 (Birmingham genitourinary fistulae in Ethiopia between affection with genitourinary fistula University and Maternity unit , around Africa,2007 2001-2005 in Nigeria (prepared by grassroots health Monze , Southern province , (UNFPA report) organization of Nigeria) (2005) Zambia) 33% 45% 22% 29% 15% 40% 60% 71% deserted by husband 85% divorced deserted by husband and begging food divorced still married get support from get support from husband & divorced get family support husband and family family Fistula Repairs Fistula Cure • Treatment complexity and success depend on multiple factors including: • Complete continence by day – Fistula type and night – Size For a 100% • Bladder capacity> 200ml – Degree of scarring cure; the following • No SIU – Involvement urethra, conditions • Normal coitus without ureter and bladder must be fully satisfied: dyspareunia – Provider capacity • No traumatic amenorrhea – Postoperative care and • Ability to bear children compliance Outcome of surgery by repair attempt in Zambia , 2005 Fate of V.V.F repair (source : Maternity Unit, Monze Mission Hospital, Monze, Southern Province, Zambia Department of Public Health and Epidemiology, The Medical School, in Nigeria University of Birmingham) 76% 80.00% 65.00% 90 80 60.00% 70 60 40.00% 50 6.00% 19.00% 40 20.00% 18.00% 30 16% 20 0.00% 10 0 first repair cured women has had first attempt second attempt one or more third attempt previous repair first attempt second attempt third attempt stress incontinence failed cured cured 90 50 33 failed 10 50 67 3 30/05/2013 Women’s potential expectations for reintegration Challenges in surgery in Africa Continence as seen by surgeons Return to fertility Increased self as desired •Severe shortage of surgeons. esteem Return to sexual Happiness •Poor conditions of service / Poor salaries; unclear life as desired PHYSICAL MENTAL Safe future HEALTH HEALTH career structure. delivery •Concentration of surgeons in towns and cities 80 – 100% in urban areas where only5 -15% of populations Reduced stigma SOCIAL ECONOMIC Economic status Participation in WELL- BEING WELL- BEING regained or lives. religious and improved social life Family support or •Limited opportunities to further education and Social support source of income training. Marriage/re- Able to support marriage as others •Lack ofopportunities to research , and learn new desired techniques. Adapted from DIRG/OFWG, 2006 Challenges in surgery in Africa Challenges in surgery in Africa as seen by surgeons: as seen by surgeons: •Poor maintenance of available equipment. •Lack of opportunities for surgeons to improve and keep •Poor or lack of specialized investigations e.g. CT SCAN, up with the times. MRI …….. etc. •Retention and motivation. dedication and devotion. •Shortage of consumables . •Severe shortage of anesthesiologist shortage of nurses •Lack of communication facilities/knowledge . / loss of well-trained operating theater veteran nurses. •Shortage of blood supply. •HIV/AIDS: unsafe surgery in era of HIV pandemic. •Absence of high care ward. •Generalized poverty/ economic constraints. •Fluctuating power supply. •Lack of appropriate/specialized equipments / •Lack of funds for research. instruments. • Distribution of surgeons in Africa (1999-2003) Prepared by UNFPA country office and Engender (source :Dep. Of surgery, Makerere university , Health under support of Columbia university ,2004 kampala , Uganda) 40000000 32,000,000 34,000,000 27,000,000 30000000 8,100,000 20000000 11,000,000 18,000,000 12,000,000 10000000 100 315 110 0 77 14 15 59 2 Rwanda surgeons population urologist gynacologist total population 4 30/05/2013 Recommendations to prevent and solve Liability to V.V.F repair in Ghana according to availability of cost ,2007 V.V.F problem: (UNFPA local office report) • The existing cases of VVF in these communities should be repaired , and adequate measures taken to ensure their rehabilitation and reintegration back into the society. 16% • Future cases of VVF, should be prevented and controlled 84% through preventing the occurrence of marriage before 18 yrs. • Awareness creation and public enlighten on the dangers of early marriage, the importance of ante natal services, as well as, hospital delivery. • Acceptability and accessibility to modern health do repair could not do repair facilities should be enhanced. •Groups, such as Mother-in-Laws, Grand Mothers, as well as, men should be given special focus. This still assist in creating a much more supportive environment, for the women in the household. •There is need for the creation of more VVF Repair Centers, as well as , the training of Doctors and Nurses to these facilities. This will control the problem of distance and accessibility, as well as, knowledge of existing services. •The Cost of VVF Repairs should be subsidized through the establishment of a National VVF Fund 5 Vaginal Fistula: Epidemiology and Quality of Life Perspectives Sohier Elneil Genital tract fistula is a problem commonly encountered in the developing world that affects young women during pregnancy
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