A Cross-Sectional Analysis of Vesicovaginal Fistula Patients At

JSAFOG ORIGINAL STUDY A Cross-sectional Analysis of Vesicovaginal Fistula Patients at Patan Hospital, Nepal A Cross-sectional Analysis of Vesicovaginal Fistula Patients at Patan Hospital, Nepal 1Kundu Yangzom, 2Meera Hada 1Chief of Service, Department of Obstetrics and Gynecology, Patan Hospital, Kathmandu, Nepal 2Consultant, Department of Obstetrics and Gynecology, Patan Hospital, Kathmandu, Nepal Correspondence: Kundu Yangzom, Chief of Service, Department of Obstetrics and Gynecology, Patan Hospital, Kathmandu Nepal, e-mail: [email protected] Abstract Nepal is a small Himalayan country with difficult geographical terrains and population of 2.3 million. Emergency obstetric care is not available in all the districts of Nepal and > 80% of the deliveries occur at home. Many women suffer from genitourinary fistulas as a result of obstructed labor. Exact incidence of fistula in the country is unknown and surgeries done so far at Patan Hospital seem to be the tip of the iceberg. Patan Hospital is a 300 bedded district hospital. Of the 300 beds, 88 beds are utilized by the obstetrics and gynecology services and the average numbers of deliveries are 7000 per year (2007). This hospital is serving as a referral hospital for genitourinary fistula repair. A cross-sectional study of genitourinary fistulas operated at Patan Hospital over a period of 16 years has been done. Three hundred cases of genitourinary fistulas attended Patan Hospital OPD during this period. Seven files could not be traced and 4 cases were referred to surgical department for urinary diversion surgery. Therefore, 293 files were analyzed and repair was done by the layered repair/flap splitting method for 289 cases. The majority of the patients were in the age group of 25 to 34 years. The youngest patient was 15 years and the oldest patient was 72 years. Three patients had never conceived, these were the cases of traumatic fistulae. 36.2% of the patients sustained their fistulae following the first pregnancy. 37.2% were multiparous, 25.6% of the patients were grande multiparous 90.8% of these cases were of obstetric origin and 90.78% cases were vesicovaginal fistulas. More than half of the cases (52.6%) were complicated. Out of the 293 cases, 11 had an associated RVF (rectovaginal fistula). 79.2% cases were cured after the first attempt of surgery. Eighteen of the failed cases underwent a second attempt operation and success rate after second attempt was 81.9%. Keywords: Genitourinary fistula, Vesicovaginal fistula, Rectovaginal fistula, Grand multipara. INTRODUCTION 58 years). Mean age at marriage of the female is 17.1 (1996) and contraceptive prevalence rate is 39.6%. 70% or reproductive Nepal is a small Himalayan country between India and China age group women are found to be anemic and malnourished. with an area of 1,47,181 sq km. It has three distinct geographical Nepalese woman still face difficulty in accessing safe regions—mountain region (35.2%), hill region (41.7%) and plain motherhood services not only due to the difficult geographical or terai region (23%). It has a population of 2.3 million and terrain but also due to very limited number of human resource almost half of the population is living in the mountain and hill in the field of health. There is one doctor available per 22,961 regions. Approach to health care becomes difficult because of population, one nurse for every 3719 population and one these difficult terrains. Comprehensive and basic emergency paramedic for every 2002 population. Many women suffer from obstetric care is not available in all the districts of Nepal. More genitourinary fistulas as a result of obstructed labor. than 80% of the deliveries occur at home. Prevalence of VVF can be taken as an indicator of quality of Maternal mortality rate is still as high as 281 per 100,000 live obstetric care available in the society. Dr James Marion Sims births (NFHS). Majority of maternal deaths occurred at home (1813 to 1883) “Father of American Gynecology” was the pioneer (67%)—62% during postpartum period, 28% during antenatal in managing fistula cases. First fistula hospital was established period and 10% during delivery. Major causes of maternal death on May 4th, 1855 to 1883 at Madison Avenue, New York and at are PPH, obstructed labor, eclampsia/pre-eclampsia, puerperal Addis Ababa, Ethiopia second fistula hospital was opened on sepsis and unsafe abortion. May 24th, 1975. Exact incidence of fistula in the country is not Women in reproductive age group comprise 23% of the known and surgeries done so far at Patan Hospital seem to be total population in Nepal and 37.8% of them are literate (67.9% the tip of the iceberg. A few of the cases also came from Indian of men). Life expectancy of a woman in Nepal is 57 years (men border. South Asian Federation of Obstetrics and Gynecology, September-December 2010;2(3):189-192 189 Kundu Yangzom, Meera Hada Health care delivery system in Nepal works through The majority of the patients were in the age group of 25 to 45556 female community health volunteers. 13507 PHC outreach 34 years. The youngest patient was 15 years and the oldest clinics, 3,195 subhealth posts, 747 health posts, 137 primary patient was 72 years. health care centers and health centers, 74 district hospitals, 11 zonal hospitals, 2 regional hospitals and 5 central hospitals. Parity Distribution Patan hospital is a 300-bedded district hospital situated in Parity Number % Total % Southern belt of Lalitpur district, 2 km from the Kathmandu P 0 3 1% 3 1% City. It is jointly run by the government of Nepal, UMN and the P 1 106 36.2% 106 36.2% community health, Lalitpur district. The services offered include: P 2 43 37.2% 109 37.2% general surgery, orthopedic surgery, anesthesia and intensive P 3 26 care, general medicine, emergency medicine, pediatrics and P 4 40 obstetrics and gynecology, well supported by laboratory, P 5 26 25.6% 75 25.6% P 6 18 pathology and blood bank facilities, ultrasound and radiology. P 7 15 Other services offered are dental, dermatology, psychiatry, P 8 4 physiotherapy and an inhouse pharmacy. P 9 8 Of the 300 beds, 88 beds are utilized by the obstetrics and P 10 2 gynecology services and the average numbers of deliveries are P 11 1 7000 per year (2007). This hospital has served for years now as P 12 1 a referral hospital for genitourinary fistula repair. Total 293 100 293 100 MATERIALS AND METHODS Three patients had never conceived, these were the cases of traumatic fistulae. 36.2% of the patients sustained their fistulae This is a hospital-based retrospective and cross-sectional study following the first pregnancy. 37.2% were multiparous, 25.6% of genitourinary fistulas operated at Patan Hospital over a period of the patients were grand multiparous. of 16 years from Aug 1986-Aug 2002. Detail information of the cases was obtained from the hospital register and also from Durations of Symptoms individual files and fistula cards that have been prepared by the Duration Number % department. The cases were analyzed in relation to age, parity, cause, < 6 months 104 35.5 duration of symptoms, type of fistula and outcome of the 1-5 years 119 40.6 6-10 years 30 10.2 surgery. The results of surgery were graded as cured, failed 11-15 years 18 6.2 and healed but incontinent (meaning the defect was closed but 16-20 years 9 3.1 there was an unacceptable urinary incontinence). > 21 years 13 4.4 RESULTS Total 293 100 • Total number of genitourinary fistulas attending Patan The shortest duration was 2 months. The longest duration was Hospital OPD – 300 52 years. • Missing files – 7 • Total number of files analyzed – 293 Causes • Refused surgery – 4 (were very severe and were referred to Causes Number % Comment the department of surgery for possible urinary diversion Obstetric 266 90.8 Following obstructed labor procedures). Gynecological 21 7.2 Following hysterectomy for • Transvaginal repair done – 289 (98.6%) gynecological disease Traumatic 3 1 Age Distribution Radiotherapy 1 0.3 Miscellaneous 2 0.7 Following dilatation and Age (years) Number % Total % curettage 15-19 19 6.48 78 26.6 Total 293 100 20-24 59 20.13 25-29 58 19.79 103 35.2 30-34 45 15.35 Type of Fistula 35-39 40 13.65 69 23.5 Type Number % 40-44 29 9.89 45-49 20 6.82 31 10.6 Vesicovaginal 266 90.78 50-54 11 3.75 Vault fistula 21 7.16 55-59 6 2.04 12 4.1 Vesicouterine fistula 3 1.02 60 6 2.04 Urethrovaginal fistula 3 1.02 Total 293 100 293 100 Total 293 100 190 JAYPEE A Cross-sectional Analysis of Vesicovaginal Fistula Patients at Patan Hospital, Nepal Vesicovaginal Fistula the disease. On the other hand, most of the women suffering from genital fistula of obstetric reason are socioeconomically Type Number % Remark less privileged group and reside in the remote areas where access Juxta-urethral 72 27.06 to health care facility for safe delivery is lacking. Once they • Simple 25 • Complicated 47 Including 1 with no urethra, have continuous urinary leakage, they are abandoned by their and 3 with RVF husbands, family and society with nobody to take care of them. Juxtacervical 108 40.60 These are few of the reasons why they seek the service of • Simple 42 fistula repair quite late. • Complicated 66 Including 3 with RVF In the developing countries, the commonest cause of fistula Midvaginal 45 16.91 is obstetrical and constitutes about 80 to 90% of cases as • Simple 36 opposed to only 5 to 15% in developed countries.12 • Complicated 9 Including 1 with RVF Vesicovaginal fistula is the commonest type (>90%) of Massive 41 15.41 genitourinary fistula prevalent here.

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