CLINICAL OBSTETRICS AND GYNECOLOGY Volume 00, Number 00, 000–000 Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. Contemporary Issues in Obstetric Fistula L. LEWIS WALL, MD, DPHIL,*† ITENGRE OUEDRAOGO, MD,‡ and FEKADE AYENACHEW, MD§ *Department of Anthropology, College of Arts and Sciences; †Department of Obstetrics and Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri; ‡Association Renaissance Arena, Ouagadougou, Burkina Faso; Danja Fistula Center, Danja, Niger; and §International Fistula Alliance, Terrewode Women’s Community Hospital, Soroti, Uganda Abstract: We discuss a variety of contemporary issues connected: for example, a vesicovaginal relating to obstetric fistula. These include definitions of fistula is an abnormal opening between these injuries, the etiologic mechanisms by which fistulas occur, the role of specialist fistula centers in diagnosis the bladder and the vagina. and management, the classification of fistulas, and the Fistulas arise in different ways. A small assessment of surgical outcomes. We also review the number of fistulas are congenital, arising growing need for complex reconstructive surgical pro- from defects that occur during embryog- cedures, follow-up challenges, and the transition to a enesis.1 More commonly, however, fistu- fistula-free world in which other pathologies (such as 2,3 pelvic organ prolapse) will be of increasing importance. las are caused by trauma. Finally, we discuss the need to develop responsive The most common fistulas occurring in systems of maternal health care that treat women with females are genitourinary fistulas (vesico- competence, compassion, respect, and fairness. vaginal fistula, urethrovaginal fistula, Key words: obstetric fistula, vesicovaginal fistula, ’ ureterovaginal fistula, etc.) and genito- obstructed labor, women s rights enteric fistulas (especially rectovaginal fistula). The term “obstetric fistula” refers to a genitourinary or genitoenteric fistula that develops as the result of complica- Definitions tions of the pregnant state (pregnancy, A fistula is an abnormal passage between labor, delivery, and the puerperium) or 2 epithelialized body cavities that nor- from interventions, omissions, incorrect mally are not connected with 1 another. treatment, or from a chain of events Fistulas are named with reference to resulting from any of the above, just as the structures that have thus become a direct maternal death is the death of a pregnant or recently pregnant woman Correspondence: L. Lewis Wall, MD, DPhil, Department of Anthropology, Washington University in St. Louis, from such causes. It is incorrect to use MO. E-mail: [email protected] the terms “obstetric fistula” and “genito- The authors declare that they have nothing to disclose. urinary fistula” interchangeably. The CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2021 www.clinicalobgyn.com | 1 Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 2 Wall et al term “obstetric fistula” should be used Labor is obstructed when the fetus only for fistulas that result from known cannot advance through the birth canal direct causes of maternal mortality and despite vigorous uterine contractions. The morbidity. In high-resource industrialized presenting part (usually the fetal head) countries, most fistulas are now caused by becomes lodged in the bony pelvis, where misadventure during pelvic surgery (com- it compresses the soft tissues of the ves- plications of hysterectomy or urinary icovaginal septum against the maternal stone surgery), by cancer, or by radiation pelvic bones (Fig. 1). The continuing therapy. In low-resource countries (espe- uterine contractions increase the compres- cially those with high rates of maternal sion of the maternal soft tissues that are mortality), most fistulas arise as the result trapped between these 2 bony plates. of delivery trauma.2,3 Eventually this pressure shuts off the blood flow to these tissues completely. If the obstruction is not relieved by prompt Fistula Etiology delivery (such as emergency cesarean When the general public hears about section), a crush injury as described above obstetric fistula, the common belief is that results, and the compressed tissues die and these injuries must arise as the result of slough away, leaving a fistula of varying “tears” occurring during labor and deliv- size. The location and extent of the fistula ery, since most people know that some that forms depends on the location in the degree of tissue-tearing (usually super- ficial) is common during normal child- birth. However, except in rare instances such as difficult forceps deliveries, acute laceration of the vesicovaginal septum is almost never a cause of obstetric vesico- vaginal fistula. Some rectovaginal fistulas result from nonhealing lacerations of the anal sphincter and/or perineum, but rec- tovaginal fistulas account for only a small percentage of the overall obstetric fistulas found worldwide. Most obstetric fistulas are the result of a crush injury occurring during labor. This fact is of fundamental importance in understanding the comorbidities that are often found in association with ob- stetric fistulas. The fact that these lesions originate in a crush injury also explains why obstetric fistulas are frequently diffi- cult to repair. In an acute laceration, the tissues are torn and are separated from 1 another, but they themselves are other- wise normal. In a crush injury, on the other hand, the fistula forms not from tissues being pulled apart, but rather from necrosis of tissues that have lost FIGURE 1. Obstructed labor due to absolute cephalopelvic disproportion. From Smellie, their blood supply at the site where the 4 fistula forms. (public domain). www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Contemporary Issues in Obstetric Fistula 3 pelvis where obstruction has occurred, the care systems, they have increasingly volume of tissues compressed, and related adopted a philosophy of task-shifting, in factors.2,3 which surgical procedures in rural and The tissues that surround the newly remote areas are provided by a cadre of formed fistula from obstructed labor are “surgical technicians” (called by different not themselves normal. Often these tissues names in different countries). Generally, have also been compressed, have lost some these are individuals with less than a of their blood supply, and have been medical degree who have been trained to injured during obstructed labor. Even provide emergency surgical procedures in though these tissues have not died, they rural health care facilities. In some cases, are not healthy. There is often heavy such technicians provide excellent care, scarring, almost always confounded by provided they are adequately supervised, serious infections and poor tissue perfu- but this issue has not been studied exten- sion, with distortion and retraction of the sively in many countries.7 surrounding structures. The size and scope What may happen in such settings is of the area affected is quite variable, but that the surgeon with the least training may be enormous, affecting other pelvic and experience attempts—under the most organ systems. In such cases, numerous, difficult circumstances and without opti- severe comorbidities may accompany the mal support—to do the most difficult obstetric fistula. The constellation of these cesarean sections: the surgical delivery of comorbidities has been called “the ob- a patient who has been in labor for 2 or structed labor injury complex” (Table 1).5 3 days, is dehydrated and exhausted, with The presence of any of these comorbidities ongoing pelvic sepsis, and a fetal head dramatically affects the care of the woman that is wedged deeply and tightly into the with an obstetric fistula. These women pelvis, with local tissues that may well be often present for care in a condition of already undergoing necrosis at the time of marked general poor health requiring a operation. Under such circumstances, it is long convalescence (both before and after not at all surprising that the number of surgical repair) and the poor and often ureteral injuries and other surgical mis- distorted condition of the local tissues haps increase. Experience from Ethiopia makes the outcome of their treatment strongly suggests that the number of extremely unpredictable. iatrogenic fistulas (such as ureterovaginal The other major cause of obstetric fistulas from surgical injury) have begun fistulas comes from surgical complica- increasing as surgical technicians with less tions, usually during emergency cesarean than full training have been deployed to section, often performed because of ob- rural areas.8 This, in turn, means that structed labor. In many of these cases gynecologic surgeons in low-income and tissue damage will already have occurred middle-income countries must develop before the performance of the cesarean better skill-sets for dealing with these section; but in other cases, the operation complications. Doing this will require itself may independently cause an injury specialized, focused training to deal with that leads to a fistula, particularly if the these specific surgical problems. injury occurs in tissues that have already This phenomenon is sometimes known been partially compromised.6 as the emergence of a “disease of medical progress”; that is, the injury is the result of the introduction of new, often