management of vesico -and/or recto-vaginal fistulae
See also presentation
A modified management of the vesico and/or recto-vaginal fistulae compared to a usual management has been studied at Bugando Medical Centre, Mwanza, Tanzania, East Africa. In the modified method, out of 100 patients with a vesico and/or recto-vaginal fistula of 21 days – 37 years duration, 92 (92%) were closed after the first operative attempt at a total cost of 45-70 USD per patient and a hospital stay of up to 30 days. Whilst in the group using the usual method, out of 100 patients with a vesico and/or recto-vaginal fistula of 97 days – 37 years, 90 (90%) were closed after the first operative attempt at a total cost of 60-300 USD per patient and a hospital stay of up to 10 months. The modified management, in addition to the equal rate of closure and lesser cost has other important advantages: it prevents the woman from becoming an outcast, reduces hospital stay, and offers less operative procedures to the patient.
The modified management implies:
The obstetric fistula is a major public health problem on the rise for which the solutions have not yet been implemented in many developing countries. Obstetric fistula is totally preventable. Having survived the ordeal of prolonged obstructed labour for the prize of a dead baby, also a vesico and/or recto-vaginal fistula, the real suffering starts since the woman is no longer acceptable in her own community and becomes an outcast.
Vesico-vaginal fistula, is an abnormal communication between the bladder and the vagina: a urine fistula.
Recto-vaginal fistula, is an abnormal communication between the rectum and the vagina: a stool fistula.
The causes are:
Prolonged obstructed labour (obstetric fistulae); iatrogenic (surgery: hysterectomy, colporrhaphy, caesarean section); malignancy; radiation, example in carcinoma of the cervix; direct trauma to the bladder and /or rectum; congenital malformation; infection.
Though the obstetric fistula has disappeared from the industrialized world it is still very common in the developing world and accounts for over 85% of all the fistulae world-wide (Ref 6-8).
Due to constant dribbling of urine down their legs, the wetting of their clothes and accompanying smell, the social consequences are even more miserable than the medical aspects. The best rehabilitation is a successful repair. Therefore the intention is to provide a high quality fistulae repair which is simple, safe, effective, feasible, sustainable and payable under primitive conditions.
It has been a generally accepted rule to wait with the repair of a fistula for a minimum period of 3 months until all the tissue reactions have subsided (Ref. 1-5). Also during this waiting period heavy doses of antibiotics are often given routinely as also treating urine or excoriative dermatitis with antibiotic creams. However, this seems to be in sharp contrast with the established management of other necrotic lesions such as bedsores (also pressure necrosis) and burn wounds (thermal necrosis). Here routine systemic antibiotics are considered to be malpractice and the wounds are immediately attended to, first by repeated debridement and then by covering or closure as soon as the wounds are clean. So, for example, why should the obstetric fistula be treated differently? Over the years 1984 to 1992 an immediate management of fresh obstetric fistulas was developed according to basic surgical principles: decompression of the bladder by catheter, debridement, early closure, high oral fluid intake and no antibiotics (Ref. 6-8). The usual management implies also examination under anaesthesia at first visit; opening colostomy in case of medium/large recto-vaginal fistula; light diet three days before surgery; enemas twice a day for two days; use of general anaesthesia; non absorbable sutures for repairing the vaginal mucosa and episiotomy; antibiotics post operative for seven days; in the case of combination vesico-vaginal and recto-vaginal fistula to start closing vesico-vaginal fistula followed by recto-vaginal fistula; routine use of Martius fat graft; post-operatively: to keep the vaginal pack for 3-4 days ; to stay in bed for fourteen days; vaginal swabbing; fluid diet for fourteen days ; free urine drainage into kidney dish; removal of episiotomy sutures and foley catheter in operating theatre. This delayed management could contribute to make the first step into the woman becoming an outcast with progressive downgrading medically, socially and mentally.
Materials and Methods
From April 1996 to September 2003; 565 patients with vesico and/or recto-vaginal fistula were treated at Bugando Medical Centre, Mwanza, Tanzania, East Africa. Among these, the usual protocol has been used for all patients but 100 patients were managed in a modified way.
In a usual way, 100 patients were selected randomly, (see table 1,2,3); at first presentation of the patient an extensive history was taken and a vaginal examination (some of them under anaesthesia) noting the fistula size and anatomical location. All with fresh fistula were appointed for surgery after 3 months.
Excoriative dermatitis were treated with antibiotic creams. Those with medium/large recto-vaginal fistula, colostomy was opened. Before surgery: enemas twice daily were given for 2 days, light diet for 3 days; use of general anaesthesia, non absorbale sutures for repairing the vaginal mucosa and espisiotomy, antibiotics pre and post – operatively. Those with a combination of vesico and recto vaginal fistula, first the vesico-vaginal fistula was closed followed by recto-vaginal fistula. Use of Martius fat graft; vaginal pack for 2-3 days followed by twice daily vaginal swabbing; fluid diet and no ambulation for 14 days; free urine drainage, removal of episiotomy sutures and foley catheter in operating theatre.
In the modified group (100 patients), after extensive history taking, a side room examination was done in a gynaecology ward. Some of the patients had early surgical closure; this is, as soon as the fistula edge was clean, and they did not have to wait until 3 months have passed. Before teh surgery, 2 enemas were given; spinal anaesthesia with a long acting agent was the anaesthesia of choice and antibiotic prophylaxis at the beginning of the operation was administered. Only absorbable sutures were used. In case of a combination with vesico-vaginal fistula the recto-vaginal fistula was closed first. All patients in the two groups were operated vaginally.
The comparison group had been selected randomly for age, cause and size of vesico and/or recto-vaginal fistula.
Table 1: Age distribution for the two groups (the age ranged from 14 up to 65 years)
Table 2: Aetiology of vesico and/or recto-vaginal fistulae for the two groups
Table 3: Size of fistula for the two groups
In100 patients receiving the standard method, the success rate was 90%, 9% failure rate and a mortality rate of 1%. The cause of post-operative mortality was uraemia; both ureters were tied during VVF repair. In the modified method out of 100 patients the success rate was 92%, unsuccessful 8% and a mortality rate of 0%
This is the first time a retrospective comparative study in the management of vesico and/or recto-vaginal fistula between the usual method and a modified method has been described. It means a change from a delayed management of waiting 3 months allowing the patient to become an outcast to an active surgical strategy, the earlier the better. Its main advantages is not only the equal success rate as in the usual method, but especially the prevention of the girl/woman from being ostracized from her own society, her friends and even her family. To close the fistula is the most important thing, once the edges are clean (Ref. 6,8). If the patient is sent away and told to come back after 3 months this is the first step into the direction of becoming an outcast in her own society. Urine or excoriative dermatitis disappears on its own once the fistula is closed, as there is no more irritation to the skin. Vaginal examination at first visit without anaesthesia is enough; examination under anaesthesia is done at the beginning of the operation followed up immediately by surgery in the same session, the fistula is classified and a final decision taken how to tackle this specific fistula. Normal diet is given till afternoon the day before the operation followed by oral fluids in the evening and two enemas at 10.00 p.m. and 6.00 a.m. Opening colostomy in recto-vaginal fistula patients increase the expenses and stress to the patient; colostomy is not curative but a help; only if it can be guaranteed that 2 weeks after colostomy the RVF is repaired and that 4 weeks after successful RVF repair the colostomy is closed. It has already been demonstrated that spinal anaesthesia with a long acting agent is the anaesthesia of choice as it is easy to learn, does not need intensive intra and/or post-operative monitoring, is as effective as general anaesthesia, does not require electricity and is safe and cheap (Ref. 6-8). Prophylactic antibiotics are given only pre-operative as the high urine output will prevent ascending urinary tract infection. In case of a combination fistula, the closure of the recto-vaginal fistula is followed by the closure of the vesico-vaginal fistula to minimize contamination. Avoid routine use of Martius fat graft as other fistulae are not complicated. Early ambulation and normal diet at day 2; (in recto-vaginal fistula normal diet day 4). Foley catheter with a urine bag to allow easy mobilization.
Even more research is needed in this field, our study shows that the proposed modified management of vesico and/or recto-vaginal fistula prevents the woman from becoming an outcast in her society and her family. The modified management has a similar success rate as the usual method; it is simple, fast, safe, effective, easy to learn, cheap and can be applied under primitive conditions. That is exactly what is needed in developing countries with a high annual incidence of fistula patients.
Any woman who develops a fistula, an early repair should be performed unless the fistula has healed by catherization.
Edited by Aldo Campana,