Obstetric vesicovaginal fistula as an international public-health problem.
ABSTRACT Vesicovaginal fistula is a devastating injury in which an abnormal opening forms between a woman's bladder and vagina, resulting in urinary incontinence. This condition is rare in developed countries, but in developing countries it is a common complication of childbirth resulting from prolonged obstructed labour. Estimates suggest that at least 3 million women in poor countries have unrepaired vesicovaginal fistulas, and that 30 000-130 000 new cases develop each year in Africa alone. The general public and the world medical community remain largely unaware of this problem. In this article I review the pathophysiology of vesicovaginal fistula in obstructed labour and describe the effect of this condition on the lives of women in developing countries. Policy recommendations to combat this problem include enhancing public awareness, raising the priority of women's reproductive health for developing countries and aid agencies, expanding access to emergency obstetric services, and creation of fistula repair centres.
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ABSTRACT: Background: Vesico Vaginal Fistula (VVF), as seen in this environment, is a major cause of severe morbidity and potential mortality, which can result in marital disruption, rejection and, eventual destitution. To determine the socio-demographic characteristics, fistula features, and evaluate the intervention measures in Jos, North Central Nigeria. This study was carried out at the VVF Centre, ECWA Evangel Hospital, Jos, North Central Nigeria. Descriptive retrospective study. The patients' records from January 1 to December 31, 2007 were retrieved and analyzed for the demographics, clinical features, management and outcome using EPI Info version 3.4.3, 2008. A total of 314 patients were treated. The patients aged between 12 to 60 years (SD 6.19) with a mean parity of 3.7. Seventy percent (70%) of the patients were married and living with their husbands, while 65% of the patients were illiterate farmers. Christians and Muslims patients made up 60% and 40% respectively. Juxta-cervical (26%) and juxta-urethral fistulae (26%) were the commonest types, with obstructed labour being the causative factor in 82% of the patients. Ninety three percent of the repairs were repaired via the vaginal approach. The success rate at repair was 69%. Post-operative complications occurred in 16% of the patients. Vesico- vaginal fistula is a problem in this environment, occurring mainly amongst the illiterate farmers after prolonged obstructed labour. Public enlightenment and appropriate ante-natal care and delivery would reduce the incidence.Journal of the West African College of Surgeons. 1(2):50-62.
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ABSTRACT: A 43-year-old woman presented with 20-year history of leakage of urine per vaginam. She had one failed repair attempt. Pelvic examination with dye test showed leakage of clear urine suggestive of ureterovaginal fistula. The preoperative intravenous urogram revealed duplex ureter and cystoscopy showed normally cited ureteric orifices with two other ectopic ureteric openings and bladder diverticula. The definitive surgery performed was ureteric reimplantation (ureteroneocystostomy) of the two distal ureteric to 2 cm superiolateral to the two normal orifices and diverticuloplasty. There was resolution of urinary incontinence after surgery. Three months after surgery, she had urodynamic testing done (cystometry), which showed 220 mLs with no signs of instability or leakage during filling phase but leaked on coughing at maximal bladder capacity. This is to showcase some diagnostic dilemma that could arise with obstetric fistula, which is generally diagnosed by clinical assessment.Case reports in urology. 01/2014; 2014:801063.
Article: Of fl ukes and fi stulae[Show abstract] [Hide abstract]
ABSTRACT: In September, 2005, a 26-year-old woman came to our clinic, having been leaking urine constantly for 2 years. She had lived in rural Gambia, until migrating to Germany in July, 2005. She had given birth 3 years before she started to leak urine; the birth had been uncomplicated. She recalled no injury or surgery to the urinary tract or genitals. Examination, with a speculum, revealed a defect in the anterior vaginal wall, 3 cm from the introitus, through which urine was passing. Transvaginal ultrasonography showed no abnormality, except that the bladder could not be fi lled. Cystoscopy showed the fi stula to open into the bladder. Near the opening of the fi stula, we saw two blisters, nearly 1 cm in diameter. The blisters were yellow and fi ne-grained in appearance, rather like sand. We took biopsy samples from the blisters: histopathological examination showed eggs of Schistosoma haematobium, surrounded by chronic granulomatous infl ammation (fi gure). Cystography with contrast, and CT with contrast, showed the path of the fi stula; CT also showed the posterior wall of the bladder to be irregular, consistent with scarring from schistosomiasis. Blood tests showed eosinophilia, and a high concentration of IgE (2990 IU/mL; normal range ≤100 IU/mL). Dipstick testing of urine showed microhaematuria and proteinuria. Microscopy of a fresh urine sample obtained at noon, and passed through a nucleopore fi lter, revealed eggs of S haematobium, in which the larvae moved spontaneously, indicating that the eggs were viable. An indirect immunofl uorescence test showed antibodies to soluble egg antigen of Schistosoma spp, at a titre of 1:320. We tested for other infections by microscopy, culture, and PCR of urine and vaginal fl uid; many stool examinations; fi ltration of blood through nucleopore fi lters, after administration of diethylcarbamazine, which encourages fi larial larvae to move into the blood; and serological testing. However, we found no infections apart from schistosomiasis—and specifi cally, no evidence of chlamydia, syphilis, cytomegalovirus, HIV, human T-cell leukaemia virus, hepatitis B, hepatitis C, lymphatic fi lariasis, amoebiasis, or tuberculosis. We prescribed praziquantel, at a dose of 40 mg/kg, for 3 days. 8 weeks later, examination of a 24 h urine specimen showed no eggs of schistosoma; cystoscopy showed no blisters, although some sandy patches and cystitis cystica persisted. The fi stula opening was smaller than before. Histopathological examination of a biopsy sample from the sandy patches revealed a single, non-viable, egg of schistosoma. Since the patient continued to leak urine, we inserted a permanent catheter, but removed it 10 days later, because the patient found it uncomfortable. 4 months later, cystoscopy showed no mucosal abnormalities; moreover, the fi stula was very small indeed. The patient preferred surgery to further conservative treatment. She recovered well from the operation. When last seen, in March, 2008, she was well, and fully continent of urine. At least 3 million women are thought to have an untreated vesicovaginal fi stula (VVF). 1 VVF are usually attributed to injuries sustained during childbirth, or female genital mutilation 1 —although they can also be caused by infections. Schistosomiasis often aff ects the reproductive tract, 2,3 and was suspected, as long ago as 1907, to cause VVF. 4 However, it has not been established as a sole cause of VVF, since patients with schistosomiasis have tended to have other possible causes of VVF. 5 We were unable to identify any other cause of VVF in our patient, indicating that perhaps, after all, schistosomiasis can be a sole cause of VVF. Treatment of the disease coincided with regression of the fi stula. Schistosomiasis should always be treated before a fi stula is resected;01/2008;
www.thelancet.com Vol 368 September 30, 2006 1201
Obstetric vesicovaginal fi stula as an international
L Lewis Wall
Vesicovaginal fi stula is a devastating injury in which an abnormal opening forms between a woman’s bladder and
vagina, resulting in urinary incontinence. This condition is rare in developed countries, but in developing countries
it is a common complication of childbirth resulting from prolonged obstructed labour. Estimates suggest that at
least 3 million women in poor countries have unrepaired vesicovaginal fi stulas, and that 30 000–130 000 new cases
develop each year in Africa alone. The general public and the world medical community remain largely unaware
of this problem. In this article I review the pathophysiology of vesicovaginal fi stula in obstructed labour and
describe the eff ect of this condition on the lives of women in developing countries. Policy recommendations to
combat this problem include enhancing public awareness, raising the priority of women’s reproductive health for
developing countries and aid agencies, expanding access to emergency obstetric services, and creation of fi stula
Vesicovaginal fi stula is an abnormal opening between
the bladder and the vagina that results in continuous
and unremitting urinary incontinence (fi gure 1). In
industrialised countries, such fi stulas are rare, and
arise mainly from malignant disease, radiation therapy,
or surgical injury (usually to the bladder during
hysterectomy).1,2 In the poor countries of Africa and
south Asia, however, vesicovaginal fi stulas are a
common problem, affl icting many women. In these
countries, fi stulas are usually caused by prolonged
obstructed labour, which was also once the most
common cause of fi stulas in Europe and the USA.
Fistula from obstructed labour was eradicated from
industrialised nations by the middle of the 20th century
as eff ective systems of obstetric care were developed to
cover the entire population of childbearing women. As
a result of this success, contemporary published work
on obstetric fi stulas is woefully inadequate by the
standards of 21st century evidence-based medicine, a
situation that is not uncommon for medical problems
that are largely confi ned to poor countries. A
comprehensive review in 2005 of existing medical and
surgical reports on obstetric fi stulas concluded that “the
Western medical literature on obstetric fi stulas is old
and relatively uncritical by current scientifi c criteria.
This literature consists mainly of anecdotes, case series
(some quite large), and personal experiences reported
by dedicated surgeons who have labored in remote
corners of the world while facing enormous clinical
challenges with scanty or absent resources at their
disposal.”3 The precise extent of the fi stula problem in
developing countries is, therefore, unknown, but review
of the available evidence suggests that this problem is
both enormous and neglected.
In 1993, a generally accepted estimate (admittedly not
well grounded in hard data) suggested that at least
2 million women in the developing world had
unrepaired obstetric fi stulas, and even this number was
regarded by many observers as too low at that time.4 A
recent conservative attempt to estimate the incidence of
obstetric fi stulas with a population-based survey of
severe obstetric morbidity in West Africa concluded
that there were probably at least 33 000 new cases each
year in sub-Saharan Africa.5 At the other end of the
spectrum, the most recent estimate from the WHO
Lancet 2006; 368: 1201–09
pages 1146 and 1147
Department of Anthropology,
Washington University School
of Medicine, St Louis,
MO 63110, USA (L L Wall MD)
Search strategy and selection criteria
A MEDLINE search was done from 1966 onwards with the
keywords “fi stula,” “vesicovaginal fi stula,” and “obstructed
labor,” along with intensive bibliographic checking of older
published books and journals. The material was reviewed by a
select committee of fi stula experts currently working in
developing countries, who supplemented published sources
with their own personal experience, as part of the Third
International Consultation on Incontinence in Monaco in
2004, and updated since. The full report of the committee
has been published.3
Figure 1: Moderate-sized vesicovaginal fi stula from obstructed labour
A metal catheter passed through the urethra is clearly visible through the bladder
base, which is missing. Copyright Worldwide Fistula Fund, used by permission.
www.thelancet.com Vol 368 September 30, 2006
Global Burden of Disease Study suggested that
obstructed labour aff ects at least 7 million women every
year, 6·5 million of whom live in the least-developed
regions of the world where access to competent obstetric
care is poorest and the likelihood of serious
complications is greatest.6 If only 2% of obstructed
labours in the developing world result in a subsequent
fi stula, 130 000 new cases would be added each year,
and because women may live for decades with this
condition, the burden of suff ering borne by these
women measured in quality-adjusted life years is
enormous. Because the capacity to repair obstetric
fi stulas lags far behind the incidence in these countries,
as many as 3·5 million women might be suff ering
from this condition. Results of a qualitative survey of
the extent of the fi stula problem in nine African
countries by EngenderHealth on behalf of the UN
Population Fund confi rmed that this condition is
Although much talk and many conferences have been
devoted to safe motherhood over the past 20 years, the
British Journal of Obstetrics and Gynaecology recently
referred to the maternal health crisis in the world’s
poorest nations as “the scandal of the century”.8 A
100-fold disparity exists between maternal mortality
ratios in affl uent industrialised countries and those in
poorer countries; 99% of the world’s 529 000 annual
maternal deaths occur in the developing world; and if a
woman’s lifetime risk of dying as the result of a
complication of pregnancy or childbirth is considered,
the disparity is even greater.9 For example, a woman’s
lifetime risk of dying as the result of a pregnancy-related
cause is estimated to be one in 29 800 in Sweden, but as
high as one in six in the most impoverished, least
developed regions of Africa and Asia (such as Sierra
Leone and Afghanistan).9 The international aid
community has been largely uninterested in funding
programmes that provide emergency obstetric services
for the poor women of the world. As a result, many
have come to regard “safe motherhood” as an “orphan
Tragic as any maternal death is, the loss of life that
occurs from avoidable obstetric causes is dwarfed by
the number of women in developing countries who
sustain crippling, non-fatal obstetric injuries. The
precise prevalence of serious maternal morbidity in
developing countries remains unknown, but evidence
suggests that it is alarmingly high. For example, Fortney
and Smith12 calculated the ratio of serious maternal
morbidity to maternal mortality for Indonesia,
Bangladesh, India, and Egypt and estimated that 149,
259, 300, and 591 serious maternal injuries occurred in
these countries, respectively, for every maternal death.
The most dramatic maternal birth injury is vesicovaginal
fi stula. Although substantial numbers of fi stulas are
caused by trauma, by sexual abuse or coital injury in
child brides, by infection (particularly with lympho-
granuloma venereum), and by harmful traditional
practices such as female genital cutting or other forms
of unwarranted surgery, the most common worldwide
cause of vesicovaginal fi stula is obstructed labour.13–15
Obstructed labour and its consequences
Labour becomes obstructed when a woman cannot
deliver her baby through her birth canal because of a
discrepancy between the size of the fetus and the space
available in her pelvis (fi gure 2). Two major evolutionary
forces have made human females uniquely susceptible
to this cephalo-pelvic disproportion: the assumption of
an erect bipedal posture, which has imposed structural
constraints on the architecture of the human pelvis;
and the increasing size of the human brain over time.
As a result, the mechanics of childbirth are more
complicated in Homo sapiens than in any other
mammalian species.16 To negotiate the changes in pelvic
anatomy imposed by an upright posture and bipedal
gait, the human fetal head must constantly readjust its
position in the pelvis throughout the second stage of
labour. If the passenger will not fi t through the passage,
a pelvic impasse results. The disproportion between the
Figure 2: 18th-century obstetrical drawing of obstructed labour from
absolute cephalopelvic disproportion
From William Smellie’s Sett of Anatomical Tables, 1752. Note overlapping parietal
www.thelancet.com Vol 368 September 30, 2006 1203
presenting fetal part (usually the head) and the available
space in the maternal pelvis is the key to the development
of obstructed labour.17 This problem is especially
prevalent in parts of the world where girls grow up
malnourished, marry early, and become pregnant
before they have achieved full pelvic growth.18,19
The problem faced by women trapped in obstructed
labour must be solved by surgery (caesarean delivery),
but timely access to emergency obstetric services is
often non-existent in developing countries.20 In such
cases these women might be in labour for as long as
4 or 5 days without any eff ective intervention.3,21–24 What
this problem means for the unfortunate woman has
been succinctly summarised by Deborah Maine: “...we
have all had our hearts wrenched by photographs of
starving children. But how many people have imagined
what it means to be in labour for fi ve days, in pain,
exhausted, knowing that your baby is already dead and
you will die soon because the hospital where a cesarean
section could be done is out of reach, either physically,
fi nancially, or socially?”.25 In Africa, obstructed labour
is a major cause of maternal mortality, but for many
women the consequences of surviving this ordeal may
be worse than death itself.
In obstructed labour the soft tissues of the pregnant
woman’s vagina, bladder, and rectum are compressed
between the fetal head and the maternal pelvic bones by
the contractions of the uterus. As the fetal head is forced
tighter and tighter into the pelvis, the blood supply to
the mother’s soft tissues is progressively constricted,
and, ultimately is shut off completely. The result is a
widespread ischaemic injury that produces massive
tissue damage throughout the maternal pelvis as well
as fetal death from asphyxiation. In a day or two the
dead fetus becomes macerated, softens, and changes its
conformation in the maternal pelvis suffi ciently that it
can be expelled through the vagina. A few days later a
slough of necrotic tissue comes away, leaving a fi stula
between the bladder and the vagina (or sometimes
between the rectum and the vagina) in its place
(fi gure 2).
Vesicovaginal fi stula that occasionally occurs after a
hysterectomy is a relatively simple injury: it is caused
by a discrete wounding of otherwise normal tissue
(such as a misplaced clamp or a suture in combination
with a pelvic haematoma or abscess). By contrast, the
fi stula produced by obstructed labour is the product of a
massive fi eld injury caused by the impacted fetal head.
The most visible evidence of this process is the area of
central necrosis in which the fi stula develops, but the
fi stula itself is surrounded by a variable area of living
but still abnormal tissue that has sustained a sublethal
ischaemic injury. This damage in turn may result in
dense scarring that makes subsequent surgical repair
extremely diffi cult.21 Although the focus of clinical
interest has traditionally been the injury to the bladder
that occurs in these cases, vesicovaginal fi stula is only
one of a range of devastating injuries that can be
produced by obstructed labour. Because the crush
injury in this condition aff ects a broad area that
corresponds to the size of the presenting fetal part, the
tissue destruction is often extensive, resulting in a
cascade of related multisystem injuries known as the
obstructed labour injury complex (panel).22 These
additional injuries include vaginal stenosis due to scar
Panel: The obstructed labour injury complex
Vesicovaginal fi stula
Urethrovaginal fi stula
Ureterovaginal fi stula
Uterovaginal fi stula
Complex combined fi stulas
Urethral damage, including complete urethral destruction
Marked loss of bladder tissue from extensive pressure
Cervical injury, including complete cervical destruction
Secondary pelvic infl ammatory disease
Rectovaginal fi stula formation
Rectal stenosis or complete rectal atresia
Anal sphincter incompetence
Foot-drop from lumbosacral or common peroneal nerve injury
Complex neuropathic bladder dysfunction
Chronic excoriation of the skin from maceration by urine or
Fetal case-fatality rate of about 95%
Depression (sometimes with suicide)
www.thelancet.com Vol 368 September 30, 2006
tissue formation and subsequent vaginal contracture
(sometimes with virtual obliteration of the vagina),26,27
amenorrhoea and secondary infertility,28 rectovaginal
fi stula formation,21,23,29 hydroureteronephrosis and renal
failure,30 damage to the pubic symphysis,31 and foot-drop
caused by compression injuries to the nerves supplying
the lower extremities.32
The location of an obstetric fi stula depends on where in
the course of the second stage labour becomes
obstructed and which tissues are trapped between the
bony pelvis and the fetal head.33 Thus, a fi stula can
involve almost any series of contiguous structures in
the pelvis: ureterovaginal fi stula, vesicouterine fi stula,
vesicocervical fi stula, vesicovaginal fi stula, urethro-
vaginal fi stula, rectovaginal fi stula, and combinations
of such injuries. Since the work of J Marion Sims in the
19th century, surgeons have devised various systems for
classifying and describing the nature and location of
obstetric fi stulas,34 but there is still no general agreement
on how this should be done. As McConnachie noted in
1958, “It is common to fi nd that each author has either
used his own form of classifi cation based solely on the
anatomical structures involved, or the size of the fi stula,
or even one of convenience”.35 Fistulas are most
commonly described simply by location, as mid-vaginal,
juxtacervical, urethrovaginal, and so on. Although new
systems for classifi cation continue to be proposed,36,37
there is still a general lack of agreement about what a
classifi cation system ought to do. In oncology, for
example, many internationally accepted systems exist
for staging cancer. These systems have all been
correlated with the prognosis for treatment of the
particular cancers for which they have been developed.
Similarly, any useful classifi cation system for obstetric
fi stulas should be more than descriptive: it must
evaluate or score prognostic factors relevant to treatment
outcome. To date, no proposed classifi cation system for
obstetric fi stula has been prospectively evaluated to
investigate how it correlates with surgical outcome.
Until this is done, classifi cation systems for obstetric
fi stulas will remain intellectual exercises of limited
Detailed review of published work suggests that the
main prognostic factors aff ecting the treatment of
obstetric fi stulas are the degree of scarring in the
operative area, whether the continence mechanism of
the urethra and bladder neck is involved in the fi stula,
the size of the fi stula (particularly if there has been
extensive loss of bladder tissue from necrosis), and the
presence of other serious injuries, such as a concurrent
rectovaginal fi stula.3
The treatment of obstetric vesicovaginal fi stula depends
on when the patient presents for care after obstructed
labour. Because of the shortage of accessible emergency
obstetric services in areas of the world where fi stulas
are prevalent, most women present months or years
after their injuries.3,21,23 If a woman presents within the
fi rst 3 months after injury, prompt initiation of
continuous bladder drainage with an indwelling
catheter can allow spontaneous closure of the fi stula,
particularly if it is small (<2 cm in diameter).38,39 Because
fi stulas from prolonged obstructed labour occur as the
result of a broad fi eld injury with an area of central
necrosis surrounded by living but still severely damaged
tissues, the traditional teaching has been that 3 months
should elapse before any attempt at surgical closure is
made so that the full extent of the injury is manifest. In
1994, Waaldijk advocated early surgical intervention in
vesicovaginal fi stulas from obstructed labour, apparently
with good success,40 although his practice of doing such
operations without anaesthesia must surely be regarded
as unethical in the 21st century.41
The ultimate goal of fi stula surgery is to restore
normal function of the lower urinary tract and any other
pelvic structures aff ected. This process is more
challenging than simply closing the fi stula, which has
been done with a high degree of success in 80–95% of
cases in most series.3 The best chance of fi stula closure
is generally agreed to be at the time of the fi rst operation.
In a large series of 2484 patients, Hilton and Ward42
reported successful fi stula closure in 83% of patients at
the fi rst attempt, whereas successful closure was
achieved in only 65% of patients who needed two or
more operations. Similarly, there is general agreement
that the fi stula, which may be encased in scar tissue,
should be freed completely from the surrounding
tissues so that the edges can be coapted easily and
closed without any tension on the suture line. The
repair should be watertight at the time of closure.
Where possible, it is generally preferable to close the
fi stula in several layers and to drain the bladder for 14
days after surgery to prevent overdistension of the
repair, although the precise duration of postoperative
bladder drainage remains more a matter of tradition
than evidence-based practice. Especially in complex
fi stulas where extensive
surrounding tissues has occurred, it is often prudent to
bring in a new blood supply by use of a bulbocavernosus
or other tissue graft as an adjunct to repair.43,44
pressure necrosis of
Urinary incontinence after fi stula closure
The emphasis on vesicovaginal fi stulas as a cause of
urinary incontinence in developing countries often
leads to the assumption that closure of the fi stula is all
that is necessary to restore continence in aff ected
women. Unfortunately, even in cases where the fi stula
has been successfully repaired, 16–32% of women
remain incontinent.21,45 Although urodynamic assess-
ments of women with obstetric fi stulas who have
undergone repair are infrequent because of the absence
www.thelancet.com Vol 368 September 30, 2006 1205
of appropriate equipment in most facilities seeing large
numbers of fi stulas,46 the most common reasons for
successful closure but continence failure seem to be
damage to the bladder neck and urethral sphincter
mechanism during labour, altered detrusor activity,
bladder fi brosis, and (in some cases) markedly reduced
bladder capacity after closure of extensive fi stulas,
which can result in a bladder with a functional capacity
of less than 50 mL. Treatment of women with persistent
stress incontinence after fi stula closure is frequently
challenging, because of the extensive scar tissue that
often forms around the aff ected tissues. Several authors
have recommended the routine placement of urethral
suspension stitches at the time of fi stula closure to
prevent post-repair incontinence, but these techniques
have only had limited success.47,48 The best results seem
to be obtained with procedures that involve some
combination of urethrolysis, which frees the urethra
from entrapment in scar tissue, and the addition of
some type of compressive suburethral sling.49–52 If the
urethra has been completely destroyed by obstructed
labour, some form of urethral reconstruction is
necessary if continence is to be restored.53
Psychosocial damage resulting from obstetric
Published work on obstetric fi stula often focuses
exclusively on the hole in the bladder and does not pay
enough attention to the whole patient. The psychosocial
circumstances in which these women fi nd themselves
as the result of having sustained an obstetric fi stula can
be even more devastating than the physical injuries
themselves. Rather than experiencing the joy of fi rst
motherhood, vast numbers of young women become
social pariahs every year because of these injuries.
Although husbands and family members may initially
be supportive and compassionate to these women,
when it becomes clear that the constant loss of urine or
faeces is a chronic condition (viewed as incurable in the
context of the traditional local culture) these women are
usually divorced or abandoned by their husbands and
are often cast out by their families.21,24,54–57 In an analysis
of patients who presented at the Addis Ababa Fistula,
Muleta24 found that women who owned property of
value were less likely to be divorced or abandoned by
their husbands, but since obstructed labour and fi stula
formation is more common in young, primiparous
adolescents who are likely to be illiterate and from
impoverished rural areas, these injuries are most likely
to aff ect women of low social status who are already
among the most vulnerable members of society.
Additionally, the cause of fi stula is not readily apparent
to the surrounding community, who may view these
injuries as a punishment from God for sexual
misbehaviour or as a form of venereal disease, in
essence blaming the victim for her predicament and
further adding to the social stigma she encounters.55,57
Although little detailed research has been done on this
issue, results of preliminary surveys suggest that
depression, anxiety, and other forms of mental health
dysfunction are widespread among women with
vesicovaginal fi stula.58
Socioeconomic factors in obstetric fi stula
Why is fi stula so prevalent in developing countries? The
answer lies in a complex interplay of biological, social,
and economic forces (fi gure 3).3,57 Obstructed labour
and subsequent fi stula formation are most common in
young primigravid women. African women are
predisposed to dystocia because of the relatively narrow
architecture of their pelves compared with Europeans.59
Additionally, many African girls are married at a very
Low socio-economic status of women
Malnutrition Limited social roles
Illiteracy and lack of
Childbearing before pelvic growth is complete
Relatively large fetus
Lack of access to emergency obstetric services
Harmful traditional practices
Obstructed labour injury complex
Complex urologic injury
Vaginal scarring and stenosis
Chronic skin irritation
Fecal incontinence Urinary incontinence
Isolation and loss of social support
Divorce or separation
Suffering, illness, and premature death
Figure 3: The obstetric fi stula pathway
Copyright Worldwide Fistula Fund, used by permission.
www.thelancet.com Vol 368 September 30, 2006
early age. The likelihood of obstructed labour is
increased in areas where early marriage and childbearing
are common, because although growth in height stops
or slows with the onset of menarche, the capacity of the
bony pelvis normally continues to expand after the
epiphyseal growth plates of the long bones have fused.19
These problems are worsened if girls have been
undernourished throughout childhood and adoles-
cence.18 Thus, although girls are capable of becoming
pregnant at a relatively early age, their pelves do not
develop their full capacity to accommodate childbearing
until much later, and many will have their lives
destroyed by obstetric injury before they have even
crossed the threshold into true adulthood. In most
case series, the average age of a fi stula patient is
younger than 25 years, and many are as young as 13
or 14 years.13,14,21,23,24,60,61 Although the risk of obstructed
labour is greatest in younger mothers, any woman can
develop the condition if the right combination of
obstetric factors converge:
malpresentation, intervening disease or malnutrition,
etc. A bimodal distribution of fi stulas has often been
reported, with the highest peak in primigravid women
and another peak among women who have had four or
more pregnancies—a refl ection, perhaps, of the
tendency of birthweights to increase with subsequent
Probably the most important factors contributing to
the high incidence and prevalence of obstetric
vesicovaginal fi stulas in
socioeconomic (fi gure 3).57,62,63 Poverty is the breeding-
ground where obstetric fi stulas thrive. Early marriage,
low social status for women, malnutrition, and
infrastructures are all more common in poor areas.
Most importantly, lack of access to emergency obstetric
services is ubiquitous in the poor areas of the world.
Fistulas are most prevalent where maternal mortality
is high. Most maternal deaths are due to preventable
causes: haemorrhage, infection, hypertensive disorders
of pregnancy (pre-eclampsia and eclampsia), unsafe
abortion, and obstructed labour. Although the
prevention of maternal death from these causes requires
skilled medical and surgical care, none of these
interventions requires high-technology resources. The
essential elements of emergency obstetric care are
intravenous fl uids, antibiotics, blood transfusion,
oxytocic drugs, and basic surgical services (which can
usually be provided under spinal anaesthesia).8,10,64
However, even these simple life-saving services are
usually unavailable in low-resource areas.
From a historical point of view, it should be noted that
maternal mortality rates in western Europe and the
USA at the beginning of the 20th century were similar
to those in the developing world. The widespread
diff usion of access to emergency obstetric services
accounted for the dramatic fall in maternal deaths
large fetal size,
Africa, however, are
social and economic
between 1935 and 1950, and it is largely the absence of
eff ective access to emergency obstetric services that
accounts for both the high levels of maternal death and
the tragic prevalence of vesicovaginal fi stulas throughout
Africa today.8,10,62,65 In parts of the world where obstructed
labour is a major contributor to maternal mortality, the
rate of vesicovaginal fi stula might even approach the
maternal death rate.42,60
Prevention and treatment: the public-health
Virtually all obstetric fi stulas could be prevented by
adequate intrapartum care that would detect the
abnormal progression of labour and would allow timely
intervention before labour became obstructed. Simple
graphic analysis of the progress of labour (the
partograph) used by trained birth attendants reduces
maternal deaths, prevents prolonged labour, and even
results in a decrease in operative intervention (by
allowing normal labour to proceed without unnecessary
interference);66 yet even this level of basic obstetric care
is absent throughout most of the developing world.8,10,62
The provision of essential obstetric services has never
been a top priority for the governments of countries
where the fi stula problem is most severe. The maternal
health programmes that do exist are often restricted to
provision of rudimentary prenatal care or emphasise
birth control, but family planning programmes and
antenatal health care services by themselves will never
have more than a marginal eff ect on maternal mortality.
Most maternal deaths are due to unexpected comp-
lications that cannot be predicted in advance but that
demand prompt intervention when they occur:
haemorrhage, hypertensive crises, sepsis, complications
of unsafe abortion, and obstructed labour. The
international public health community has not
emphasised the critical need for surgical services in the
developing world, and this problem has been made
worse by lack of meaningful ongoing communication
between the public-health community and clinical
In the meantime, the backlog of unrepaired fi stulas
continues to increase throughout these impoverished
countries. Since fi stulas by themselves are not fatal, the
millions of women thus affl icted continue to live lives
of unremitting misery, while tens of thousands more
are added to their ranks every year. The basic techniques
needed for fi stula repair have been known for more
than 150 years.3,68 Most recent advances in fi stula surgery
have come in the areas of improved anaesthesia,
synthetic suture materials, better urinary catheters, and
techniques of tissue grafting, rather than from
breakthroughs in basic science. Fistulas can be repaired
at minimal cost with low-technology surgical operations
done under spinal anesthesia, yet even these basic
surgical services are unavailable in most developing
regions.3 Pilot studies have shown that the techniques
www.thelancet.com Vol 368 September 30, 2006 1207
needed to repair uncomplicated fi stulas can be taught
quickly and effi ciently to doctors who already have basic
surgical skills.69 There are even spectacular cases in
which intelligent but uneducated individuals with good
manual dexterity can be taught to become expert fi stula
However, possession of surgical skills is not enough.
Numerous other problems are associated with providing
fi stula repair services in developing countries.3,21,24,55,70,71
Fistula suff erers tend to be young, illiterate, destitute
women from rural areas, without political infl uence or
economic resources.21,24,30,56,57 These women cannot pay
even the modest rates charged for surgery at most
hospitals in Africa. Fistula repair must be an act of
charity, but other surgical patients who are required to
pay for their own care resent the provision of free
services of this kind. Furthermore, fi stulas are severely
stigmatising. In many African countries, diffi cult labour
is believed to be a punishment sent by God or the
ancestors for adultery on the part of the woman, loading
a moral stigma on top of a physically off ensive
condition.54–57,72 The necessity for prolonged catheter
drainage after surgery (10–14 days) to permit the bladder
to heal means that fi stula patients need longer hospital
stays and more intensive nursing care than do many
other surgical patients—which, in turn, makes them
unpopular with nursing staff . Furthermore, fi stula
cases are rarely emergencies. In hospitals that provide
general surgical services, scheduled fi stula cases are
frequently bumped from the operating list because of
road traffi c accidents or other life-threatening
emergencies. In no area of the health-care systems of
developing countries are fi stula patients a high priority.
They are at the bottom of the heap socially, sexually,
economically, politically, and medically.
There is, therefore, an urgent need for countries with
large numbers of women who have vesicovaginal fi stulas
to develop specialised centers dedicated exclusively to the
care of these women. Not only does this focused factory
approach allow maximum effi ciency of patient care (the
Addis Ababa Fistula Hospital, the outstanding model of
this kind, has now treated more than 25 000 fi stula
patients), but it also allows for the development of a
uniquely supportive sisterhood of suff ering among these
women that is a key component in healing their
psychosocial wounds.55,72 Much of the nursing care in
such a hospital can actually be provided by current or
former fi stula patients, which further strengthens the
sense of community among these women.
The most important need, however, is for the obstetric
fi stula problem to move up the list of international
health-care priorities. The launch of an international
campaign to end fi stula spearheaded by the United
Nations Population Fund (UNFPA) and partnering
organisations such as Engender Health and the
Worldwide Fistula Fund is a step in the right direction,
but little true progress will be made until politicians
For Campaign to End Fistula
see http://www.endfi stula.org
For Worldwide Fistula Fund
and health administrators in developing countries put
this issue on their national health-care agendas
themselves. As Shiff man and colleagues have shown,
the factors that raise the priority of safe motherhood
and related issues in such countries are complex, but
individual case studies suggest that cooperative
relations between ministries of health and international
organisations, creation of inclusive international
health-policy networks, and provision of adequate
external aid, coupled with pressure from dedicated local
activists, can reshape health-care priorities for women
in countries as diverse as Indonesia and Honduras.73,74
A heightened awareness of the burden of injuries such
as vesicovaginal fi stulas might help to rekindle the
faltering international commitment to reduce maternal
mortality, especially if dedicated fi stula champions
mobilise support at the local level to demand that action
be taken on this issue.70,71,74,75
Although the obstetric vesicovaginal fi stula has
vanished from the collective memory of more developed
countries, it continues to ruin the lives of tens—if not
hundreds—of thousands of young women every year.
This situation is a mark of shame on the world medical
community and demands urgent and sustained action.
Confl ict of interest statement
I am the founder, President, and managing director of the Worldwide
Fistula Fund, a not-for-profi t charitable organisation registered in the
state of Illinois, which is recognised as a public charity under section
501[c] of the United States Internal Revenue Code. The purposes of
this charity are to provide direct clinical services to women in the
developing world suff ering from childbirth injuries, especially
vesicovaginal fi stulas from prolonged obstructed labour, and to
advance public awareness, education, surgical training, and advocacy
for these women.
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