FISTULA EXPLAINED

Fistula is an abnormal hole in a woman’s birth canal. A fistula that occurs in a woman’s birth canal is known as an obstetric fistula. It is a hole that develops between the birth canal and one or more of the woman’s internal organs, such as the rectum and the bladder. The hole causes permanent incontinence, meaning inability to control urine or faeces, in either case.

What causes fistula?

Over 90 per cent of obstetric fistula cases result from prolonged obstructed labour when the baby cannot pass, as it should, through the birth canal. The baby’s head gets stuck and compresses the soft tissues of the birth canal against the maternal pelvic bones. If there is no relief or prompt medical attention, typically a Caesarean section, the compression becomes persistent and blood supply to these soft tissues is cut off, causing them to die, rot and eventually fall out. This results in a hole (fistula), either between the urinary bladder and the vagina (known as vesicovaginal fistula or VVF) or between the vagina and the rectum. This is known as a rectovaginal fistula.

Fistula can also be caused when the bladder and the rectum have been pierced with foreign objects. This may happen, for instance, due to abortion or road traffic accidents. It is also believed that excessive forms of female genital mutilation can result in fistula during child birth.

Presentation of fistula
Some victims develop extreme nerve damage to the lower limbs, a condition known as ‘drop foot’, which makes them unable to walk properly.

Conditions under which a fistula occurs can also lead to damage of the pelvic floor muscles, the lateral walls of the vagina and the cervix. Sometimes damage to the entire tissue regime in the pelvic region may result in a •frozen’ pelvis. Vaginal atresia (closure of the vagina) can also occur when the affected tissues heal with scars which extend over to the birth canal.

The most visible effects of fistula are inability to control urine or faeces, and pyschological effects of ostracisation by the local community and neglect, abuse or divorce by husbands. Low self esteem and mental agony as a result of foul smell, also affect the victim.

Incontinence of urine or faeces leads to hygiene concerns, which can be costly to maintain as the woman must clean herself and her garments regularly.

Due to both social stigma and personal embarrassment, most fistula patients live in isolation, working, eating and sleeping alone. Some end up committing suicide.

Due to constant wetness a woman develops skin changes (excoriations) in her private parts leading to wounds.

Victims of fistula

Fistula can affect anyone, but trends have shown that some categories of people are particularly at risk.

Young people who have not reached maturity age and therefore cannot handle a normal pregnancy.

Short people or people with stunted growth. In case of a short person the birth canal is always contracted while for those with stunted growth, every port of the body becomes stunted and the baby may have problems negotiating its way out.

Poor people especially those residing in rural areas and cannot access proper obstetric medical care.

High risk pregnancies. Women with multiple gestations or abnormal baby presentations face increased risk of developing fistula.

Prevention, treatment and management of fistula

Unfortunately, fistula can only be managed in hospitals. The best way to prevent it is by attending antenatal clinic or having pregnancy monitored by a qualified medicare giver. An assessment is made as pregnancy progresses to check if the baby is lying transversely or abnormally, is excessively big. or if the mother has too small a pelvis or is carrying co-joined twins. This enables early preparation for an elective Caesarean section.

Once a pregnant woman is diagnosed as having or at risk of developing obstructed labour, the solution is to undertake a Caesarean section at the opportune time. If after a C-section or normal difficult delivery tissues are found to be damaged, these should be repaired surgically and meticulously.

A woman who observes any signs of fistula should proceed to hospital immediately.

Dr. Weston Khisa is a Consultant Obstetrician/ Gynaecologist based at Hurlingham Family Health Clinic, Nyaku House, Hurlingham. Nairobi.

Dr. Kiiru JM is a Consultant Obstetrician/ Gynaecologist and Fistula Surgeon, based at Reliance Centre, Westlands. Nairobi. westmedc@gmail.com

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