Trends in the aetiology of urogenital fistula: a case of ‘retrogressive evolution’?

Abstract

It has long been held as conventional wisdom that urogenital fistulae in low-income and middle-income countries are almost exclusively of obstetric aetiology, related to prolonged neglected obstructed labour, whereas those seen in high-income countries are largely iatrogenic in nature. There is, however, a growing perception amongst those working in the field that an increasing proportion of urogenital fistulae in low-income and middle-income countries may be iatrogenic, resulting from caesarean section. Recent studies suggest that adverse patterns of care may also be emerging in high-income countries; an increase in the risk of both vesicovaginal and ureterovaginal fistulae following hysterectomy has been reported, concurrently with the reduction in overall use of the procedure. These apparent secular trends are discussed in the context of evolution of practice, teaching and training in obstetrics and gynaecology.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda

“…19 A review article recently published also supports the idea that there may be more iatrogenic fistulas than previously thought. 20 Further clinical examination would be required to clarify the true cause of the fistulas in this study and in other women in Uganda experiencing obstetric fistula. The fact that there were higher resourced patients (eg, those with college education) as well as a relatively high rate of live births (19,35.85%) could indicate a subset of the population had iatrogenic injury.…”

Rising trends in iatrogenic urogenital fistula: A new challenge

“…However, contrary to the previous trend, a significant shift has been observed regarding the etiology of female urogenital fistula. Recent studies have shown a growing incidence of iatrogenic fistula . Trends observed in various studies conducted over a period of 13 years in Pakistan show a significant increase in iatrogenic fistula.…”

Aetiology of Vesico Vaginal Fistula (VVF)—Observation in Patients Managed at CCBRT (Comprehensive Community Based Rehabilitation in Tanzania) Hospital, Dar es Salaam, Tanzania. January to March 2016

“…In order to get more precise data on whether a fistula is truly iatrogenic Hilton [23] suggested to describe those fistulas as a "true obstetric or ischaemic fistula" where women who experienced obstructed labour, maybe sometimes for days, ultimately delivered a stillborn baby vaginally. He agrees with Raassen [25] as well as referrers to Onsrud [32] and Loposso [28] who describe that women who are delivered by CS of a live baby in a health facility after obstructed labour had been identified and who still develop a VVF "would be reasonably described as having an iatrogenic injury".…”

“…Should these lesions be looked on as 'obstetric', iatrogenic, or a combina-tion?" He points out that it is not always clear and easy to define an OF after a CS as only ischaemic or only iatrogenic, but more likely mostly the combination of both [23].…”