Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula

Abstract

Objective To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence. Design An observational clinical study.Setting A specialised fistula unit in a developing country.Population Women following successful anatomical closure of obstetric genitourinary fistula.Methods Fifty-five women were enrolled from the Fistula Hospital in Ethiopia, following obstetric fistula repair. Their case records were reviewed and details regarding (1) antecedent obstetric factors, (2) the site, size and type of fistula and (3) pre-operative bladder neck mobility and vaginal scarring were recorded. All women were questioned regarding symptoms of faecal and urinary incontinence. Women reporting urinary incontinence following fistula repair underwent urodynamic investigations. Main outcome measures Clinical and urodynamic assessment.Results The mean age of the women was 23 years (range 16 -45 years). The fistula in 38 women (69%) followed the first delivery and in 17 women (31%) following a subsequent delivery. The mean duration of labour was four days (range 1-9 days). Forty-four women (80%) had an isolated vesico-vaginal fistula and 11 (20%) had a combined vesico-vaginal and recto-vaginal fistula. The mean diameter of the fistula was 2.9 cm (0.5 -6 cm). Successful repair occurred in all women. Thirty women (55%) reported persistent urinary incontinence and 21 (38%) altered faecal continence at follow up. In the former group, urodynamic investigations identified genuine stress incontinence in 17 women (31%), detrusor instability in two (4%) and mixed incontinence in 11 (20%). Conclusion This study demonstrates the high rate of successful closure of the fistula in a specialised fistula unit, but highlights the problem of persistent urinary incontinence following closure.

A community‐based long‐term follow up of women undergoing obstetric fistula repair in rural Ethiopia

“…Community‐based follow up of women who have undergone fistula repair surgery has been stated to be extremely difficult 4,6–8 . To the best of our knowledge, only one previous study have succeeded in such follow up 10 .…”

“…Despite many reports on the primary closure rates of fistula surgery, 3–5 there is a paucity of data on long‐term outcomes following fistula repair, in particular a lack of data on urinary symptoms, reproductive health and quality of life among the treated populations. Reasons cited for this lack of population‐based follow up include the remote and inaccessible residence of most women with fistula, poor roads, the lack of telephones and postal services, and the relatively high cost of traveling 4,6–8 …”

Current practices in treatment of female genital fistula: a cross sectional study

“…In an uncontrolled observational study, 55% of women reported persistent urinary incontinence after surgery, while 38% reported altered fecal continence [7]. …”

James Marion Sims: some speculations and a new position

“…Subsequent writers have cast doubt on Sims' claims of complete cure, and it may be that, although the fistulous opening was healed, bladder function remained compromised — even after modern fistula surgery, stress and urge incontinence can be problems 12 . ‐ 15 However, there is no doubt that Sims had made great progress in the understanding and techniques of fistula repair (Box 4).…”