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Obstetrics

Obstetric Fistula

An abnormal opening between the vagina and the bladder (VVF) or rectum (RVF), usually resulting from prolonged, obstructed labour causing tissue necrosis. Leads to continuous leakage of urine or faeces.

Also known as: Vesicovaginal Fistula (VVF), Rectovaginal Fistula (RVF), Birth Injury

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Referral and warning signs

When to refer

Refer ALL suspected fistula cases to specialized repair centre. Refer women immediately postpartum after obstructed labour for assessment/prolonged catheterization.

Red flags

  • Continuous leakage urine/faeces post-delivery
  • History suggestive of obstructed labour

Signs and symptoms

  • Continuous, uncontrollable leakage of urine from vagina (VVF).
  • Continuous, uncontrollable leakage of faeces from vagina (RVF).
  • Foul odour.
  • Skin irritation/excoriation of vulva/perineum/thighs.
  • Recurrent UTIs/vaginal infections.
  • Social isolation, stigma, depression.
  • History of prolonged/obstructed labour.

Risk factors

  • Obstructed labour (main cause).
  • Lack of timely skilled obstetric care (esp. C/S).
  • CPD.
  • Young age/Early marriage.
  • Poor nutrition/Short stature.
  • FGM.
  • Surgical trauma, Radiation, Cancer, Sexual violence (less common).

Diagnosis

Clinical assessment

History of continuous incontinence post-delivery. Exam: Vulval excoriation, wetness, odour. Speculum: Visualize leakage/fistula opening. Dye Test (Methylene blue in bladder via catheter) - blue dye in vagina confirms VVF. DRE for RVF.

Investigations

  • Clinical exam + Dye test often sufficient.
  • Examination Under Anaesthesia (EUA) for full assessment.
  • Fistulogram/IVU/Cystoscopy/Sigmoidoscopy (specialist).

Diagnostic criteria

Clinical history + Visualization or Positive dye test.

Management

Non-pharmacological management

  • Immediate Postpartum (Prevention/Early Healing): Continuous Bladder Drainage (Foley catheter) for 2-6 weeks after ALL prolonged/obstructed labour. High fluid intake. Hygiene. Monitor leakage post-catheter removal.
  • Established Fistula: Referral for Surgical Repair (specialized centres). Pre-op optimization (nutrition, infection). Post-op care (prolonged catheter). Psychosocial support/rehabilitation.

Pharmacological treatment

  • Immediate Postpartum: Prophylactic antibiotics (e.g., Nitrofurantoin) while catheterized.
  • Treat infections.
  • Manage skin irritation (barrier creams).
  • Nutritional supplements.

Monitoring

Monitor catheter function. Assess continence post-catheter/post-repair.

Complications

  • Chronic incontinence.
  • Skin breakdown.
  • Recurrent UTIs/Renal failure.
  • Amenorrhoea/Infertility.
  • Foot drop.
  • Social isolation/stigma/depression.

Prevention

  • Prevent Obstructed Labour (FP, delay marriage).
  • Timely Access to Skilled Obstetric Care (ANC, Partograph, EmOC).
  • Appropriate management of obstructed labour + Postpartum bladder drainage.
  • Avoid harmful traditional practices.

Patient education

  • Explanation of condition and cause.
  • Importance of prolonged catheterization.
  • Surgical repair options.
  • Need for specialized care.
  • Hygiene.
  • Psychosocial support.
  • Contraception/Future pregnancy advice.

Uganda-specific notes

Significant problem due to EmOC access challenges. Prolonged bladder drainage key prevention. Specialized repair camps/centres exist. Addressing stigma crucial.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.6.4

  • National Strategy for the Elimination of Obstetric Fistula, MOH Uganda

    (Specific fistula program documents)

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