|Year : 2013 | Volume
| Issue : 1 | Page : 35-38
Urethral catheter as an initial stage for obstetric vesicovaginal fistulae management
Department of Surgery, Kazaure General Hospital, VVF Centre, General Hospital Jahun, Jigawa State, Nigeria
|Date of Web Publication||28-Aug-2013|
Department of Surgery, Kazaure General Hospital, Jigawa State
Source of Support: None, Conflict of Interest: None
Background: Medical practitioners including some specialists who do not have vesicovaginal fistulae (VVF) management experience are in the habit of operating VVF patients and this result to a little success or even to more surgical trauma. Therefore it is imperative to have a simple, feasible and acceptable initial care of VVF patients by all medical practitioners. The objective of this study was to demonstrate the role of indwelling urethral catheter in initial management of obstetric fistulae.
Materials and Methods: In a period of 1 year (July 2009-June 2010) seven patients with obstetric fistula were evaluated prospectively and divided into two groups. Group 1 (GP1) includes five patients (71.0%) who had indwelling urethral catheter as a mainstay for their management. Group 2 consists of two patients (29.0%) who had VVF repair via vaginal approach. Demographic information, types of VVF, healing success, associated obstetric injuries, and complications were analyzed.
Results: The patients' age ranged from 14 years to 18 years with average of 16.30 years. Four patients out of the seven were booked at antenatal clinic; only two out of the former had delivered at a hospital. All babies were delivered at term with male to female ratio of 2.5:1. Four patients (57.10%) had eclampsia. Five patients (71.40%) had assisted deliveries while 2 (28.60%) had cesarean section because of prolong labor. Patients started leaking urine at average 10.40 (8-14) days after delivery. Urethral catheterization was enough to heal the fistula in 5 (71.40%) patients.
Conclusion: Urethral catheterization is feasible and acceptable as an initial stage for obstetric VVF management, especially in poor resource communities.
Keywords: Management, urethral catheter, vesico-vaginal fistula
|How to cite this article:|
Yakubu A. Urethral catheter as an initial stage for obstetric vesicovaginal fistulae management. Arch Int Surg 2013;3:35-8
| Introduction|| |
Female pelvic anatomy is made of numerous structures and viscera, appreciated as a complex and functional syncytium. Obstetric trauma always leads to isolated or combined dysfunction of urinary, genital, and gastrointestinal elements associated with disarrangement of female pelvic structures and viscera. In most of the time the vagina, bladder, urethra and rectum are involved. The injuries usually result in formation of obstetric vesicovaginal fistulae (VVF), which is a devastating childbirth injury. ,, Correction of this functional-anatomic disarrangement requires comprehensive management strategies. 
To have good surgical management outcome it is necessary to involve colorectal (and gastroenterological), urogynecologic, and urologic specialists with expert skills in VVF surgery. Unfortunately, obstetric VVF is common in sub-Saharan Africa, Asia, and the Arab region where such dedicated specialists are scarce.  Therefore, it is not uncommon for the unspecialized general practitioner to be directly involved in the management of VVF in low-income countries.
Majority of the women in sub-Saharan Africa give birth at home under supervision of non-trained traditional birth attendants (TBAs), which is often associated with significant maternal morbidity and mortality. Even in urban areas were hospitals exist there is no functional standard protocols for the existing obstetric care. 
In our setting, abnormal, complicated deliveries and their complications are often managed by general medical practitioners, nurses and clinical assistants. Many among these medical practitioners including some specialists who do not have VVF management experience are in the habit of operating VVF patients prematurely and in most of the cases the patients are exposed to more surgical trauma and sometime become inoperable even at specialized VVF centers. 
Therefore, it is imperative to have a simple, feasible, and acceptable initial care of VVF patients by all medical practitioners. To achieve this, we used urethral catheter as an immediate initial stage for VVF management. The objective of this study is to demonstrate the role of indwelling urethral catheter in the initial management of obstetric fistulae.
| Materials and Methods|| |
In a period of 1 year (July 2009 to June 2010), seven patients presented with obstetric VVF to Kazaure General Hospital, Jigawa State, Nigeria. These patients were evaluated prospectively and divided into two groups based on management approach. Group 1 includes 5 patients (71.0%) who had indwelling urethral catheter as a mainstay for their management. Group 2 (GP2) consists of 2 patients (29.0%) who had VVF repair via vaginal approach. Both groups were managed by the same team of one general surgeon, two peri-operative nurses and two bed side nurses.
All patients were clerked and clinically examined. They were taken to operative room and placed in lithotomy position. Pubic arch angle, anal reflex and other peri-anal related lesions were assessed. Vaginal examination was carried out with the following information determined : f0 istula size, fistula site related to cervix and urethral orifice, bladder depth, urethral length and any other associated injuries of the birth canal components. Based on the thorough vaginal examination findings line of management was determined. Patients managed with catheter alone were put in GP1 while those who had both catheter and surgical repair were included in GP2.
Following urethral catheter insertion or VVF repair, patients and their relatives were counseled for liberal fluid intake. They were also trained for catheter management, vaginal toileting, and personal hygiene.
Patients were followed-up at 1 week interval where gentle vaginal examination was carried out to assess healing process. In both groups catheter was removed after 6 weeks, and patients continued with bladder drill. In the subsequent visits stress urine continence was demonstrated. Vaginal penetration was allowed after 6 months of discharge. Patients, their partners and relatives were counseled for family planning and obstetric care.
Demographic information, types of VVF, healing success, associated obstetric injuries and complications were analyzed.
| Results|| |
The patients' age ranged from 14 years to 18 years with mean of 16.30 years. They got married at average of 15.0 (13-17) years; they had their menarche at 14.9 (14-16) years and delivered at average of 1.60 (1-2) years after marriage. Four patients out of the seven were booked at antenatal clinic of which only two out of them delivered at a hospital. All babies were delivered at term with male to female ratio of 2.5:1. Three babies were alive at birth; one died 1 week after delivery. In all the subjects labor started at home and they were brought to hospital a mean of 10.50 (5-48) h following failure of progress of labor at home. Four patients (57.10%) had eclampsia. Five patients (71.40%) had assisted vaginal deliveries with vacuum-extraction while 2 (28.60%) had cesarean section because of prolonged labor. Cesarean section was performed 24 h and 48 h following admission for the two patients. Average hospital stay was 10.7 (7-14) days after deliveries. All patients were catheterized in labor room on admission; catheters were removed 1-3 days after delivery. Patients started leaking urine at a mean of 10.40 (8-14) days after delivery. Urethral catheter alone was enough for 5 (71.40%) patients. Vaginal examination findings are shown in [Table 1].
|Table 1: Vaginal examination findings, associated injuries and management approach|
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| Discussion|| |
Obstetric fistula was virtually eliminated in industrialized nations more than 100 years ago through improved obstetric care. , It is still a serious challenge to policy makers, medical personnel, and social workers in developing countries, where more than two million women are affected. , It is considered to be one of the most devastating childbirth injuries - related disabilities. Women with fistula leave with persistent urinary incontinence, ashamed and often isolated from their communities. ,,,, In this study, all patients had indwelling catheter immediately they developed VVF following delivery and were trained for catheter management, and their partners and relatives were counseled. They were admitted to gynecology or maternity ward with other patients throughout their hospital stay. Therefore, none of them was isolated from the community and there was no case of divorced.
An average of 0.35% of deliveries results in fistula formation in developing countries where there is no easy access to a functional obstetric care. , In our study, the four patients did not show up at the labor room in their early labor hours, despite they were enrolled in our hospital antenatal clinic. This means that there are other factors such as poverty, ignorance or inadequate counseling during their antenatal visits.
Obstetric fistula is preventable and treatable with good obstetric care.  It is not related to race, tribe, religion or culture. Obstetric fistulae are prevented by prompt and early caesarian section within 3 h from the moment obstructed labor has developed. However, to prevent new cases of obstetric fistula from occurring, there is a need of not less than 75,000 emergency obstetric centers in Africa alone.  The key interventions in VVF management are prevention, treatment, and support before and after repair. 
This study had shown that VVF prevention is still a problem in developing countries as four of our patients have access to health facility. Hilton et al. reported that 73.1% of patients with VVF delivered in a hospital, but in 97.1% of them labor was initially managed at home, with a TBA, 34.1% were delivered by cesarean section and the live-birth rate was only 10.3% in the causative pregnancy. In the present work, all patients started labor at home, which continued for 5-48 h before they were brought to the hospital. Five of them (71.40%) had assisted deliveries while 2 (28.60%) had cesarean section. Three babies (43%) were delivered alive. Similar high fetal mortality rate has been previously reported from our sub-region. ,
Patients with VVF suffered from urinary incontinence following obstructed labor for periods varying from immediate post-partum period to as long as 35 years with the majority (48%) presenting in the 1 st year of the disease.  In our study, patients started leaking urine from 8 days to 14 days following delivery.
In VVF pathogenesis prolonged obstructed labor plays a vital role where the presenting fetal part is impacted against the soft-tissues of the pelvis and a tissue ischemic injury develops these results in tissue necrosis and subsequent fistula formation. The prolonged obstructed labor can result in multiple birth-related injuries in addition to (or instead of) the VVF. ,, One of our patients had VVF with huge hematoma of the anterior rectal wall, which was evacuated by careful longitudinal anterior rectal wall incision vaginally and a catheter was secured. The patients recovered from both lesions in 4 weeks without further intervention. In addition, VVF can also occur following assisted vaginal delivery with obstetric forceps.  Weather the fistula results from ischemic or instrumental injury an indwelling urethral catheter will facilitate the healing of the fistula by continuously draining urine and hence preventing urinary tract infection and repeated contraction of the bladder during the act of micturation. 
This study clearly demonstrated that early catheter management in patient with VVF and other related obstetric injuries was enough for 71.0% of patients with VVF, independent of the fistula size, type, and location and associated obstetric injuries. In addition, early management of patients with VVF will significantly minimize the associated psychological and social problems.
| Conclusion|| |
Urethral catheterization should always form part of the initial stage for obstetric VVF management, especially, in communities with poor income. It is feasible, cheap, and acceptable and does not need expert specialists, special equipment or operating theatre.
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