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8/9/2019 Obstetric Fistula.pptx
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Obstetric Fistula
Dr. A. P. Soibi-HarryDept. of Obstetrics & Gyneacology
Lagos University eac!ing Hospital
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Outline
"ntro#uction
$rief History
%pi#eiology
%tiology
Pat!ogenesis
'lassi(cation
'linical Presentation
Diagnosis
)anageent
Prevention
*ecent a#vances
'onclusion
*eference
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Introduction
+%very inute, a oan #ies inpregnancy or c!il#birt!, an# for
every oan !o #ies, /-0/ot!ers ill survive but it!orbi#ity, one of !ic! is obstetric
(stula1Source2 G. Leis, 3HO Press.
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Defnition obstetric (stula is an abnoral counication beteen
t!e vagina an# t!e bla##er or rectu.
Occurre# in t!e course of pregnancy an# results inuncontrolle# passage of urine, feaces or 4atus into t!evagina.
Psyc!osocial in5ury
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Brie history !e ol#est evi#ence of obstructe# labor2
"n t!e reains of 6ueen Hen!enit, of %gypt c. /7/ $'.
8902 revie of t!e 6ueen:s uy foun# a #efect in t!ebla##er counicating #irectly it! t!e vagina.
8;;02
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Epidemiology 1 Globally2
3HO estiates -E illion oen live it!untreate# (stula, it! about 7/,/// -8//,/// necases eac! year.
Alost all cases live in sub-Sa!aran Africa an#sout! Asia.
!e reporte# inci#ence rates of vesicovaginal (stula
in 3est Africa range beteen 8 per 8,///#eliveries.
igeria accounts for / of t!e orl#i#e (stula
prevalence it! approIiately /,/// ne cases
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%pi#eiology
.%n#Fistula.org.
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Epidemiology 3
.8J8/// #eliveries
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Etiology
Obstructe# labour- E=/
LacC of access to eergency obstetric care
"atrogenic causes2 'aesarian section
*epair of rupture# uterus
Forceps Delivery
Destructive operations
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Risk Factors
Poverty
%arly arriage an# c!il# bearing age
Harful tra#itional practices2
Feale genital utilation
Gis!iri- 87 (stula cases in ort!ern
igeria 'austic so#a eIposure
"nfections sc!istosoiasis,
lyp!ogranuloa
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Obstetric fstula pathay
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Pat!ogenesis
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!lassifcation o Obstetric fstulas
Site of "n5ury
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"oh#s system
Uret!ral lengt!
ype 82 Distal e#ge of (stula E0.7 c fro t!e eIternal uret!ral ori(ce K%UO,i.e. t!e uret!ra is not involve#
ype 2 Distal e#ge .70.7 c fro t!e %UO
ype 02 Distal e#ge 8.7M.7 c fro t!e %UO
ype 2 Distal e#ge M8.7 c fro t!e %UO.
Fistula siNe
Ka2 SiNe M8.7 c
Kb2 SiNe 8.70 c
Kc2 SiNe E0 c.
Scarring". o or il# (brosis aroun# (stulaJvagina, an#Jor vagina lengt! E; c ornoral capacity
"". )o#erate or severe (brosis aroun# (stula an#Jor vagina, an#Jor re#uce#vaginal lengt! an#Jor capacity
""". Special consi#erations, e.g. circuferential (stula, involveent of ureteric
ori(ces.
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$aaldi%k#s system
ype "2 Fistula 7 c fro t!e %Iternal Uret!ral Ori(ce an#
t!erefore not involving t!e closing ec!anis.
ype ""2
Fistula M7c fro t!e %UO t!erefore involves t!e closingec!anis
A. 3it!out total involveent of t!e uret!ra2 Ka it!out a circuferential #efect
Kb it! a circuferential #efect
$. 3it! total involveent of t!e uret!ra2 Ka it!out a circuferential #efect
Kb it! a circuferential #efect.
ype """2 )iscellaneous (stulae, e.g. uretero-vaginal
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!linical &resentation 1
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!linical &resentation ' 'onstant urine #rainage per vagina
%Icoriation of sCin aroun# t!e vulva
*ecurrent cystitis or U"
UneIplaine# fever, !eaturia, 4anC #iscofort an# suprapubic pain
Flatulence an# or fecal incontinence
Foul-selling vaginal #isc!arge
Decubitus ulcers
Psyc!osocial probles- social recluse #epression, lo self-estee,an# insonia
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(he Obstructed )abour In%ury!omple*
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Diagnosis
+istory
&hysical E*amination
In,estigations F$', Seru %JUJ'*, Urine for urinalysis an# )J'JS,
Ab#oinopelvic USS
0 sab test
'ystouret!roscopy
"ntravenous Urogra
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Figure 1- Obstetric ,esico.,aginal fstula rom prolonged obstructed labor-
3all LL K/8 Obstetric Fistula "s a +eglecte# ropical Disease1. PLoS egl rop Dis ;K=2 e8;9.#oi28/.808J5ournal.pnt#.///8;9!ttp2JJ.plosnt#.orgJarticleJinfo2#oiJ8/.808J5ournal.pnt#.///8;9
http://www.plosntd.org/article/info:doi/10.1371/journal.pntd.0001769http://www.plosntd.org/article/info:doi/10.1371/journal.pntd.00017698/9/2019 Obstetric Fistula.pptx
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Si:s Position
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3 /ab test
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Fistula opening in
$la##er
'ystoscpy
!ystoscopy
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0anagement
'onservative )anageent
Surgical !erapy
onsurgical "ntervention
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!O/ER2(I2E 0"E0E(
Indications Siple (stulae
M8 c in siNe
Diagnose# it!in #ays of occurrence
'ontinuous bla##er #rainage $ytransuret!ral or suprapubic cat!eter for up to
-; eeCs. Sall (stulas ay resolve spontaneously or
#ecrease in siNe.
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O /4R"I!) I(ER2E(IO
%lectrocautery fulguration
Fibrin glue
Laser el#ing it! # BAGKneo#yiu-#ope#
yttriu aluiniu laser
Psyc!osocial counseling an# re!abilitation
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/urgical 0anagement
FI/(4) RE&IR I/ O( E0ER"E!5
)ost surgeons a#vise aiting at least 0 ont!sfro tie of in5ury before operating.
"n t!e early ont!s, t!e surroun#ing tissues areoe#eatous an# !ypereic, aCing t!e friablean# #iQcult to !an#le.
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&reoperati,e care
"prove t!e patient:s general con#ition- utrition,"nfection, Deratitis, Urine aci#i(cation, Psyc!e.
'ontractures s!oul# be treate# before surgery ifpossible.
%ncourage liberal clear 4ui# intaCe until about!rs before surgery.
$oel preparation s!oul# inclu#e enea t!enig!t before.
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Intraoperati,e !are
nesthesia2 Spinal or GA
ntibiotics2 broa# spectru
/uture material2
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&atient positioning
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RO4(E OF RE&IR
Depen#s upon access to t!e (stula site, obility
of t!e vagina an# surgeon eIpertise.
/I(E &&RO!+
LO3 F"SULAUret!ral>uItauret!ral
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&rinciples o fstula repair
First attept is best .
issue obiliNation
Heostasis
A#e?uate eIposure
Aseptic easures
ension free closure
*einforceent
%Ipertise
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Repair o 2esico,aginal Fistula
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bdominal approach
"n#ications Hig! inaccessible (stula
)ultiple (stulas
"nvolveent of uterus or boel
ee# for ureteral re-iplantation 'opleI (stula
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&ost.operati,e 0anagement
'ontinuous bla##er #rainage 8/-8 #ays
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Discharge d,ice
o pass urine fre?uently
Avoi# seIual intercourse for at least 0 ont!s
o #efer pregnancy for at least 8 year
Subse?uent #eliveries s!oul# be ab#oinal
"f repair fails, local repair s!oul# be reattepte#after 0 ont!s
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Recto,aginal Fistula
D%F"""O2
Abnoral counication beteen t!e rectu an# vaginait! involuntary escape o 4atus an#Jor feces into t!evagina resulting in fecal incontinence.
'linical presentation2 "nvoluntary escape of 4atus an#Jor feces into t!e vagina
Foul selling vaginal #isc!arge it! perio#icuncontrolle# escape of gas
Appear ie#iately or -8/ #ays after #elivery
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'on(ration
!in Probe is passe# fro t!e vagina t!roug! t!e(stulous tract into t!e rectuJanal canal
)et!ylene blue #ye test
%Iaination un#er anaest!esia
"
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!)//IFI!(IO
$ase# on anatoical location of vaginal opening Lo - vaginal opening near t!e posterior fourc!ette
)i# - fro t!e level of t!e cerviI to 5ust superior to t!eposterior fourc!ette
Hig! -t!e (stula is in t!e area of t!e posterior forniI.
Siple vs 'opleI Siple are sall (stulas
'opleI are large
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0anagement
SU*G%*B
*oute2 ransvaginal Approac!
ransanal Approac!
Ab#oinal Approac!
iing2 3ait =-8 eeCs before surgical intervention to allo
surroun#ing in4aation to resolve copletely
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&re,ention 1
Priary Prevention
Girl '!il# %#ucation
3oen:s epoerent
'ollaboration it! religious an# cultural practitioners
Delaye# age at c!il# birt!Jaccess to contraceptives
3i#esprea# antenatal care coverage an# policies
utritious #iet since c!il#!oo#
Political ill
Secon#ary Prevention
Prevention of t!e 0 stages of Delay
raine# birt! atten#ants an# early referrals
Availability of eergency obstetric care
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Prevention
'aesarian section in in#icate# cases
Avoi#ance of #iQcult forceps an# #estructiveoperations
Prolonge# 'at!eter #rainage in prolonge# orobstructe# labour.
ertiary PreventionSubsi#iNe# treatent
*e!abilitation
*e-integration into t!e society
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(he igerian /cenario
Fe#eral inistry of !ealt!2 ational strategicfraeorC for t!e eliination of obstetric (stulain igeria /88-/87 Provi#e fraeorC to train !ealt! orCers an# gui#e
t!e in t!e provision of !olistic, siple, aor#able an#evi#ence# base# care for obstetric (stula patients.
http://www.fstulacare.org/pages/da/fles/5/5.4/Nigeria_National_Strategy_2011-2015.pd
0r#)ay- "nternational Day to %n# Obstetric(stula
http://www.fistulacare.org/pages/da/files/5/5.4/Nigeria_National_Strategy_2011-2015.pdfhttp://www.fistulacare.org/pages/da/files/5/5.4/Nigeria_National_Strategy_2011-2015.pdfhttp://www.fistulacare.org/pages/da/files/5/5.4/Nigeria_National_Strategy_2011-2015.pdfhttp://www.fistulacare.org/pages/da/files/5/5.4/Nigeria_National_Strategy_2011-2015.pdf8/9/2019 Obstetric Fistula.pptx
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Fistula !entres 1
$abbar *uga Hospital, Ratsina State
$irnin Rebbi Specialist Fistula 'enter, Rebbi State
Fari#at BaCubu General Hospital, Vafara State
Laure Fistula 'enter at )urtala )o!ae# Specialist
Hospital, Rano State
)arya Abac!a 3oen an# '!il#ren:s HospitalK)A3'H, SoCoto State
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Fistula !entres '
ational Fistula 'enter, %bonyi State
ingi General Hospital, $auc!i State
Ogo5a General Hospital, 'ross *iver State
Sobi Specialist Hospital, Rara State
University 'ollege Hospital "ba#an, Oyo State
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!onclusion
.op(stula.org
(+6/ FOR
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(+6/ FOR
)I/(EI"
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Reerences
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Reerences Arrosit! S, Halin ', 3all L. Obstetric labour in5ury copleI2
obstetric (stula foration an# t!e ultifacete# orbi#ity ofaternal birt! traua in t!e #eveloping orl#. ')% reviearticle. Obstet Gynecol Surv 899; 782 7;=.
Go! >3, Rrause HG. Feale Genital ract Fistula. $risbane2
University of 6ueenslan# Press, //.
3aal#i5C R. Step by Step Surgery of
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Obstetric (stula is a preventable an# curablecause of aternal ortality an# orbi#ity it!igeria accounting for about 8/ of globalr.
Hoever it !as continue# to be a !i##encon#ition because it aects t!e t!e ostarginaliNe# ebers of t!e society-poor,young,illiterate girls an# oen.
3e all as obstetricians an# gynecologist !avean oppurtunity to turn #espair to !ope an#restore #ignity to t!ese oen.
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