Obstetric Fistula.pptx

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.0001769


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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.pdf


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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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Obstetric Fistula.pptx