Obstetric Fistula

Last week, when I attended Dr. Mugyeni’s clinic, we saw a woman who has had vesicovaginal fistula for the last ten years, and who presented only now for help because she never had the money for transportation.
She had six normal deliveries, followed by a seventh pregnancy that was complicated by a long obstructed labor, which resulted, eventually, in an emergency cesarean. The baby was stillborn, and she is not sure what was done in the surgery. Since then she has had very light menses and she continually leaks urine.
She is now 37 years old, and a widow; her husband died in 2004.

We admitted her to the hospital from clinic in preparation for surgery, but were only able to get her into theatre today, one week later.
We did the repair under spinal anesthesia. Her spinal was difficult, and it was the first time I realized that they do them without numbing the area first; the women invariably tolerate the spinal without a peep. I couldn’t imagine that in the United States.
Intraoperatively, we found no cervix – probably at the time of cesarean she had had a uterine rupture and a total cesarean hysterectomy. The fistula was easy to see – it was a vertical slit-like hole, just less than one centimeter, somewhat near the apex of the vaginal vault. You could see the urine leaking from it.

Conceptually, the repair is not hard. It is the reality of it that makes it difficult. You incise the surrounding vaginal mucosa, dissect the vaginal mucosa off the bladder, close the bladder defect (we did it with a pursestring suture) and then close the vaginal mucosa. But visualization is hard, since, after all, you are operating inside a vagina. And you have to be careful about the ureters, which in her case was difficult because the cervix is usually a valuable landmark.
But this year I have found that I really enjoy vaginal surgery, largely under the tutelage of Dr. Banks and Dr. Wieland at home. This surgery in particular was quite fun, and incredibly satisfying. If it works (and I really hope it does) it will make an immeasurable difference in this woman’s life. I can’t imagine what it must be like to leak urine every minute of every day, to smell of urine constantly, to have an irritated, blistered perineum because good hygiene is impossible. And all because of one tiny little hole, less than once centimeter.

The surgery is only the first half of the fistula repair. The integrity of the repair depends deeply on the quality of the nursing care. The patient has to have a catheter in her bladder for an extended period of time, and one has to insure that the catheter does not become blocked, because overdistension of the bladder could destroy the repair. There are very few nurses here, and they cannot provide the kind of care required to repair fistulas often like this. So the patient herself will have to be vigilant about her catheter. I am going back to the ward now to check on her.