Introduction: Obstetric Fistula (OF) is a tragedy and a public health problem (physical, social, moral and psychological). Objective: To determine the clinical, therapeutic and prognostic aspects of obstetric fistula at CHUD/B-A maternity ward in 2016. Study Method: This is a descriptive, analytic study with prospective data collection from March 07 to December 31, 2016. Patients with obstetric fistula were the study population. Results: A total of 37 patients were treated including 35 operated, the other two not operated for pyuria and bladder calculus after examination under spinal anesthesia. The average age was 36.6 ± 10.5 years with the extremes of 21 years and 65 years. The mean age of onset of Obstetric Fistula (OF) was 28.9 ± 6.5 years. Patients came from southern Benin (51.4%), were married (67.6%), peasant (35.1%) and out of school (81.1%). The types of OF were vesico-vaginal fistula (VVF) (62.2%), urethro-vaginal fistula (24.3%), vesico-uterine fistula (VUF) (5.4%), and uretero-vaginal fistula (2.7%). The fistula site was supra trigonal (54.1%), urethral (18.9%), trigonal (10.8%), vesico-uterine (10.8%), cervical urethral (2.7%), ureteroid vaginal (2.7%). Fistulas were complex (70.3%), complicated (24.3%) and simple (5.4%). The vaginal route was one of the first routes (64.9%). The operative techniques used were CHASSAR MOIR hysterorrhaphy (74.3%). The cure with continence was 68.6%. Conclusion: OF is observed in young women of childbearing age. VVF is the most common. The management is surgical with several operating techniques. Healing is possible. Hence the importance of paying special attention to these patients for their care .
The World Health Organization (WHO) estimates that in countries with a high maternal mortality ratio, two to three women will have fistula for each maternal death. According to the same source, in 2002, there were between 50,000 and 100,000 carriers of obstetric fistula (OF) in Africa [
Study Framework: The study was conducted in the Gynecology and Obstetrics Department of CHUD/B Second Level Referral Hospital located in the city of Parakou and in the Borgou department in Benin.
Type of study: This was a descriptive, analytic study with prospective collection of data from March 7 to December 31, 2016 and covering three missions, the first of which was held from March 7 to 12, 2016; the second from 18 to 22 July 2016 and the third from 27 November to 03 December 2016.
Study population: It consisted of all the patients admitted to the service for permanent loss of faeces or urine during the three missions.
Inclusion criteria: Included in this study were all patients admitted for permanent urinary or faeces loss who were diagnosed with OF and who were treated during one of the three missions to CHUD Borgou.
Exclusion Criteria: Women who did not consent to participate in the study were excluded from this study
No-inclusion Criteria: Excluded from this study, women whose urinary leakage results from an injury not related to pregnancy and childbirth
Diagnosis criteria: Any woman in whom an abnormal communication between the bladder and the vagina has been demonstrated by the methylene blue test or there is abnormal communication between the rectum and the vagina.
Sampling: This was an exhaustive census of all admitted patients meeting our inclusion criteria.
Data collection tools: the information was collected on a pre-established individual survey form based on a UNFPA sample OF file and our experience.
Data sources: these are the patients themselves, the patient records and the operating protocol register.
Data collection technique: the collection technique was the direct interview with the patients associated with the examination of their file. Data were collected as patients were admitted.
At admission, we had a direct interview with the patients to inquire about socio-demographic data and patients’ antecedents. After the clinical examination leading to the diagnosis, the women were programmed and operated. Then, from the files of the patients, the data on the diagnosis and the treatment are filled in
1) Dependent Variable: the dependent variable in this study was obstetric fistula (OF).
2) Independent Variables
Sociodemographic data: age to year; height in meter; profession; religion, marital status, ethnicity; age at marriage; age at first birth. History: gynecological and obstetric, surgical,
Data related to causal delivery: parity; duration of labor of the causal delivery; way of causal delivery; place of causal delivery (home or health center); quality of the officer who attended the delivery; condition of the newborn at birth.
Clinical Data: Reason for consultation, age of fistula; socio-economic impact of fistula; fistula size; seat of fistula; delivery process; state of peri fistulous tissue; methylene blue test.
Data related to surgical treatment: approach; operative techniques used; incident-accident during operation and the outcome of the operation (success or cure with continence: the fistula is closed, without sphincteric disorder, urination is normal, and no urine leakage, closure of the fistula with residual urinary stress incontinence (SUI): the fistula is closed, sphincter insufficiency persists with periodic or constant leakage of urine, failure: the fistula is not closed, it is the failure of the fistula cure.).
Data related to postoperative follow-up: postoperative complications; wearing time of the probe; total duration of hospitalization; need for recovery.
The collected data was captured using the EPI data software after verification of data consistency. Then the data analysis was done with the software Epi info version 7. The quantitative variables are expressed on average with their standard deviation and the qualitative variables in percentage with their 95% confidence interval.
The Local Committee of Ethics for Biomedical Research of the University of Parakou (See the ethical opinion in appendices) and the authorities at various levels (Faculty of Medicine of the University of Parakou, Departmental University Hospital of Borgou; Gynecology and Obstetrics, Project NICHE BEN 202), as well as women with obstetric fistula gave their favorable opinion for the realization of this study. The inquiry cards were filled in anonymity. The confidentiality of the collected data was ensured.
During the study period, 37 cases of obstetric fistula (6 cases at the first mission, 16 cases at the second and 15 cases at the third) were identified, 35 of which were operated. The socioeconomic characteristics of women with fistula are presented in
At the time of fistula occurrence, the predominant age group of patients was 20 - 30 years old with 43.2% of cases and the mean age at that time was 28.9 ± 6.5 years with extremes of 17 years and 45 years. Women with fistula came from rural areas in 81.1%. All patients were married before the onset of OF (100%) compared with 67.6% after.
The average age at marriage was 17.4 ± 3.2 years with extremes of 12 and 25 years. Mean age at first birth was 18.4 ± 3.2 years with extremes of 13 and 26 years. The patients (48.6%) were married before the age of 18 years (
Number | Percentage | |
---|---|---|
Age | ||
15 - 30 | 13 | 35.1 |
30 - 45 | 18 | 48.7 |
45 - 50 | 2 | 5.4 |
>50 | 4 | 10.8 |
Level of education | ||
Primary | 5 | 13.5 |
Secondary | 2 | 5.4 |
Unschooled | 30 | 81.1 |
Profession | ||
Peasant | 14 | 35.1 |
Household | 11 | 29.7 |
Shopping | 10 | 27 |
Craftswoman | 04 | 8.1 |
Total | 37 | 100 |
Nomber | Percentage | |
---|---|---|
Age at marriage | ||
˂ 5 | 7 | 18.9 |
[15 - 18[ | 11 | 29.7 |
≥18 | 19 | 51.4 |
Total | 37 | 100.0 |
Age at first birth | ||
≤15 | 7 | 18.9 |
15 - 20 | 21 | 56.8 |
20 - 25 | 8 | 21.6 |
25 - 30 | 1 | 2.7 |
Total | 37 | 100.0 |
Pregnancy was often not followed (56.4%) or was poorly followed with fewer than four prenatal visits. The average duration of labor was 37.6 ± 25.4 hours with extremes of 8 hours and 96 hours. The work lasted at least 24 hours in 81% of cases. These patients had delivered by caesarean section in 70.3% of cases. Delivery in a maternity ward accounted for 83.8% of cases. Delivery was often performed by qualified personnel (83.8%). Perinatal mortality for obstetric fistula was 78.4%. Fistula appeared within 24 hours after delivery in 54.1% of patients. The reason for consultation was permanent urine loss (94.6%) and catamenic haematry (5.4%). The seniority of TF was 96 ± 85.6 months with extremes of 1 month to 288 months. OF was associated with ammoniacal dermatitis (73%). Vesico-vaginal fistulas (VVF) were the most common (62.2%) followed by urethrovaginal fistulas. These were often complex lesions in 70.3% of cases that were trigonal or urethral in 10.2% and 16.8% of cases, respectively (
Of the 37 patents admitted for a surgical cure of OF, 35 were actually. For the other two patients, the surgical treatment was delayed one because of a severe local infection and the other because of the presence of bladder stones. The 35 patients underwent surgery under anesthesia. The patients were on their first course in 64.9% of cases. The vaginal surgical cure accounted for 62.9% of the cases. The fistulorraphy according to Chassar Moir was the most used surgical technique (
Number | Perrcentage | |
---|---|---|
Age (in months) | ||
≤60 | 18 | 48.7 |
60 - 120 | 10 | 27.0 |
120 - 240 | 7 | 18.9 |
>240 | 2 | 5.4 |
Associated lesions | ||
Lithiasis and calcifications | 1 | 2.7 |
Ammonia dermatitis | 27 | 73 |
Genital mutilation | ||
Yes | 10 | 27 |
No | 27 | 73 |
Diagnosis | ||
Destruction of the urethra | 1 | 2.7 |
Retro trigonal fistula juxta-cervical-uterine | 22 | 59.5 |
Trigonal fistula | 4 | 10.8 |
Left uretero-vaginal fistula | 1 | 2.7 |
Wide urethro-trigonal fistula | 1 | 2.7 |
Vesico-uterine fistula | 3 | 8.1 |
Complete urethral transection | 2 | 5.4 |
Partial urethral transsection | 6 | 16.2 |
Type of fistula | ||
Simple | 2 | 5.4 |
Complex | 26 | 70.3 |
Complicated | 9 | 24.3 |
Number | Percentage | |
---|---|---|
Rank of cure | ||
First cure | 24 | 64.9 |
Second cure | 9 | 24.3 |
Third cure | 2 | 5.4 |
Surgical way | ||
Low | 22 | 62.9 |
High | 11 | 31.4 |
Mixed | 2 | 5.7 |
Surgical technique | ||
Fistulorraphy according to Chassar Moir | 26 | 74.3 |
Urétroplastie anastomotique | 5 | 22.9% |
Anastomotic urethroplasty | 2 | 14.3% |
Urethroplasty + interposition according to Martius | 1 | 2.8% |
Uretero-vesical reimplantation | 1 | 2.8% |
Intraoperatively, there was one case of perforation of the rectum (2.7%). Postoperatively, the mean bladder catheter duration was 14 ± 3.9 days with the 3-day and 21-day extremes. Complications recorded were haemorrhages by thread release: 4/35 (11.4%), vaginitis: 2/35 (5.7), parietal suppuration: 1/35 (2.9%). The mean duration of hospitalization was 15.2 ± 7.3 days with the extremes of 10 days and 20 days. Patients had a duration greater than or equal to two weeks in 73.0% of cases and less than two weeks in 27.0% of cases. At the end of this stay, 24 patients (68.6%) were cured with continence of urine, two or 5.7% had a closure of the fistular opening but had a stress urinary incontinence and in nine cases the treatment failed with no closure of OF.
In our study, 37 cases of obstetric fistula were recorded in 10 months compared to 56 cases collected in 7 months in 2006 [
The mean age of the patient was 36.6 ± 10.5 years with the extremes of 21 years and 65 years. This average age is consistent with that reported by Tébeu et al. in Cameroon (2010) which was 36.2 ± 14.3 years old [
The average age of patients at fistula onset was 28.9 ± 6.5 years with the extremes of 17 years and 45 years. Diallo et al. in Guinea (2016) reported an average age of fistula patients that was 25 years old with extremes of 12 and 55 years [
These patients with OF are abandoned by spouses. Thus divorces or cases of abandonment are frequent. They range from 18.9% in Benin to 87% in Niger. [
The labor of delivery lasted on average 37.6 ± 25.4 hours with extremes of 8 hours and 96 hours. In 81% of cases, it lasted at least 24 hours. In several African studies, OF often result from labor over 24 hours [
The predominant anotomoclinic types of OF remain vesico-vaginal fistula in most authors [
The fistulorraphy according to Chassar Moir was the most performed surgical technique (74.3%), followed by urethroplasty (22.9%) and then uretero-vesical reimplantation in 2.8% of cases. In the literature, hysterorrhaphy were the most commonly used surgical technique [
The therapeutic results judged after two controls (postoperative day and day 14) by the methylene blue test were 68.6% cure with continence, 5.7% fistula closure with a residual IUE and 25.7% of total failure. Several authors have found similar results to ours [
The limit of this study happens to be the small sample size for a study that is purely descriptive. The results cannot be generalized to the entire region of Borgou in Benin. Nevertheless, they allow to characterize the patients who suffer from OF and treated with CHUD/B. Further studies will be needed, however, to identify the factors that determine the occurrence of TF to lay the foundation for better prevention.
In Benin, the incidence of OF has been decreasing for about 20 years. Clinically, vesico-vaginal fistulas are the most common and they result in urinary losses. They affect poor women who are often stigmatized and abandoned by their husbands. The most commonly used surgical technique is Chassar Moir’s fistulorraphy, which has proved very effective. The success rate of surgical treatment is 68.6%, 5.7% fistula closure with a residual IUE and 25.7% of total failure. In view of the results, it is possible to eradicate OF in Benin. To do this, treatment campaigns led by foreign missions must be replaced by treatment campaigns led by local doctors supported by African experts with long experience in the field. On the other hand, studies must specify factors that determine the success of surgical treatment. All supported by effective prevention based on the correct monitoring of pregnancies and deliveries assisted by qualified providers.
The authors declare no conflicts of interest regarding the publication of this paper.
Salifou, K., Dayi, A., Hounkponou, F., Tamou, S., Sidi, I.R. and Alihonou, E. (2018) Obstetrical Fistula: Clinical, Therapeutic and Prognostic Aspects at the Gynecology and Obstetrics Department of Borgou University Hospital Center in Benin. Open Journal of Obstetrics and Gynecology, 8, 1052-1062. https://doi.org/10.4236/ojog.2018.811106