| Abstract|| |
Background: Obstetric fistulae are still very common in developing countries with many patients living with this agony due to the huge backlog of untreated cases. This study aim to look at the large number of cases repaired and the good outcome they had, from a single center in Northern Nigeria, over a 12 months period, at Murtala Muhammed Specialist Hospital, Kano. Materials and Methods: We review case files of 288 patients that had fistula repair between October 2011 and September 2012. The result was analyzed using statistical Package for the Social Sciences version 18 and presented in tabular forms. Results: A total of 343 patients were seen at the center with vesicovaginal fistula, rectovaginal fistula or both. 288 (83.97%) had the repair and all were successfully closed with only 11.1% of those repaired having stress incontinence. All cases were done through the vaginal route using spinal anesthesia and had no significant surgical or anesthesia-related complications. Conclusions: We believe with good commitment and training of more fistula surgeons the reservoir of untreated patients in developing countries will reduce. Effective health education, provision of skilled birth attendant at delivery and presence of adequate obstetric emergency facilities is corners stone in obstetric fistulae prevention.
Keywords: Outcome, rectovaginal fistula, repair, vesicovaginal fistula
|How to cite this article:|
Ahmed ZD, Abdullahi HM, Yola AI, Yakasai IA. Obstetrics fistula repairs in Kano, Northern Nigeria: The journey so far. Ann Trop Med Public Health 2013;6:545-8
|How to cite this URL:|
Ahmed ZD, Abdullahi HM, Yola AI, Yakasai IA. Obstetrics fistula repairs in Kano, Northern Nigeria: The journey so far. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Feb 24];6:545-8. Available from: http://www.atmph.org/text.asp?2013/6/5/545/133712
| Introduction|| |
A fistula is defined as an abnormal communication between two epithelial surfaces or cavity.  The two must common ones are the rectovaginal fistula (RVF), i.e., communication between the vagina and rectum and vesicovaginal fistula (VVF), i.e., communication between the vagina and bladder. These conditions are distressing with associated social and medical problems. 
Many women in developing countries are crippled by this menace. About 5000 new cases of obstetric fistula are estimated to occur annually in Sudan (refer). Three out of every 1000 deliveries in West African countries develop VVF and about 200,000 women await surgical repair in Nigeria alone.  Even if all these cases are to be treated, it will take 20-30 years to clear the burden. 
Majority of the cases are as a result of prolonged obstructed labor, which account for 80-82.4% cases of fistulas in Nigeria , and 94.2% in Ghana.  Other causes include ruptured uterus, operative vaginal deliveries, difficult caesarean section, symphysiotomy and Gishiri cut.  It could also arise from gynecological trauma, example abdominal or vaginal hysterectomy, anterior colporrhaphy and Manchester repair. 
Women of low socio-economic status are the main victims of this problem. About 70% of them are younger than 21 years of age  and the fistulas occur mainly in their first delivery. 
There are very few surgeons that are skilled in the repair and also those that operate, therefore living a lot of patients on the waiting list for repair in the few centers that do it.
Laure fistula center in Kano state is one of the few centers that provide repair for VVF and RVF affected women free of charge.
| Materials and Methods|| |
This is a retrospective study of all patients that presented to Laure fistula center and had repair of VVF and RVF from October 2011 to September 2012.
Laure fistula center is situated at Murtala Muhammed Specialist Hospital in Kano, which is a tertiary health institution, which provides fistula care for the entire Kano state as well as its neighboring states. There is only one permanent fistula surgeon in the center while the authors and an expatriate surgeon visit the center weekly. The center receives assistance from Kano state government and some non-governmental organizations.
This was a retrospective study using data obtained from the VVF clinic and review of patient's hospital records for the period of 12 months.
Details of patient's management including the patient's state of continence on discharge and the number of surgeries done before achieving continence were retrieved and analyzed. A successful repair was defined "as the patient going home dry."
| Results|| |
A total of 814 patients presented at the fistula center, after assessment 343 patients were found to be suitable for repair. About 288 (83.97%) were repaired over the 12 months period. 55 (16.03%) were not available for analysis. All the repairs were done through the vaginal route under spinal anesthesia.
The mean age of the patients was 16 years with the majority between 12 and 20 years. 202 (70%) were primipara and 86 (30%) were multiparous. Complications of childbirth was the major cause of the fistulae as a result of obstructed labor comprising 259 (90%), while the rest occurred due to hysterectomy while one case was due to female genital cutting to treat uterovaginal prolapse.
Out of the 288 cases repaired, 249 (86.45%) had only urinary fistula, 13 (4.52%) had both urinary and RVFs while 26 (9.03%) had only RVF [Table 1].
For the number of surgeries done for those with VVF alone and combined VVF and RVF, 212 (206 VVF, 6 RVF) (73%) had their first repair, 29 (24 VVF, 5 RVF) (10.1%) had second repair and only 21 (19 VVF, 2 RVF) (7.9%) had more than two repairs. Although all those with RVF (26) had surgery only once [Table 2].
|Table 1: Types of fistula repair surgeries performed by quarter (months)|
Click here to view
The outcome of surgery for those with urinary VVF only and VVF/RVF showed that 230 (79.9%) of the patients were closed and dry before discharged, while 32 (11.1%) though were closed but had stress incontinence. Patients with only RVF 26 (9%), all were closed and dry with no incontinence of stool and/or flatus [Table 3] and [Table 4]. The study showed that all the patients repaired had no major surgical, anesthesia-related or post-operative complications.
|Table 3: Outcome of fi stula surgeries for those with urinary only and urinary/RVF|
Click here to view
| Discussion|| |
The study has shown that many people are now aware that the condition is amenable to cure, since over 800 women presented within the 12 months period seeking for medical help. Although the majority was found to have other urinary conditions other than the fistula. After examination, 343 women were found to have VVF, RVF or both and over 80% of them were repaired within 1 year. This we believe is a huge achievement compared with other places where the same number were done in 4 years. 
The mean age at presentation was 16 years similar to was found by Wall et al. where they reported the age of "typical patients" to be 15.5 years.  However, this is much higher than the study from Sokoto where the mean age was 13 years.  Similarly, another study from Ethiopia and Sudan found that more than 95% of the patients were teenagers. , More recent studies have showed the mean age to be 27 years  and 35 years,  which is attributed to the different etiologic factors for the fistula.
All the cases were done through the vaginal route, no abdominal repair was done. The route of the repair could be determined based on the site of the fistula and the experience of the surgeon. Many Gynecologists prefer the vaginal route to abdominal route, because it is much easier and most VVF could be accessible through this route.
Majority of the patients 212 (73%) with VVF and both VVF/RVF had only one repair and 29 (10.1%) had their second repair. The low result for second repair found in this study is to that in other studies, implying that the first repair is always the best repair. 
21 (7.9%) had three or more repairs elsewhere before coming to this center.
All the patients were found to have their fistulas closed at discharge and after 3 months follow-up. There were no cases of residual fistula, however stress incontinence was found in 32 (11.1%), but considered cured by our findings and definitions in this study. This was found to be a good achievement for the unit, as previous studies had shown a 90% of success rate in this center and in other places. ,, Stress incontinence as found in this study is not an uncommon complication for post-repair patients. , Some of the patients may need further interventions while others usually get better with time.
There was no record of any anesthesia-related or surgical complications in all patients.
| Conclusion|| |
This study has shown that with good commitment and funding for the repair of fistula patients, a lot of their unmet needs will be tackled and a time will come when we may have no backlog of unrepaired cases.
We also believe that with effective health education, provision of skilled birth attendant at delivery and presence of adequate obstetric emergency facilities in all corners of our communities, new cases of obstetric fistulae may be a history in developing countries.
| References|| |
|1.||Danso KA. Genital tract fistulas. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Gynaecology in the Tropics. Accra: Graphic Packaging Limited; 2005. p. 174-81. |
|2.||Kabir M, Ilyasu Z, Abubakar SI, Umar UI. Medico-social problems of vesico-vaginal fistulae in Murtala Muhammed Specialist Hospital Kano. Ann Afr Med 2003;2:54-7. |
|3.||Hassan MA, Ekele BA. Vesicovaginal fistula: Do the patients know the cause? Ann Afr Med 2009;8:122-6. |
|4.||Ojengbende OA. Bladder capacity, maximum urethral length and stress incontinence in repaired vesicovaginal fistulae. Trop J Obstet Gynaecol 1996;13:25-8. |
|5.||Ijaiya MA, Aboyeji PA. Obstetric urogenital fistula: The Ilorin experience, Nigeria. West Afr J Med 2004;23:7-9. |
|6.||Tahzib F. Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynaecol 1983;90:387-91. |
|7.||Danso KA, Martey JO, Wall LL, Elkins TE. The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:117-20. |
|8.||Brian H, Mhain C. Vesicovaginal fistula surgery in Uganda. East Cent Afr J Surg 2004;9:32-9. |
|9.||Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: Characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011-9. |
|10.||Ibrahim T, Sadiq AU, Daniel SO. Characteristics of VVF patients as seen at the specialist hospital Sokoto, Nigeria. West Afr J Med 2000;19:59-63. |
|11.||Gessessew A, Mesfin M. Genitourinary and rectovaginal fistulae in Adigrat Zonal Hospital, Tigray, north Ethiopia. Ethiop Med J 2003;41:123-30. |
|12.||Mohamed EY, Boctor MF, Ahmed HA, Seedahmed H,.Abdelgadir MA, Abdallah SM. Contributing factors of vesico-vaginal fistula (VVF) among fistula patients in Dr Abbo′s Hospital Khartoum. Sudanese J Public Health 2009;4:259-64. |
|13.||Bassem SW, Mohammed MK. Repair of vesicovaginal fistula: Single-centre experience and analysis of outcome. Arab J Urol 2011;9:135-8. |
|14.||Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996;51:568-74. |
|15.||Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: A review of 25 years′ experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9:189-94. |
Ibrahim Adamu Yakasai
Department of Obstetrics and Gynaecology, Bayero University Kano, Aminu Kano Teaching Hospital Kano, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]