Obstetric Fistula Advocacy Group

A fistula is defined as an abnormal communication between two major organs. A vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina resulting in continuous and uncontrollable incontinence. It is one of the worst complications of a gynaecological or obstetric procedure.

A vesicovaginal fistula occurs when there has been an injury to the vaginal wall. It is a tract or hole between the female bladder and the vagina. It allows the involuntary passage of urine from the bladder through the vagina and is a disease that only affects women.

The main cause of a vesicovaginal fistula is childbirth. If there is a large tear or episitomy or the baby is too large for the birth canal there can be a necrosis of vaginal tissue and the death of the tissue erodes into the bladder, causing a hole which becomes permanent. The vesicovaginal wall, which is a single wall that connects the bladder to the vagina is very thin and can easily form a deep enough hole to open into the bladder.

A violent rape can cause a vesicovaginal fistula. It is common in developing countries where rape is a part of war, such as in the Republic of Congo. Doctors there are very skilled in repairing these types of fistulas as they are common war wounds.

SYMPTOMS

The symptoms of a vesicovaginal fistula include the constant dripping of urine from the vagina. It can be as little as a few drops or as much as a stream depending on how large the hole is. The vulva and vagina become irritated by the constant wetness and there can be stinging and pain in the vaginal or vulvar area.

There can also be a feeling of air in the bladder as you urinate and/or tissue coming out as well. And UTI’s are a common symptom too.

HOW IS IT DIAGNOSED?

Doctors can diagnose a vesicovaginal fistula using a visual examination of the vagina. An irritated hole can be found in the anterior wall of the vagina. Sterile dye or sterile milk can be inserted into the bladder via a catheter so that the dye or milk is looked for in the vaginal vault. Radio-opaque dye can be used to show the passage of dye into the bladder via a catheter and outside the bladder into the vaginal space. X-rays of the bladder are necessary to see the passage of the dye into the vagina.

TREATMENT

The treatment of a Vesicovaginal Fistula can involve simply treating the irritation and not to take care of the Vesicovaginal Fistula at all. This is not something I recommend due to increased risk of UTI’s and sepsis.

In other cases, it involves the cutting out of the fistula tract and repairing the area involved in the fistula. The fistula is often infected with bacteria so antibiotics are used to clear up the infection before the fistula is removed. This is the primary reason why the fistula can’t just be sealed over as infection prohibits the actual closing of the fistula. The fistula can be repaired via an abdominal or vaginal approach and a new blood supply may need to be introduced in order to make sure the surgery to repair the vesicovaginal fistula actually takes and is successful..

Usually a vesicovaginal fistula is treated by giving the individual a urinary catheter to wear.  This takes the pressure off the fistula so that the fistula tract  begins to heal on its own. It is not a path I recommend due to the stress and pain involved. In my case, the catheter was used beforehand and then alongside surgery in order to take the added pressure off my bladder while I healed the repaired fistula.  I wore a catheter for 2 months prior to surgery and for about 12 months afterward and highly recommend this method.

SURGERY

There are a variety of methods to repair a VVF. My surgery involved taking a labial fat graft and tunnelling this through to create a new wall between the bladder and vagina,  a urinary catheter was then placed in the bladder to allow the bladder to heal, along with multiple drains which were removed on day 3.  The blue dye test was successful upon completion of the surgery and this was undertaken again 6 weeks post surgery.

Other methods involve surgery via the abdomen, taking a graft from the stomach to create a new wall or by using muscle located around the vagina to create a layer over the fistula opening and act as a new blood supply to the area.

The important thing is that surgery is not attempted too early. The basic rule for fistula surgery is that the first operation has the best chance of success. Surgeons therefore should approach the repair with caution and should not attempt a repair unless they have the expertise to do so. Many of my fistula sisters have told stories of surgeons who have used them as test guinea-pigs, with no experience or expertise in this specialised surgery, their surgeries have subsequently failed. Once this happens, it is very difficult and problematic to achieve a successful repair.

LIVE AFTER VESICOVAGINAL FISTULA

Women in developing countries, unable to control the flow of urine are often ostracized by their husbands, families and communities.  Women in developed countries may have more access to health care but this does not change the effect that incontinence will have on her life. Both women suffer a sense of shame and struggle to find someone who can repair them.

Finding a surgeon suitably qualified to repair an Obstetric Fistula is extremely difficult, mainly due to the fact that it is a rare condition and therefore not many Surgeons see this condition during their training.

For vesico vaginal fistula sufferers, even once successfully repaired, there may still be ongoing bladder issues such as Interstitial Cystitis (IC or Painful Bladder Syndrome), urinary tract infections and problems with pelvic floor and nerve damage from surgery. There is rising evidence that IC is actually an embedded infection and needs to be treated differently to IC. (A new page on this is coming)

Financially, emotionally and psychologically a vesicovaginal fistula will take a toll on sufferers and their families with many simply not surviving the process – emotionally, mentally or physically.