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CLERK AND DISCUSS THE SOCIAL FACTORS THAT HAVE
CONTRIBUTED TO THE CASE OF VESICULO VAGINAL
FISTULA IN A FEMALE PATIENT CURRENTLY BEING
MANAGED AT BINGHAM UNIVERSITY TEACHING
HOSPITAL
• Egbaiyelo Olamide BHU/18/01/03/0002
• Ahmed Amana BHU/18/01/01/0045
• Abosi Flora Okoro BHU/17/01/01/0131
• Ogbuti Sharon BHU/22/01/01/0162
• Edmund Claudia Y BHU/18/01/01/0030
• Obande Patience BHU/18/04/02/0008
• Musa Racheal BHU/18/01/01/0024
• Martin Martina BHU/17/01/01/0174

OUTLINE
INTRODUCTION
EPIDEMIOLOGY
AETIOLOGY
PRESENTATION OF CASE SCENARIO
DISCUSSION
TREATMENT
RECOMMENDATIONS
REFERENCE

INTRODUCTION
A fistula is defined as a pathological
communication between two epithelial
surfaces or cavities
Female genital fistula is an abnormal
communication between the female
genital tract and the urinary tract or lower
gastrointestinal tract or the outer surface
The common fistulae seen in women are
vesicovaginal fistula, recto vagina fistula
and ureto vaginal fistula

INTRODUCTION
Vesicovaginal fistula is an
abnormal opening between
the bladder and the vagina
that results in continuous
and unremitting urinary
incontinence

There are four major types of fistulas:
• Enterocutaneous: This type of fistula is from the intestine to the
skin. An enterocutaneous fistula may be a complication of
surgery.3 It can be described as a passageway that progresses
from the intestine to the surgery site and then to the skin.
• Enteroenteric or enterocolic: This is a fistula that involves the
large or small intestine.
• Enterovaginal: This is a fistula that goes to the vagina.
• Enterovesicular: This type of fistula goes to the bladder. These
fistulas may result in frequent urinary tract infections or the
passage of gas from the urethra during urination.
INTRODUCTION

Classification
according to site of fistula
1. High fistula
•juxta cervical
•Vault(vesico-uterine)
2. Mid vaginal fistula
3. Low fistula
•Bladder neck (urethra intact)
•Urethral involment(segmental i.e partial b.neck loss)
•Complete bladder neck loss(circumfrential fistula)
4. Massive vaginal fistula
•encompasses all three fistulas & may include one/both ureters in addition

Classification
According to size
Small <2cm
Medium 2-3cm
Large 4-5cm

EPIDEMIOLOGY
• Vesicovaginal fistula is still a major cause for
concern in many developing countries
• The existence of VVF is believed to have
been known to the physicians of ancient
Egypt, with examples present in mummies
before 2,000 years bc
• However, the World Health Organization
estimated that over 20 million women are
living with this condition, with 50,000 to
100,000 new cases per annum.2,6,7 The
incidence in West Africa is estimated to be 3
to 4 per 1000 deliveries

EPIDEMIOLOGY
• The exact magnitude of VVF worldwide is unknown.
However, the World Health Organization (WHO) estimated
that over 20 million women are living with this condition,
with 50,000 to 100,000 new cases per annum.2,6,7 The
incidence in West Africa is estimated to be 3 to 4 per 1000
deliveries.
• In Nigeria alone, 800,000 to 1,000,000 women are estimated
to be awaiting repair. in Nigeria, the prevalence of obstetric
fistula is estimated at 3.2 per 100 births; approximately
13,000 new cases are recorded annually
• An average of 357 new cases of female genital fistula a
year in BHUTh and about 70% are vvf cases, majority of
this women are from the north east and the north central
being the next. affect both Muslims and christians. affects
women of child bearing age more. majority of cases are of
obstetric and teratogenic causes, 6-7% of vvf cases are as
a result of female genital mutilation and very few are
congenital.

ECTOPIA
VESICAE
The posterior wall of the urinary
bladder is exposed to the exterior
• It is caused by the failure of the
anterior abdominal wall and
anterior wall of the bladder to
develop
• It is due to inability of the
mesoderm of the primitive streak
to migrate around the cloacal
membrane

Obstetrical causes
• Underdeveloped pelvic bony structure is a risk factor for
obstructed labor and obstetric fistula or the development of
VVF in developing countries
• Prolonged obstructed labour denotes suboptimal obstetric care
and hence is rife in areas where medical health facilities are
inexistent or sparse and/ or skilled personnel short in supply
• Other cultural factors that increase the likelihood of obstetrical
UGFs include outlet obstruction due to female circumcision and
the practice of harmful traditional medical practices such as
Gishiri incisions and the insertion of caustic substances into the
vagina with the intent to treat a gynecologic condition or to
help the vagina to return to its nulliparous state

Gynecological Causes
• In the developed world, the leading cause of vesicovaginal
fistula is bladder injury during gynecologic, urologic, or pelvic
surgery
• The most common surgical injuries to the lower urinary
tract happen during hysterectomy, while others are
associated with general surgery procedures in the pelvic
area, anterior colporrhaphy or cystocele repair, anti-
incontinence surgery, or other urologic procedures Around
3-5% of VVF cases in industrialized countries are a result of
locally advanced malignancies, with the three most common
forms being cervical, vaginal, and endometrial carcinoma
• In simpler terms, VVF is most commonly caused by bladder
injury during surgery, especially during hysterectomy

•SOCIO-
DEMOGRAPHICS
• Mrs C.J.S
• 38 year old, Christian female
• Resides at Gulak Adamawa state
• Married at the age of 20 and is
Marghi by tribe

•CURRENT LOCATION
• Vesico-vaginal fistula ward, Bed
4, Bingham University Teaching
Hospital, Jos

•MEDICAL HISTORY
• Patient was clerked 6 days ago with a 1
week history of abdominal pain and
urinary incontinence secondary to
prolonged labor
• Patient had a labor of almost 48 hours due
to absence of the medical doctor who was
supposed to perform the caesarian session
on the patient which also led her to losing
the child

•FAMILY AND
SOCIAL HISTORY
Patient is married in a monogamous family
and is a para 7 with 3 dead, she has
secondary level of education and she’s a
hospital staff and Husband is a farmer
Patient lives in a family house and have a
room and a parlor for herself, husband and
children
The room have 2 windows They use
firewood and charcoal for cooking and
source of drinking and cooking water is
borehole

DISCUSSION
• From the case scenario presented certain social
factors are associated with Mrs. C.J.S leading to
prolonged labour resulting to VVF
• Lack of medical personnel and poor health
services
• National insurgency
• Low socioeconomic status; poverty

Social
demographic
Mrs H.A
14yrs, muslim, Hausa,female,
from Sokoto state.
Current location at time of
clerking:VVF centre BHUTH

Medical History
Patient presented to the VVF ward
with continuous leakage of urine of
5days duration which she noticed
3days after delivery
She went into labour at home
which lasted for over 48hrs
She was assisted by a group of
elderly women in the community
who were not trained midwives

Medical History
She eventually delivered through
vaginal delivery
She had a still birth.
3 days later, she noticed a constant
leakage of fluid draining down her
leg which she later realized to be
urine due to the smell.

Family and
social History
She is the 3rd wife of a 46year old muslim
livestock trader, who had promised to help
her family out with their finances in
exchange for her hand in marriage
Her husband is financially supporting her
but is not so supportive emotionally as he
has 3 other wives and children
She lives in family compound house with a
room for each wife with a general
bathroom and kitchen

Family and
social History
She cooks uses firewood and
charcoal to cook and their source of
water for drinking and cooking is
from the well.
She learned about this center from a
relative
She has undergone a VVF repair at
this center and has been discharged
with no further complications.

DISCUSSION
• From the case scenario presented certain
social factors are associated with Mrs H.A.
which led to her presentation with VVF
• 1. Socioeconomic status
• 2. Culture
• 3. Education

VVF investigations
and management
guidelines

Investigations
There are several tests that can be done to check if you
have a fistula, where it is and how big it is
It is important to take all of the antibiotics even if you do
not feel unwell ,because if you don’t the infection might
come back
This test can also give clues as to where the fistula is
depending on whe the rthe top,middle or bottom swab is
stained
This allows the doctor to decide which treatment will
have the best chance of success
Your doctor will tell you if this needs to be done

•Investigations
• Urine specimen analysis.
• • You will be asked to give a urine sample
which will be tested for signs of infection.If th
sample does show these, it will be sent to th
lab for further testing.This will take 48hours.
there is an infection your family doctor will be
asked to give you antibiotics.It is important to
take all of the antibiotics even if you do not
feel unwell ,because if you don’t the infection
might come back.

•Investigations
• Vaginal examination
• • An instrument called a speculum ma
be used to gently open the vagina so
that you can look and feel inside to
check for leakage.An opening may be
seen It may be necessary to scan

•Investigations
• Cytoscopy and examination under anesthesia
• • EUA is an examination under anaesthetic.While you are asle
your doctor will pass a cystoscope (a small telescope)along th
urethra and into the bladder.The vagina is also examined.By
looking at these tissues the doctor can see exactly where the
fistula is,now big it is and check that there is only one fistula s
that others are not missed.This allows the doctor to decide
which treatment will have the best chance of success.
• Radiographic examination.
• • It may be necessary to scan your kidneys,ureters(tubes takin
urine from the kidneys to the bladder) and bladder before
treatment.Your doctor will tell you if this needs to be done.

VVF Prevention
• Some of the ways to prevent a vvf are :
Adequate antenatal care should be
extended to at risk mothers who are likely to
develop obstructed labor, a cs is advised for
those at risk
• In case of a long standing obstructed labor,
the urinary bladder should be drained
continuously for a period of 5 to 7 days
following delivery of the baby

Conservative
management
• This type of treatment defined by the avoidance of
invasive measures such as surgery or other invasive
procedures with the intent to preserve function or
body parts If vvf is diagnosed within the first few
days of surgery ,a trans urethral or supra public
catheter should be placed and maintained for up to
30 days,small fistula less than 1cm may resolve or
decrease during this period if caution is used to
ensure proper continuous drainage,if there is no
improvement in 30 days surgery is required

Medical management
/intervention
• Some patients will have active infection when
they present with a fistula and this requires
clearing up before definitive treatment can be
decided
• Estrogen replacement therapy optimise tissue
vascularization and healing in post
menopausal patients
• Barrier ointment such as zinc oxide or vaseline
application in treatment of perineal and
ammonites dermatitis

Surgical management
• The ideal time for surgery of vvf due to
obstructed labor is after 3 months by
this time the general condition of the
tissue improves and the local tissues
are likely to be free from infection
• The repair is done through either the
vagina or the abdomen

Post operative
complications
• Early complications : Excessive
bleeding, Surgical wound infection,
continued urine leakage through the
fistula
• Late complications: Risks of abdominal
and pelvic adhesions if abdomimal
approach is used,risks of dyspareunia
and tenderness,vaginal stenosis

RECOMMENDATIONS
• Government
• Schools
• Hospital
• Community
• Family
• Individual

Government:
Increase investment in healthcare infrastructure, particularly
in rural and underserved areas, to improve access to maternal
healthcare services and facilities.
Implement and enforce laws against harmful cultural
practices, such as FGM, and provide education to
communities on the associated health risks.

Organize awareness campaigns and workshops for students and teachers on issues
related to maternal health and VVF prevention.
Integrate comprehensive sexual and reproductive health education into the school
curriculum, emphasizing the importance of maternal health and early recognition of
complications.
Schools:

Hospital:
Strengthen obstetric
and gynecological services in healthcare
facilities to ensure timely management
of labor-related complications.
Offer counseling and support services to
VVF patients to help reduce stigma and
improve their emotional well-being.

Establish support groups for VVF patients, creating a safe space for sharing experiences
and reducing feelings of isolation.
Engage with community leaders and influential members to raise awareness about
maternal health, VVF prevention, and the importance of seeking medical care during
pregnancy.
●Community:

●Family:
Encourage families to prioritize the education of girls and
delay marriages until they are physically and emotionally
ready for childbirth.
Educate families on the potential risks associated with
traditional birthing practices and promote the utilization of
skilled birth attendants.

● Individual:
Encourage women to attend regular antenatal
check-ups and seek medical care promptly if they
experience any pregnancy-related complications.
Promote self-care and empower women to
prioritize their health and well-being

• 1.Malik MA, Sohail M, Malik MT, Khalid N, Akram A. Changing trends in the
etiology and management of vesicovaginal fistula. Int J Urol. 2018
Jan;25(1):25-29.
• 2.Hadley HR. Vesicovaginal fistula. Curr Urol Rep. 2002 Oct;3(5):401-7.
• 3.Stamatakos M, Sargedi C, Stasinou T, Kontzoglou K. Vesicovaginal fistula:
diagnosis and management. Indian J Surg. 2014 Apr;76(2):131-6.
• 4. Medlen H, Barbier H. Vesicovaginal Fistula. [Updated 2023 Feb 6]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK564389/
• 5. Stamatakos M, Sargedi C, Stasinou T, Kontzoglou K. Vesicovaginal fistula:
diagnosis and management. Indian J Surg. 2014 Apr;76(2):131-6. Available
from: https://doi.org/10.1007/s12262-012-0787-y
• 6. Medlen H, Barbier H. Vesicovaginal Fistula. 2023 Feb 6. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID:
33232059.
• 7. Garthwaite M, Harris N. Vesicovaginal fistulae. Indian J Urol. 2010 Apr-
Jun;26(2):253-256. Available from: https://doi.org/10.4103/0970-1591.65400.
REFERENCES

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