immediate management of the obstetric fistula

kees waaldijk MD PhD

babbar ruga fistula teaching hospital

the management of the obstetric fistula starts the moment the leaking

of urine is manifest

• prevention of the fistula is a utopia for at least another century

• prevention of the woman from becoming an outcast is very well feasible by the immediate management by:

catheter and/or early closure

• waiting 3 months is malpractice since one allows the woman to become an outcast by pure neglect of the fistula

the management of the obstetric fistula starts the moment the leaking

of urine is manifest

if no fistula expertise available:

• do not waste valuable time• insert FOLEY catheter Ch 18 for 4 weeks• high oral fluid intake of 6-8 liters per day• ensure free urine drainage preferably free into pot• no routine antibiotics since it is pressure necrosis• antibiotics only on indication, e.g. puerperal sepsis• immediate mobilization of patient, if necessary with stick• oral iron preparations; systemic if needed• high protein diet

the management of the obstetric fistula starts the moment the leaking

of urine is manifest

if surgical expertise available

• vaginal examination for assessment• insert FOLEY catheter Ch 18• examine patient_fistula once a week• if it seems healing leave catheter in situ• if not healing excise slough and prepare for early closure• as soon as wound clean perform an early closure• mobilize patient at all times• attend to the other needs of the patient

mass campaign

immediate indwelling bladder catheter

at least 25-30% will be curedwith a minimum of 25,000 a year

immediate managementcatheter and/or early closure

4,424 patientskano/katsina

1984 thru 2008

• total of 13,800 procedures• in total of 11,460 patients

• 4,424 immediate management– 39% of patients and 32% of procedures

immediate indwelling catheter2,031 patients

• total procedures: 13,800• total patients: 11,460• immediate management: 4,424

• immediate catheter: 2,031– 18% of patients and 15% of procedures– 46% of immediate management

resultsin 2,031 catheter treatments

• total no of patients: 2,031

• completely healed/dry: 1,579 (78%)

• kano: 705 (82%) healed/dry out of 864 patients

• katsina: 875 (75%) healed/dry out of 1,167 patients

catheter treatment as start of immediate management

• total immediate management: 4,424

• immediate catheter: 2,031 (46%)

• cured by catheter: 1,579 (36%)

catheter treatmentin relation to total number of patients

• total no of procedures 13,800• in total no of patients 11,460

• catheter treatment 2,031– 18% of patients– 15% of procedures

catheter results in relation to total number of patients

• total no of procedures 13,800• in total no of patients 11,460

• healed/dry by catheter 1,579– 14% of patients– 11.5% of procedures

mass campaignimmediate indwelling bladder catheter

• implement that any woman gets an indwelling bladder catheter the moment leakage of urine starts; with an annual incidence rate of 80,000 to 100,000

• then at least 25-30% would be prevented from developing a fistula: minimum of 25,000/year

• which is more than all operations by all fistula surgeons in the world combined

indwelling bladder catheter andhigh oral fluid intake

at 15 days and at 43 days

necrotic fistula and atonic bladderat 15 days

13 days later at 28 days

necrotic lesions vulva, sphincter ani rupture with atonic bladder

at 11 days debridement

catheter, sitzbath with detergent9 days later at 20 days repeat debridement

16 days later at 27 days

patient sent home at 2 mth with healed wounds

sphincter ani reconstruction etcat 3.5 mth

everything healed at 4 mth; and 16 days after sphincter ani repair

reported back at 10 mth with amenorrhea of 3 mth

failed catheter treatmentat 21 days; 8 days after debridement

at 33 resp 46 days

early closure at 47 days