Obstetric Fistula, Why include Physical Therapy?

Theresa Spitznagle PT DPT WCSAssociate Professor Program in Physical Therapy and OB-Gyn

Washington University School of MedicineSt Louis Mo.

Disclosure

• I have no relevant financial relationships to disclose

What Systems are Affected with Obstetric Fistulas?

• Urologic• Gynecologic• Gastrointestinal• Musculoskeletal• Neurologic • Vascular

Hamlin Fistula Hospital and Outreach Centres

Musculoskeletal Injury

• Pubis Symphysis Injury• Contractures/foot drop• Weakness of musculature along

lumbo sacral plexus (L5-S2)• Hip abductors/Extensors• Anterior Tibialis• Intrinsic foot flexors

Neurological Injury

• Foot-drop from lumbosacral or common peroneal nerve injury

• Complex neuropathic bladder dysfunction

Vascular Injury• Necrosis of pelvic tissues• Intolerance to dependency

of their limbs.

Psycho-Social Impact of Fistula• Fetal fatality 95%• Social Isolation/Stigmatization• Divorce/Abandonment• Victim blaming (punishment from God due to sexual

misbehavior)• Malnutrition• Depression/Anxiety

• Suicide

Goh 2005

• Persistent urinary incontinence after successful repair – 20-55%

Hancock 2009Murray 2002

“a woman who is closed and dry post-repair vs. one who is still incontinent is more likely to live with her husband, eat with others, earn money and attend community gatherings”

• Landry E, Glob Public Health 2013: 8: 926–942.

Obstetric Fistula Clinical Management….Why include Physical Therapy? Castille 2013, 2015• Pre operative rehabilitation

• Pt education:• Intra-abdominal pressure control• Positioning• Pelvic muscle anatomy

• Strengthening/Endurance training• Gait training

• Post operative: • Pt education• Home program for pelvic floor muscle coordination

• Community reinforcement of education by nursing

Surgical Outcomes are Improved with PT:

• Surgical success• Control group, 57 (57.6%)• Physiotherapy group, 77 (68.8%)

• Surgical Failure rate• Control 35 (35.4%) procedures failed, and 7 (7.1%) women went on to have a urinary

diversion.• Physiotherapy 29 (25.9%) procedures failed, 2 (1.8%) women went on to have a urinary

diversion

• The likelihood of recovery was 1.2 times higher (relative risk 1.19; 95% CI 0.96–1.47; Wald test P = 0.047) for women who received physiotherapy than for those in the control group.

• The odds ratio of recovery was 2.72 (95% CI, 1.30–5.93; P = 0.008) for women in the physiotherapy group, compared with control patients.

Reduced Incidence of Post Surgical Stress Urinary Incontinence:• 30 (52.6%) control group • 17 (22.1%) women in the physiotherapy

• (Fisher exact test P < 0.001).• Castille 2013, 2015

• Increased endurance and strength of the pelvic floor muscles• Keyser 2014

Methods of Physical Therapy Program Implementation in Low Resource Area’s• Established Hospital system with Stable Workforce• Identification of individuals who are willing to be trained to do pelvic

floor muscle examination and treatment.• Education on basic clinical algorithm for pre and post operative care• Interdisciplinary team development

• MD• Nurse• Social worker• PT /PT tech• Post operative follow up

Danja Fistula Center: Success Story

• 2-3 visits per year PT-Educator• Education for Tech/nursing

• Can you feel my touch?• Does it hurt? Vaginal icing• “What do I feel” scar assessment: Soft tissue

mobilization• Can you contract on my finger? Strengthening• Abdominal muscle performance• Intra-abdominal pressure control with functional

activities• Education for Nursing: Intra-abdominal Pressure

managment• Bowel management/massage

First Quarter PT care results Danja Fistula Center• PT team treated 19 patients for urinary incontinence • 11 (58%) were dry at the end of therapy.

Physical Therapy improves outcomes even in low resource area’s…….