×÷Õߣºprosper e. gharoro, chukwunwendu a. okonkwo

¡¾ÕªÒª¡¿  objective: objective: to investigate the localization and aetiological factors associated with urinary fistulae at the university teaching hospital in beninª²city, nigeria. methods: records on 96 patients treated by the authors at the gynaecological ward of the university of benin teaching hospital, beninª²city, nigeria between january 1997 and december 2006 were analyzed. information extracted and analyzed included data on socioª²biological, demographic, and obstetric event of the antecedent pregnancy. results: the average age of patients with vesicoª²vaginal fistula(vvf) was 34 years with a mean parity of 3. the various mean values for patients' height, weight and body mass index (bmi) were 1.58m, 58.29kg and 24.13 respectively. the majority (92.7%) of fistulas are obstetric in origin. while 5.21% were due to total abdominal hysterectomy and 2.08% due to post irradiation for advanced gynecological malignancy. 53(55.21%) patients had obstetric operative interventions (forceps or vacuum extraction, and or caesarean section). caesarean section contributed 23.96% to the total figure. juxtaª²cervical fistula was the most frequent, next mid vagina and followed by vesicoª²uterine (32. 98%, 24.4% and 19.15% respectively).conclusion: obstetric surgical intervention by care providers is a major cause of vvf formation with particular reference to caesarean section. vesicoª²uterine fistulas are on the increase.

¡¾¹Ø¼ü´Ê¡¿  urinary fistula; caeserean section; aetiological determinant; obstetric interventions

 introduction

    all over the world patients with vesicoª²vaginal fistula (vvf) have an enormous problem to overcome in the ordinary day to day living due to the involuntary loss of urine. the quality of life is adversely affected by the health impact of the disease, which includes mental and direct physical injuries to the reproductive organs. this burden is compounded in the developing world by the extra burden of social segregation for a perceived reproductive failure £Û1ª²3£Ý. they suffer loss in matrimonial and economic values, which contribute to insufferable poverty and malnutrition. fistula is universal in occurrence; unfortunately that is where comparison ends between the developed world and the third world.

    obstetric fistulae were a burden in europe 100 years ago. with improvement in obstetric interventions there has been a dramatic decline in the relative importance of the condition. the most frequent cause of vvf today is iatrogenic lesions after hysterectomy. however, a single fistula is still a burden to the patient and care providers £Û4, 5£Ý. today the aetiological determinants are quite different between countries with or without developed market economies. while gynaecological surgical operations are the major aetiological factors responsible for vvf in the developed world, obstetric problems still account for most of the vvf in the third world. £Û6ª²10£Ý

    this study is an analysis of the clinical profile, aetiological risk factors and types of injuries suffered by patients treated at the university of benin teaching hospital (ubth), beninª²city, nigeria, over a period of 10 years, with a diagnosis of vvf to determine if obstetrics continues to play a major causative role in fistulation.

    materials and method

    records of 96 patients treated by the authors at the gynaecological ward of the ubth between january 1997 and december 2006 were analysed. information extracted included data on socioª²biological, demographic, and obstetric events of the antecedent pregnancy.

    these were subjected to statistical analysis using appropriate computer software.    

    results

    a total 90 of the 96 patients were referred to the uroª²gynaecological unit of the department of obstetrics and gynaecology from within edo and delta states of the country. the patients presented to the unit within a day and fifteen years of the injury that resulted in the development of the fistula.

    table 1 shows some selected socioª²biological characteristic of patients in the study. the average age of patient with vvf was 34.4 years ¡À 2.96, with a range of 1ª²11. the various mean values for patients' height, weight and body mass index (bmi) are 1.58m, 58.29kg and 24.13 respectively.table 1  socialª²biological characteristics ofpatients with fistula

    table 2 shows the antecedent events in the patients developing a fistula. the majority (92.7%) of fistula were obstetric in origin, while 5.21% were due to abdominal hysterectomy and 2.08% post irradiation for advanced gynaecological malignancy.table 2  aetiological factors associated with fistula formation

    table 3 shows the frequency distribution of the various types and localization of fistula in the study. a third 31 (32.3%) of the patients had a juxtaª²cervical fistula. twentyª²three (23.9%) midª²vagina fistulas, while 18 (18.7%) had a vesicoª²uterine fistula. massive fistula was present amongst 7 (7.3%) of the patients, while 2 (2.1%) patients had in addition to vvf rectoª²vaginal fistula. juxta urethral fistula accounted for 15(15.6%).table 3  classification of fistulas

    discussion

    in the evolution history of vesicoª²vaginal fistula various aetiological risk factors take on varying roles of importance as determinant of vvf, reflecting the accessibility of medical resources and the state of the national economy. the northern and southern regions of the country vary tremendously both in availability of medical personal and its economy. the biosocial characteristic of age and parity of the patients in this study are different from that reported by various workers in the northern region of the country £Û5ª²7£Ý. patients in the north of the country are usually young and primigravidas, the age difference is between 15ª²20 years. our patients are multigravidas with a mean parity of 3. the observed characteristic is similar to the findings of hilton and ward in calabar £Û8£Ý and inimgba et al from portª²harcourt £Û2£Ý, both in the south of the country. also, the mean height of patients in the study that developed vvf was 10cm more than the northern patients of 149cm £Û3£Ý. our patients were not the typical short stature patients, which is one of the accepted vvf risk factors. the biosocial characteristics of the patients in this study are within normal range of the childbearing population and different from patients in the northern region of the country. this difference in biosocial characteristics is also noticeable when comparison is drawn with vvf patients from other part of africa £Û4£Ý. the implication of this finding is that patients with normal biostatic and multigravidas (grandmultiparas included) are developing fistula following childbirth, which should not happen under ideal medical environment.

    the picture is different in the north of the country where most patients have spontaneous vaginal delivery and a large percentage have a history of no hospital attendance £Û3ª²8£Ý. however, in the series of ibrahim.  5 (16%) patients had forceps delivery and 4 (13%) had caesarean section£Û3£Ý. in the series from calabar£Û8£Ý, caesarean section was responsible for 6.9% of the obstetric vvf 7 and 15.5% from the portª²harcourt series 2, while in kumasi, ghana 8.5% of the obstetrics fistulas were as a result of  caesarean section 9. fistulas are mostly due to prolonged neglected labour in the north we observe that a high percentage of our patients have either a caesarean section, instrumental delivery or both. the contribution of obstetric interventions as a risk factor for fistula formation in our community cannot and should not be neglected in contemporary practice.

    it is very difficult to compare the localization and type of fistula as most series do not report accurately the different type nor is there a uniforms acceptable classification. vesicoª²uterine fistulas were few in the large series by waaldijk k. from the laure fistula centre. kano £Û10£Ý. most series from the north of nigeria report a low incidence for vesicoª² uterine fistula £Û11£Ý or none at all £Û3£Ý. in our series vesico uterine fistula was the third most common fistula type. this is probably a reflection of the quality of intervention that the patients received for difficult and or prolonged labour. the argument has always been that the intervention is not the cause of the vvf, but that the prolonged obstructed labour is responsible. this cannot be true, as the series from calabar showed that 34.1% of the patients were delivered by caesarean section, while 6.9% fistulas were attributed to this particular obstetric intervention £Û7£Ý. the quality of the service provider makes a lot of difference to the outcome of the particular intervention in labour. the quality of medical service available today in the country varies with the geographical region. the number of health establishments (private and public) is more in the south of the country in particular in edo/delta state. however, they operate in a poorly regulated environment with very poor continued medical education programmes for doctors and virtually no refresher courses for the midwife practitioners.

    the proportion of vvf associated with gynaecological surgery (hysterectomy) and radiotherapy for advance cancer was small (7.3%) in this series, but higher than reported values from the northern region. all the fistulas in the series from sokoto and katsina were obstetrics in origin £Û3£Ý. it could be concluded that most vvf in our contemporary obstetrics practice today are iatrogenic and points to the quality of intervention by the service providers. this picture is also present in some of the  developing countries with emerging  economy £Û12,13£Ý which is different from that of the developed world were the most frequent cause of vvf are iatrogenic lesions after hysterectomy £Û14, 15£Ý

    conclusion

    the majority of fistulas are obstetric in origin, however obstetric surgical intervention by care providers is a major vvf predisposing risk factor with particular reference to caesarean section. the incidence of vesicoª²uterine fistulas is on the increase, which conveys negatively the quality of service delivery.

¡¾²Î¿¼ÎÄÏס¿
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