18.19 Vesicovaginal fistulae (VVFs)

Fistulae between the bladder and the vagina are the most exacting gynaecological problem in the developing world. Some hospitals in Northern Nigeria have waiting lists of more than 600 patients, most of whom will never be treated. They were once equally common in Europe.

In the developing world VVFs are usually the result of obstructed labour in a young primigravida (18.3), and less often of a traumatic vaginal delivery (particularly with Kielland’s forceps), of unskilled Caesarean section, or of rupture of the uterus into the bladder, especially through the scar of a previous section. They can occur: (1) Near the cervix (juxta- cervical). (2) In the middle of the vagina. (3) Near the urethra (juxta-urethral). (4) As a massive combination of the first three. (5) In the vault of the vagina as the result of vaginal surgery. Wherever the patient’s fistula, she usually thinks she is incurable, and, as it does not kill her, she is likely to endure great misery for a long time, especially if she is very young (16 is the average age in Northerern Nigeria). She may have lain at home for weeks in a pitiable emaciated state with contractures and bed-sores from lying curled up on her side, expecting to be returned to her parents and divorced by her husband.

Fistulae have the reputation of being almost impossibly difficult to repair. One contributor believes that there is no such thing as an ‘easy’ VVF, and that only the occasional generalist with ‘golden fingers’ can do them. Nevertheless, in one district hospital (Chogoria in Kenya) 15 VVFs were successfully repaired without any failures by a succession of general-duty doctors, all working ‘from the book’, and with no individual doctor doing more than two. So if you cannot refer VVFs, you may be justified in attempting to repair the smaller, less difficult ones, which do not involve a patient’s urethra. If you succeed, she will be immensely grateful. If you get a reputation for repairing them well, patients will come to you from a long way away. As always, learn from an expert, if you can. These are very rewarding patients!

Most VVFs are due to pressure of the child’s head during a prolonged labour. The best time to repair them is about 6 to 8 weeks after delivery (one contributor waits 12 weeks), when the slough has separated and the tissues are no longer friable, but before they have had time to become fibrotic. If a patient presents later than this, fibrosis makes the operation much more difficult. As soon as you diagnose a new VVF, keep the patient in hospital and give her salt baths two or three times a day to keep the wound clean.

These fistulae can be repaired abdominally through the bladder, but we only describe the vaginal route. Aim to incise round the edges of the fistula, and free three planes—her vaginal mucosa, her bladder mucosa, and if possible a layer of tissue in between them—if you can define it. If you can sew up these layers separately, you will probably cure her fistula. See also Primary Mother Care Section 24.3, and the reference below: