While vesicovaginal fistula has been virtually eradicated in the developed world, it remains one of the most harmful conditions to women in developing countries, according to Serigne M. Gueye, MD, Professor of Urology at University Cheikh Anta DIOP and Chair of Urology at Hopital General de Grand Yoff in Dakar, Senegal.
Dr. Gueye discussed the challenge of treating and preventing vesicovaginal fistula in the annual Societe Internationale d’Urologie (SIU) Lectureduring Saturday’s Prime Time plenary session.
“This remains a major public health issue, especially in sub-Saharan Africa and parts of Southeast Asia, with the main cause being prolonged obstructed labor,” Dr. Gueye said. “Fistula caused by rape and other sexual abuse is probably far more common than we know because many victims do not seek treatment because they lack access and often fear stigmatization. Proportion of fistulas caused by sexual abuse can increase substantially in situations of war and civil unrest.”
Along with the obvious health impact on a woman’s quality of life, Dr. Gueye said the condition can also have a profound social impact.
“A large proportion of fistulas occur among women in traditional cultures, where women’s status and self-worth may depend almost entirely on marriage and childbearing,” Dr. Gueye said. “Many fistula patients are abandoned or divorced by their husbands, particularly when it becomes clear that the fistula will not be cured. Society often blames the woman for her condition and she becomes an outcast accused of infidelity or even witchcraft.”
It’s estimated that as many as 2 million women are currently affected by obstetric fistula in the developing world, Dr. Gueye said, and studies by the World Health Organization estimate 50,000 to 100,000 new cases each year.
“Current best estimates regarding the global capacity to treat fistula patients is only about 16,000 women per year, which is less than half of the projected number of annual new patients,” Dr. Gueye said. “That means we need collaboration and cooperation of all associations to be able to clear the backlog of women waiting for surgeries.”
Dr. Gueye said there are many challenges to addressing the treatment deficit, including the lack of a standard classification system. There’s no consensus on the terminology used to differentiate between “simple,” “complex” and “complicated” fistulas, he noted.
“Without consensus on how we classify the condition, it’s very difficult to set training standards and assessment criteria. We need to reach consensus in order to have an impact on training, research and, ultimately, surgical outcomes,” Dr. Gueye said. “Important parameters to consider for obstetric fistula classification are anatomical description, including quality of tissues; functional repercussions, especially involvement of the closing mechanism; surgical complexity; and predictability of success or failure.”
When and where surgical repair is available, Dr. Gueye said it’s critical that surgeons are equipped to handle potential complications.
“Complications of vesicovaginal fistula surgery are very common,” he said. “Complications need to be recognized very quickly for better management. Training is the key component to prevent complications during vesicovaginal fistula surgery.”
There are initiatives under way with the goal of eliminating obstetric fistula, including the Campaign to End Fistula, launched in 2003 by the United Nations Fund for Population Activities. The goal of the campaign is to eradicate obstetric fistula worldwide by the year 2030 through prevention and treatment strategies, and social reintegration.
Dr. Gueye said the most effective way to prevent fistula is to increase access to quality maternal health care services such as family planning, skilled birth attendants and emergency obstetric care. Prevention also entails tackling underlying social and economic inequities to empower women and girls, enhance their life opportunities, and delay marriage and pregnancy.
“Zero fistula by 2030 is an achievable goal in most sub-Saharan African countries with a comprehensive, locally anchored approach,” Dr. Gueye said. “The combination of intensification of surgical repair, and effective and efficient prevention strategies, particularly through safe motherhood and access to emergency obstetric care, is the key for the elimination of obstetric fistula.”