When one hears of Fistula, the next thing that comes to mind could be pregnancy and childbirth.
But, all of us should be concerned.
There is a vulnerability and susceptibility in the event one is sexually active before the age of 18 years, a victim of physical assault, rape, engages in use of sex toys, inserting or stashing objects in the vagina and anus during sexual play, torture or as a result of hiding objects that may be contraband.
But, why should Key Populations (KP) be exceedingly concerned?
There are six reasons why KP should be emancipated enough to contribute to reduction of Fistula cases in their communities.
- It is treatable and those who seek care go on to lead confident fulfilling lives.
- It affects a big number of people than previously known.
- Contributing to its reduction, means improving health and achievement of the SDGs.
- You may be called upon to take care of someone after surgery. You need to know what they go through.
- It does not hurt to know or be informed about Fistula.
- Because you may be a human Rights Defender and your task is to advocate for dignity of all persons.
According to the WHO (2019) report, Obstetric fistula is preventable; it can largely be avoided by:
- delaying the age of first pregnancy;
- the cessation of harmful traditional practices; and
- timely access to obstetric care.
There are many resources one can use to get information on fistula condition. In a resource by Amie (2019), symptoms and types of fistula are listed.
Symptoms:
Symptoms of fistulas vary depending on their location and severity. However, some symptoms are common in most cases. People often feel very unwell and run a fever. They also feel pain or tenderness at the site of the fistula. Itching may develop, especially if the fistula involves skin. Fistulas often exude pus, which may have an unpleasant or foul smell.
Risk Factors:
Certain conditions place a person at a higher risk of developing a fistula. Crohn's disease and diverticular disease are two conditions highly likely to cause fistulas. Around one in three people with Crohn's disease will get a fistula at some point. Certain cancer therapies, in particular, radiation therapy, can make fistulas more likely to form. An unusual cause of enterovaginal fistulas is obstructed labor when doctors delay intervention for too long. This is rare in the United States as women usually receive a high level of care during childbirth.
Sepsis:
If left untreated, fistulas can become chronic. They can also cause sepsis, a potentially life-threatening condition that develops when the immune reacts to an infection. Symptoms of sepsis include a high-grade fever, a rash, and confusion. It can also result in a fast heart and breathing rate. Sepsis is a medical emergency and requires immediate hospital treatment.
Treatment with Enteral Diet:
Doctors may prescribe enteral diets to those with fistulas in the small or large intestines. When a person is on an enteral diet, they will consume only liquid food for a period. They may require a feeding tube. This type of diet ensures one receives all the nutrients they need without taking in any solid food, thus reducing the amount of stool passing through the intestines and rectum. With this treatment, the fistula has a chance to heal and may even close on its own.
Surgical Intervention:
If the fistula is large or does not respond to less invasive treatments, it will require surgical removal or repair. Where possible, surgeons will use laparoscopic methods, inserting cameras and tools through very small incisions. However, some fistulas require transabdominal surgery involving larger incisions in the abdominal wall. In some cases, a fistula may develop in a diseased part of the bowel. Doctors may resection the bowel and remove the diseased section, including the fistula. In this situation, the person may require a pouch after surgery. This will temporarily divert stool away from the resectioned area to give it time to properly heal.
Statistics:
Preventing and managing obstetric fistula contribute to the Sustainable Development Goal 3 of improving maternal health.
According to fistualfoundation.org, there are over one million women suffering from obstetric fistula worldwide. Fistula is most prevalent in sub-Saharan Africa and Asia.
Fewer than 6 in 10 women in developing countries give birth with any trained professional, such as a midwife or a doctor. When complications arise, as they do in approximately 15% of all births, there is no one available to treat the woman, leading to disabling injuries like fistula, and even death.
The root causes of fistula are grinding poverty and the low status of women and girls. In developing countries, the poverty and malnutrition in children contributes to the condition of stunting, where the girl’s skeleton, and therefore pelvis as well, do not fully mature. This stunted condition can contribute to obstructed labor, and therefore fistula.
Obstetric fistula is both preventable and treatable. It can be prevented if laboring women are provided with adequate and timely emergency obstetric care when complications arise. Once a fistula has developed, however, the only cure is surgical treatment.
In the WHO (2019) report, each year between 50,000 to 100,000 women worldwide are affected by obstetric fistula. The development of obstetric fistula is directly linked to one of the major causes of maternal mortality: obstructed labour.
Women who experience obstetric fistula suffer constant incontinence, shame, social segregation and health problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.
Definitions:
The most common fistulas are listed. A fistula occurs when two organs or structures within the body form an abnormal connection. Fistulas can begin in various ways, but many start as an abscess. Abscesses are pus-filled pockets of tissue. Gradually, the abscess may fill with a bodily fluid such as urine. After a while, the abscess invades another structure in the body. This connects the two structures and forms a fistula. You can think of it as a tunnel that should not be there. Fistulas are most common in the abdomen but can occur anywhere in the body.
Enterocutaneous fistulas connect the small intestine to the skin. They often result from surgical complications.
Enteroenteric or enterocolic fistulas involve either the small or large intestine connecting to another structure in the body.
Enterovaginal fistulas are fistulas involving the vagina.
Enterovesicular fistulas enter the bladder and can cause the person to contract frequent urinary tract infections.
A fistula:
A fistula is a hole, or abnormal opening, in the birth canal, that results in chronic leakage of urine and/or feaces.
Obstetric Fistula:
An abnormal opening between a woman’s genital tract and her urinary tract or rectum.
According to fistulacare.org, each year, more than a quarter million women die in pregnancy and childbirth. Of those that do not perish, an unknown number suffer long-term health problems. The maternal injury with perhaps the most devastating aftermath is obstetric fistula.
Obstetric fistula due to obstructed labour is by far the most common form of genital fistula, constituting an estimated 80-90% of all genital fistula cases.
Obstetric fistula is usually caused by several days of obstructed labor, without timely medical intervention or cesarean section. During this time, the soft tissues of the pelvis are compressed between the baby’s head and the mother’s pelvic bones. The lack of blood flow causes tissue to die, creating a hole between the mother’s vagina and bladder or between the vagina and rectum, or both, and resulting in leakage.
Left with chronic leaking, women with obstetric fistula are often abandoned or neglected by their husbands and families, unable to work, and ostracized by their communities. Women who develop obstetric fistula usually have had a stillbirth, so they must also deal with the loss of a baby. Women with fistula are often among the most impoverished and vulnerable members of society.
Iatrogenic Fistula:
Sometimes genital fistula can be caused unintentionally by a health care provider. This type of injury is called iatrogenic fistula. For instance, during a cesarean section, it is possible that the bladder is accidentally cut, resulting in a hole or abnormal opening through which urine leaks.
Iatrogenic fistula can also occur by accident during surgeries unrelated to childbirth. In many of the countries where we work, approximately 10-15% of the overall patient caseload is due to iatrogenic causes. Training surgeons and other health care staff in emergency obstetric care and other surgical skills is essential to preventing new cases of iatrogenic fistula.
Traumatic Fistula
Traumatic fistula is a condition that can occur as the result of sexual violence, often in conflict and post-conflict settings. There are no solid estimates of its prevalence, but traumatic gynecologic fistula can make up a significant part of the overall genital fistula caseload in places where sexual violence has been used as a weapon of war.
Rape, often aggravated by the thrusting of objects into the vagina or anus, can result in a hole between a woman’s vagina and bladder or rectum, or both, resulting in the leaking of urine and/or feces.
Survivors of sexual assault may have additional, severe physical injuries and are at an increased risk for unwanted pregnancy and sexually transmitted infections, including HIV.
Survivors live not only with chronic incontinence, but also with the psychological trauma and stigma of rape.
Fistula is life-shattering: Women contend with chronic incontinence and often are ostracized by their husbands, families, and communities. The good news is that fistula can be completely repaired up to 90% of the time if fistula survivors have access to a trained surgeon at a hospital providing fistula repair.
Beyond surgical repair, other needed support includes comprehensive counseling and physiotherapy, as needed, as well as treatment of concurrent disabilities. When repaired women leave a health facility, there is need to link them to community-based organizations that support their reintegration back into their community.
Human Rights Defenders Can Contribute to Prevention of Fistula
Prevention
Many of the approaches that prevent obstetric fistula are the same ones that make motherhood safer in general. Engage with your community or advocate for improved Health facility services. Improving maternal health, strengthening obstetric care and facility-based prevention work focuses on:
Family Planning
Family Planning allows couples to delay early births, space desired births, and limit family size. Up to one-third of all maternal deaths and injuries could have been prevented if women had access to contraception. Family planning can also help women with a repaired fistula achieve a successful pregnancy, if that is their desire, by helping them delay a future pregnancy until they are fully healed. Women who have experienced repair are generally advised to abstain from sexual relations for a period of time to allow them to heal. In some situations, for some women find it difficult to comply with this recommendation. Other women may need a longer time before they are able to successfully sustain a pregnancy, and family planning methods can help couples determine when is the best time to get pregnant.
Promotion of the Partograph
The partograph is a low-tech tool for preventing and managing prolonged or obstructed labor, a significant cause of reproductive morbidity and mortality. It is a preprinted one-page form on which observations of the progress of labor and information about maternal and foetal condition are recorded.
The partograph is designed to act as an “early warning system,” alerting doctors, midwives, and nurses to the need for action—e.g., referral to a higher level facility, labor augmentation, or cesarean section. Correct and consistent use of the partograph has the potential to reduce obstructed labor and its adverse consequences, including fistula.
Immediate Catheterization
If a woman with obstructed labour arrives at a hospital and is believed to be at risk for obstetric fistula, immediate catheterization can help to prevent the fistula from developing. The catheter should remain in place until well after the end of labour.
Cesarean Section
Timely Cesarean Section is critical for women with obstructed labor. Doctors performing a cesarean delivery must be competent so that they do not inadvertently create an iatrogenic fistula. Fistula Care Plus works with hospitals to ensure that quality cesarean sections are available from trained health professionals.
Community-Based Prevention
Be part o the effort preventing fistula at the community level. Activities include social mobilization and awareness-raising campaigns, dramas and broadcasts about the importance of antenatal care and assisted delivery, and support for transportation and referrals.
Remember, you too can contribute to preventing Fistula
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