On Fistulas And Why We Don’t Have Them Here

Many of our patients ask me about my work with the West Africa Fistula Foundation in Sierra Leone, and the first question they usually ask if “what is a fistula?”

A fistula is an abnormal connection between two organs, and in gynecology the most common fistula occurs between the bladder and the vagina. The bladder sits right on top of the anterior vagina (the wall of the vagina closest to the abdomen) and the two organs are separated by a thin but strong wall of tissue. When damage occurs to the area between the vagina and the bladder, a hole can form which then connects the bladder to the vagina. Since the bladder now has a hole in it, urine constantly leaks into the vagina and the patient is constantly wet with urine.

In the developing world where obstetric care is often not available, fistulas develop when a woman is in labor for a prolonged period of time and is unable to deliver the baby. The baby’s head sits in the vagina sometimes for days, crushing the anterior vaginal wall and bladder together and permanently damaging the tissue. After days of labor the baby inevitably dies and eventually the head will collapse enough to come out. In some cases the patient is able to have a C-section to remove the dead baby, in others she simply has to wait for it to come out by itself which can take days or even weeks. After delivery, the patient with a fistula may also have nerve damage to her legs from the prolonged pressure and commonly has permanent foot drop. Fistulas between the rectum and vagina are less common but can also form this way, causing chronic loss of stool and gas. Obviously, having these kind of problems is a huge social disaster. The patients smell bad, are unable to work, usually lose their husbands and are ostracized by their own community. Remember they don’t have showers, laundry facilities, flush toilets or sanitary pads. They are modern day lepers.

Fistulas from obstructed labor have been completely eradicated in the Western world. As busy ob/gyns in the US, we have never seen a single case of an obstetric fistula. They just don’t happen, since medical care is available in cases where a baby simply will not come out after a prolonged labor and a patient would never be in the late stages of labor for days. The occasional fistulas that we see in the US are almost all caused by surgery. The most common fistula occurs after a difficult hysterectomy or C-section in which the bladder was inadvertently damaged. Other trauma or radiation for cancer treatment can also cause gynecologic fistulas but these are very rare.Most obstetric fistulas are correctable with relatively minor surgery performed vaginally. Sometimes the hole is so big that after closing the hole, very little of the bladder remains. These severe cases may need to be addressed with a major surgery diverting urine away from the bladder to a new pouch made out of intestine that then drain though the abdominal wall. For most women with a fistula in Africa, help is only available from Western charity organizations such as WAFF since local doctors are not trained to perform the surgery and patients don’t have money to pay for treatment. Please visit WAFF’s website at www.westafricafistulafoundation.org to learn more about my work with WAFF and learn more about this completely preventable problem.