Introduction: Urogenital fistula is an abnormal communication between the urinary and the genital systems. It may occur following vaginal deliveries or following pelvic surgeries. Data concerning urogenital fistula post-surgery is limited and we have noticed in recent years in Sub-Saharan Africa, an increase in the burden of iatrogenic urogenital fistula. Objective: The aim of this study was to assess the epidemiology, clinical profiles and therapeutic aspects of urogenital fistula following obstetric and gynaecologic surgeries repaired at the Nkwen Baptist Hospital Bamenda. Materials/Methods: This was a longitudinal descriptive study with a retrospective and prospective phase carried out at the Nkwen Baptist Hospital for 5 months. However the complete duration of the study was about 17 months. Data was collected using a pretested questionnaire containing socio-demographic information, clinical features, and therapeutic methods used. We used the statistical software SPSS (Social Package for Statistical Sciences) V 26.0 for data analysis. Results: The number of participants in the study was 40. The mean age was 43.5 years (+/- 13.3) ranging from 16 - 74 years. The prevalence of urogenital fistula post obstetric and gynecologic surgeries at the Nkwen Baptist hospital was 64.6%. The most common symptom was urine leakage and the most common surgery that exposed the patient to the urogenital fistula was total abdominal hysterectomy (60%) followed by caesarean section (35%). The different indications for these surgeries were mostly symptomatic leiomyoma (70.8 %) and prolonged labor (64.2%) respectively. The different types of fistula encountered were Vesicovaginal fistula (55%), Ureterovaginal fistula 40% and Vesicoutetrine fistula 5%. The different treatment modalities used were trans abdominal (77.5%) and transvaginal repair (22.5%). T he overall repair success rate after one month was 85%. Conclusion: There is high burden of urogenital fistula post surgeries in our setting. Having more specialists trained in obstetric and gynaecologic procedures may help in the prevention of such an event.
A urogenital fistula is an abnormal communication between the urinary and the genital system which results in leaking of urine [
The major symptoms are leakage of urine through the vagina that can lead to infection, genital ulceration, pain, depression, isolation and social stigmatization [
The management of urogenital fistula depends on the type of fistula but is based on the principle of psychosocial support, conservative or surgical interventions and reinsertion into normal community life [
With this devastating medical and social condition, we intend to raise awareness on the burden of iatrogenic fistula in our context.
Urogenital fistulas lead to devastating medical, social, and psychological problems; thus negatively impacting the lives of women living with them, especially in developing countries where they are victims of stigmatisation, shame and social segregation cause by the persistent offensive odour [
Despite its importance, we noticed that the cases are still largely neglected in the developing world, and the data regarding urogenital fistula after obstetric and gynaecologic surgeries are limited [
To the best of our knowledge there is paucity of data on urogenital fistula resulting from obstetrical and gynaecological surgeries in our setting.
Urogenital fistula is one of the most devastating complications that can result from labour or urogenital surgeries. Fistulas typically develop during prolonged, obstructed labour, but providers can also inadvertently cause a fistula when performing obstetric or gynaecological surgery [
1) What is the prevalence of iatrogenic urogenital fistula among all women who presented with urogenital fistula in the Nkwen Baptist hospital?
2) What are the clinical and diagnostic modalities of patients with urogenital fistula following obstetric and gynaecologic surgeries?
3) What are the therapeutic options and outcome of iatrogenic urogenital fistula at Nkwen Baptist hospital?
To assess the epidemiological profiles, clinical features and therapeutic modalities of urogenital fistula following obstetric and gynaecologic surgeries repaired at the Nkwen Baptist Hospital.
To measure the prevalence of iatrogenic urogenital fistula cases among all women who presented with urogenital fistula at the Nkwen Baptist hospital.
To assess the clinical and diagnostic options of patients with urogenital fistula following obstetric and gynaecologic surgeries.
To identify the therapeutic options used in the management of iatrogenic urogenital fistula and their outcomes.
This study was a hospital-based longitudinal descriptive study with a retrospective and a prospective phase.
Thisstudy covered the period from January 2019 to May 2022.
The study lasted for 5 months study, from the 1st of February 2022 to July 2022.
The study was carried out at Nkwen Baptist Hospital, which is located in Bamenda II municipality. Bamenda is a city in the North West region of Cameroon and the capital of this region. The North West region has a population of about 2,278,503 people. The Nkwen Baptist Hospital receives patients from both the rural and urban areas in the region.
Nkwen Baptist Hospital is strategically located in the heart of health care provision in the capital city of the North-West Region of Cameroon.
The study was carried out precisely at the urology department of Nkwen Baptist Hospital. NBH is a Faith-based multi-specialty Hospital classified as a secondary referral health facility in Bamenda town and is managed by the Cameroon Baptist Convention (CBC) health services. The Hospital provides comprehensive health care among which the following services standout: Urology, eye surgery, general surgery, orthopaedic surgery, Ear, Nose & Throat (ENT) surgery, Genecology, internal medicine and paediatrics. The health team in the urology department is made up of two urologists, three general practitioners and three urology surgical technicians. The hospital has 445 staff members; 135 nurses, 21 doctors among which 7 specialists (1 urologist, 1 orthopedist, 1 ophtalmologist, 2 internists, 1 paediatrician, 1 ENT surgeon); the hospital counts approximately 110 beds among which 49 beds in the surgical ward; the number of daily consultations per month is approximately 11,943 patients.
It consisted of all patients with urogenital fistula at NBH during the period of interest.
Selection criteria
1) Inclusion criteria
Were included in this study:
• All women with urogenital fistula who consented to take part in the study.
2) Exclusion criteria
• Patients with non-iatrogenic fistula
• Fistulas that were not repaired
Patients were recruited consecutively following the inclusion criteria.
Administrative approval was sought from Faculty of Health Sciences of the University of Bamenda, the North West Regional Delegation of Public Health and the Director of the Nkwen Baptist Hospital Bamenda.
After obtaining the necessary ethical clearance and administrative approvals, we retrieved all files and records of patients that have been managed for urogenital fistula from January 2019 to May 2022 at the Nkwen Baptist hospital. We reviewed the files for our inclusion and exclusion criteria. Most of the patients were referred from different hospital facilities.
Extraction of data was done using pre-designed data collection sheets (questionnaires) with concealment of the participant identities and each of them was assigned a code. The questionnaire was designed and tested for reliability and validity using AMOS SPSS by an expert in the field. Data on various variables was extracted. The participants recruited retrospectively were invited through a phone call for participation consent and evaluation of repair outcome and those that were recruited prospectively were invited to sign the consent form.
1) Socio-demographic parameters:
• Age: in years as recorded in the file at the moment of the consultation or by subtracting the year of birth to the year of the repair of the fistula.
• Occupation: will be classified as employed, not employed or retired.
• Marital status: married, single, divorced or widow.
• Region of origin: will be determined according to the 10 regions of Cameroon.
• Religion: will be classified as Muslim, Christian or animist.
2) Clinical parameters:
• Presenting complaint: the duration of symptoms was assessed before consultation (in days), then we collected all the patient’s symptoms and signs as recorded in the files including: leakage of urine through the vagina, foul smelling discharges from the vagina, passing gas from urethra when urinating, urine incontinence, faecal incontinence, genital ulcer.
• Past surgical history: the patients’ medical (HTN, DM, HIV) was assessed and surgical history as it was recorded in the file including caesarean section, hysterectomy, or any other pelvic surgery.
• Paraclinical investigations: The results were obtained from the exam result sheets including: the Dye (blue methylene) test, cystoscopy, retrograde pyelogram, fistulogram, flexible sigmoidoscopy, MRI, vaginal ultrasound or CT urogram.
3) Diagnostic aspect:
• The types of fistulas were registered as recorded in the file (low vesicovaginal fistula, high vesicovaginal fistula, Urethrovaginal fistula, ureterovaginal fistula, or rectovaginal fistula).
4) Therapeutic options:
• type of management were collected from the files (conservative or surgical: transvaginal repair, trans abdominal repair, laparoscopic repair, ureteral reimplantation, urethral reimplantation, cystoplasty, mitrofanoff, etc.).
5) Therapeutic options:
• Treatment outcomes: Part of it as assessed in the files, also through a telephone call and physical exam of patients that could come for follow up: post op complications, catheter duration, take back to OR, recurrent fistula and continence.
Data entry was done using CS pro 7.7 (Census and Survey Processing System) and analysed using the statistical software SPSS (Social Package for Statistical Sciences) V 26.0.
Categorical variables were presented using frequencies and percentages while continuous variables as mean and standard deviation.
This study was carried out strictly for scientific publications and academic purposes. Ethical clearance was obtained from the Institutional Review Board of the University of Bamenda, while administrative authorization was obtained from Faculty of Health Sciences of the University of Bamenda, the Northwest Regional Delegation of Public Health and the Director of the Nkwen Baptist Hospital.
Participant’s consents were sought after a brief explanation of the aim, risk and benefits of the study. Only consenting participants (written) were included in the study. Participants were not sanctioned when they chose not to participate in the study. Participants were interviewed individually. Each questionnaire was coded to ensure anonymity and kept privately. Participant names were kept in a diary accessible only to the investigator. All information derived from the study was used for research purposes only and not to generate any profit. The data collected were handled so as to maintain patient’s confidentiality always by assigning each participant a code.
Postoperative or postpartum patients 1 to 2 weeks out from pelvic surgery or obstructed labor with a complaint of abnormal vaginal fluid leakage should be properly evaluated to determine the accyrate diagnosis, and the clinician should have a high index of suspicion for vesicovaginal fistula. The diagnosis is traditionally established utilizing clinical evaluation and tampon dye testing. A high creatinine level of the vaginal fluid can confirm the discharge is urine, but the clinician should be cautious in interpreting this as other types of urinary incontinence can also result in the urine collecting in the vagina. Office cystoscopy and imaging studies are also often utilized on the evaluation. The differential diagnosis of postoperative or postpartum abnormal vaginal fluid leakage includes infection, inflammation, malignancy, urgency or stress urinary incontinence, or other urogenital abnormalities.
In this study, 65 patients with urogenital fistula were identified. Of the 65 patients, 42 had iatrogenic urogenital fistula following obstetric and gynecologic surgeries meanwhile 23 had non iatrogenic fistula and were excluded. The fistula was repaired in 40 of the 42 patients. These 40 patients all consented for inclusion in the study (
In this study, the mean age of the patients was 43.5 (+/−13.3) years and ranged from 16 to 74 years. The most common age group was 45 to 54 years (n = 15; 37.5%). Majority of the patients were married (n = 25; 62.5%), unemployed
(n = 30; 75%), Christians (n = 35; 87.5%) and reside within the North West region (n = 28, 70%) as seen in
Out of the 65 patients with urogenital fistula, 42 were iatrogenic following O & G surgeries and 23 were non-iatrogenic giving a prevalence of 64.6% amongst all patients with urogenital fistula. As illustrated in
1) Signs and Symptoms
All the patients included in the study presented with urine leakage of which 9 (22.5%) had vulvar dermatitis and 2 (5.0%) had foot drop as demonstrated in
2) Surgeries preceding the fistula
The surgeries, as described by
3) The different indications for the surgery
The different indications for these surgeries were mostly symptomatic leiomyoma and prolonged labor among these patients, 3 (7.5%) had a previous
| Variables | Number (n = 40) | Frequency (%) |
|---|---|---|
| Age categories | ||
| 15 - 24 | 5 | 12.5 |
| 25 - 34 | 7 | 17.5 |
| 35 - 44 | 8 | 20.0 |
| 45 - 54 | 15 | 37.5 |
| 55 - 64 | 3 | 7.5 |
| 65 - 74 | 2 | 5.0 |
| Marital status | ||
| Married | 25 | 62.5 |
| Single | 8 | 20.0 |
| Widow | 3 | 7.5 |
| Divorce | 4 | 10.0 |
| Region of origin | ||
| North West | 28 | 70.0 |
| Out of North West | 12 | 30.0 |
| Religion | ||
| Christian | 35 | 87.5 |
| Muslim | 5 | 12.5 |
| Employment status | ||
| Unemployed | 30 | 75.0 |
| Employed | 10 | 25.0 |
cesarean section and one patient (2.5%) had a myomectomy before. As seen in Tables 2-4.
After the surgery, the median time for the onset of urine leakage was 6.5 (3.3 - 13.5) days and the mean duration of fistula before surgical intervention in this study was 5.36 (±7.7) years ranging from 0 to 30 years as seen on Tables 2-4.
| Caesarean section | ||
|---|---|---|
| Indications | Number (n = 14) | Frequency (%) |
| Prolonged labour | 9 | 64.2 |
| Macrosomia in previous scar | 3 | 21.4 |
| Cephalopelvic disproportion | 2 | 14.2 |
| Hysterectomy | ||
|---|---|---|
| Indications | Number (n = 24) | Frequency (%) |
| Symptomatic leiomyoma | 17 | 70.8 |
| Endometrial cancer | 3 | 12.5 |
| PPH | 2 | 8.3 |
| Cervical cancer | 1 | 4.2 |
| Cervical ectopic pregnancy | 1 | 4.2 |
| Indication | Number (n = 2) | Frequency (%) |
|---|---|---|
| Symptomatic leiomyoma Total vaginal hysterectomy | 1 | 50 |
| Incomplete abortion Dilatation and curettage | 1 | 50 |
4) Comorbidities
The most common associated comorbidities among the patients were Hypertension (6; 15%), HIV (2; 5%) and Diabetes mellitus (1; 2.5%).
A dye test (methylene blue test) was performed on all the patients. The blue dye test was positive in 24 (60%) patients confirming the diagnosis of Vesicovaginal fistula in 21 (52.5%) and vesico-uterine fistula in 3 (7.5%) patients in whom the dye leaked through the cervical os.
Of the 16 patients with a negative methylene blue test, abdominal ultrasound was performed in 9 (56.2%) and intravenous urography in 5 (31.2%). In the 16 women with a negative blue dye test, a CT urogram confirms the diagnostic of Ureterovaginal fistula. CT urogram findings indicated in
Among the 40 patients with urogenital fistula, 22 (55%) had a Vesico-vaginal fistula, 16 (40%) had an Uretero-vaginal fistula and 2 (5%) had a Vesico-uterine fistula.
The 22 cases of Vesicovaginal fistula were classified into: low VVF without urethral involvement 3 (7.5%), low VVF with urethral involvement 1 (2.5%) and high VVF 18 (45%).
Among the 16 patients with Ureterovaginal fistula, 10 (62.5%) had left UVF, 4 (25%) had right UVF and 2 (12.5%) had bilateral UVF shown in
The different therapeutic modalities used were: Transabdominal/Transvesical repair and Transvaginal repair.
Transvaginal route was mostly adopted for patients with low VVF or even simple high VVF that could be approached from the vaginal route. The Martius (88%) and Falandry flap (11%) were used to buttress the repaired while transabdominal route was for patients with fistula that could not be satisfactorily approached through the vagina based on the surgeon’s experience as well as in most complex VVF.
Of the transabdominal repair, ureteral reimplantation was done for patients with ureterovaginal fistula. Augmentation cystoplasty with mitrofanoff urine
| Variables | Number (n) | Frequency (%) |
|---|---|---|
| Methylene blue test (n = 40) | 40 | 100 |
| Positive | 24 | 60.0 |
| VVF | 21 | 52.5 |
| Urine leakage through the cervical OS | 3 | 7.5 |
| negative | 16 | 40.0 |
| CT Urogram (n = 16) | 16 | 100 |
| Left hydonephrosis | 6 | 37.5 |
| Right hydronephrosis | 4 | 25.0 |
| Left ureterohydronephrosis | 2 | 12.5 |
| Bilateral hydronephrosis | 2 | 12.5 |
| Fistulous tract | 2 | 12.5 |
| Variables | Number (n = 40) | Frequency (%) |
|---|---|---|
| Vesicovaginal fistula | 22 | 55 |
| Low VVF | 3 | 7.5 |
| High VVF | 18 | 45 |
| VVF with urethral involvement | 1 | 2.5 |
| Ureterovaginal fistula | 16 | 40 |
| Left | 10 | 62.5 |
| Right | 4 | 2.5 |
| Bilateral | 2 | 12.5 |
| Vesicouterine fistula | 2 | 5.0 |
derivation was used for patients that had reduced bladder capacity with significant destruction of the urethra meanwhile augmentation cystoplasty without the mitrofanoff was used for patients who had reduced bladder capacity with their urethra conserved. Furthermore, orthotopic bladder reconstruction was done in patients with complete destruction of the bladder and intact urethra visible in
The average duration of transurethral catheter for patients with VVF was 30 days in 23 (57.5%) patients and 14 days in 17 (42.5%) patients. For patients with uretero-vaginal fistula a ureteral stent was placed for 6 weeks.
Also, for patients with the mitrofanoff, the catheter was kept in place for two weeks.
Out of the 40 patients recruited in this study, 32 (80%) had an early (1 month)
| Variables | Number | Percentage % |
|---|---|---|
| Transvaginal repair | 9 | 22.5 |
| Transabdominal repair | 31 | 77.5 |
| Ureteral reimplantation | 16 | 40 |
| Augmentation cystoplasty with Mitrofanoff | 5 | 12.5 |
| Augmentation cystoplasty without Mitrofanoff | 2 | 5.0 |
| Orthotopic bladder | 2 | 5.0 |
| VVF repair | 6 | 15 |
successful outcome from the primary surgery, 7 (17.5%) patients suffered a repair breakdown, 1 (2.5%) patient had acute urinary retention.
Some of the patients with repair breakdown and acute urinary retention were re-operated. The mean time from the primary surgery to the reoperation was 1.1 (±0.3) day. Among the re-operated patients, 2 (25%) had a successful repair giving an overall success rate after one month of 34 (85%).
Others complications were surgical site infections 3 (7.5%), bladder spasm post-surgery 15 (37.5%) and surgical site infections 3 (7.5%).
The average follow-up period was 30 days and the intervention was a single surgeon experience.
In this study, we sought to determine the epidemiologic profile, the clinical features and the therapeutic modalities of urogenital fistula following obstetric and gynecologic surgeries repaired at the Nkwen Baptist Hospital.
Our study population had a mean age of 43.5 (±13.3) years. This is similar to 42 years obtained by Raasen et al. (2014) after reviewing 805 patients in 11 Eastern African countries. This mean age is also consistent with the average age (45.7 years) of patients who undergo hysterectomy as reported by Egbe et al. in Douala, Cameroon (2018) [
The prevalence of iatrogenic UGF in our study was 64.6% among all patients with UGF. It is higher than that reported by Tebeu et al. in Yaoundé Cameroon, 2014 who had an iatrogenic UGH prevalence of 19.78% [
In addition to this, hysterectomy was the most common aetiologic surgery for UGF (60%) followed by cesarean section (35%) in our study. This result goes in pair with that recorded in Pakistan by Tasnim et al. in 2020 [
The median time for our patients to experience urine leakage after surgery was 6.5 days. This result is similar to a study performed by Raasen et al. in 11 African countries in 2018 [
The mean duration from onset of UGF to fistula repair was 5.36 (SD 7.7) years. Tebeu et al. in Cameroon 2019 had a similar result [
The blue dye test was negative in all the patients with ureterovaginal fistula. This typical finding was found in a study done by Lengman et al. in Nigeria 2017 [
Our study also revealed that VVF was the most represented type of fistula (55%) followed by ureterovaginal fistula (40%). This is similar to a study carried out Pakistan by Hanif et al. 2005, where VVF was also the most fistula represented type but with a higher percentage (63%) followed by ureterovaginal fistula (36%) in the same study.
More so, it was observed that in patients with ureterovaginal fistula, the left ureter (62.5%) was more affected than the right (2.5%). This goes in line with a study carried out in Pakistan by Hanif et al. in 2005 [
The transabdominal route was adopted for 77.5% of our patients. This is different from a study carried out in Cameroon by Ngaroua et al. in 2019 [
On the other hand, the transvaginal repair in our study was buttressed with martius or falandry flap. This is contrast to a study carried out by Bohoussou et al. in Cote d’Ivoire 2019 where their technique was performed without the addition of neighborhood structures.
One hundred percent of ureterovaginal fistulas in our study, were treated by the ureteroneocystostomy. This is similar to a study done by Lengman et al. in Nigeria 2017 [
Our early therapeutic result was obtained after a period of one month post- surgical repair.
The primary success rate in our study was 80% which is higher than that reported by Bohoussou et al. in Cote d’Ivoire 2017 [
The overall success rate of our study was 85% and this corresponds to a study done by Raasen et al. in 11 African countries in 2014 [
Our study was limited by the following factors:
• Being a single Centre hospital based study may not reflect the true picture of fistula and fistula disease in the community.
• Its retrospective nature limits the parameters that could have been exploited in this study such as the qualification and experience of the operator who carried out the surgery that led to the fistula.
• All patients who had cesarean section following prolonged labour were assumed to have iatrogenic fistulae, but the actual cause of the fistula may not necessarily be due to cesarean section.
However, the strength of our study lies in the fact that to the best of our knowledge no previous study has been carried out in the North West region on iatrogenic urogenital fistula and as such, this study is the first to bring out the burden of iatrogenic fistulas in our context.
1) The prevalence of iatrogenic urogenital fistula is 64.6%.
2) The major aetiologic factor for the UGF is total abdominal hysterectomy followed by caesarean section. The methylene blue is used to make the diagnosis of VVF and vesicouterine fistula while the CT urogram is used for the diagnosis of ureterovaginal fistula.
3) The overall repair success rate at one month in Nkwen Baptist Hospital is 85%.
The authors declare no conflicts of interest regarding the publication of this paper.
Takang, W.A., Landry, M.M., Titus, N.T.E. and Dohbit, J.S. (2023) Epidemiologic and Therapeutic Aspect of Urogenital Fistula Following Obstetric and Gynecologic Surgeries Repaired at the Nkwen Baptist Hospital. Open Journal of Obstetrics and Gynecology, 13, 427-443. https://doi.org/10.4236/ojog.2023.133041