immediate management of the obstetric fistula kees waaldijk MD PhD babbar ruga fistula teaching hospital

the management of the obstetric fistula starts the moment the leaking of urine is manifest prevention of the fistula is a utopia for at least another century prevention of the woman from becoming an outcast is very well feasible by the immediate management by: catheter and/or early closure waiting 3 months is malpractice since one allows the woman to become an outcast by pure neglect of the fistula

the management of the obstetric fistula starts the moment the leaking of urine is manifest if no fistula expertise available: do not waste valuable time insert FOLEY catheter Ch 18 for 4 weeks high oral fluid intake of 6-8 liters per day ensure free urine drainage preferably free into pot no routine antibiotics since it is pressure necrosis antibiotics only on indication, e.g. puerperal sepsis immediate mobilization of patient, if necessary with stick oral iron preparations; systemic if needed high protein diet

the management of the obstetric fistula starts the moment the leaking of urine is manifest if surgical expertise available vaginal examination for assessment insert FOLEY catheter Ch 18 examine patient_fistula once a week if it seems healing leave catheter in situ if not healing excise slough and prepare for early closure as soon as wound clean perform an early closure mobilize patient at all times attend to the other needs of the patient

mass campaign immediate indwelling bladder catheter at least 25-30% will be cured with a minimum of 25,000 a year

immediate management catheter and/or early closure 4,424 patients kano/katsina 1984 thru 2008 total of 13,800 procedures in total of 11,460 patients 4,424 immediate management –39% of patients and 32% of procedures

immediate indwelling catheter 2,031 patients total procedures:13,800 total patients:11,460 immediate management: 4,424 immediate catheter: 2,031 –18% of patients and 15% of procedures –46% of immediate management

results in 2,031 catheter treatments total no of patients:2,031 completely healed/dry:1,579 (78%) kano: 705 (82%) healed/dry out of 864 patients katsina: 875 (75%) healed/dry out of 1,167 patients

catheter treatment as start of immediate management total immediate management:4,424 immediate catheter:2,031 (46%) cured by catheter:1,579 (36%)

catheter treatment in relation to total number of patients total no of procedures13,800 in total no of patients11,460 catheter treatment 2,031 –18% of patients –15% of procedures

catheter results in relation to total number of patients total no of procedures13,800 in total no of patients11,460 healed/dry by catheter 1,579 –14% of patients –11.5% of procedures

mass campaign immediate indwelling bladder catheter implement that any woman gets an indwelling bladder catheter the moment leakage of urine starts; with an annual incidence rate of 80,000 to 100,000 then at least 25-30% would be prevented from developing a fistula: minimum of 25,000/year which is more than all operations by all fistula surgeons in the world combined

indwelling bladder catheter and high oral fluid intake at 15 days and at 43 days

necrotic fistula and atonic bladder at 15 days

13 days later at 28 days

necrotic lesions vulva, sphincter ani rupture with atonic bladder at 11 daysdebridement

catheter, sitzbath with detergent 9 days later at 20 daysrepeat debridement

16 days later at 27 days patient sent home at 2 mth with healed wounds

sphincter ani reconstruction etc at 3.5 mth

everything healed at 4 mth; and 16 days after sphincter ani repair reported back at 10 mth with amenorrhea of 3 mth

failed catheter treatment at 21 days; 8 days after debridement

at 33 resp 46 days

early closure at 47 days