Gynecological fistula in the DR Congo

Abstract

Background: Gynecological fistula is an international public health problem afflicting many women in the poor countries of Africa and south Asia. Although the magnitude is unknown, it is believed to be a great problem in the DRC. Preliminary hospital data from the DRC indicates that complicated cesarean section and sexual violence are important causes of fistula in addition to obstructed labor. This clinical picture deviates from the results reported from research performed in other Sub-Saharan African countries. There is almost no previous academic research on fistula in the DRC. Objective: The objective was to establish knowledge of the characteristics of gynecological fistula in the eastern DRC in terms of fistula etiology, patient demographics, fistula attributes and predictors of surgery outcome. Methodology: A retrospective analysis of hospital records of 604 consecutive patients who received treatment for gynecological fistulas at a fistula referral centre in the eastern DRC during a 24 month period. Results: 82% of the women developed a fistula following obstructed labor and 17% after medical mismanagement, of which 70% involved cesarean section. 5 cases (0,9%) were caused by sexual violence. The median age at fistula development was 23 and median height 150 cm. 17% of the women were divorced, 41% were primiparous and 34% were parity four or more. The majority spent two or more days in labor in the index delivery and 90% of the babies were stillborn. 42% delivered by cesarean section and 85% of the cesarean sections were performed on dead babies. Women with fistulas from obstructed labor took a median of three years to seek treatment whereas one year for women with iatrogenic fistulas. 31% of the women had previous failed repairs. Overall success rate was 87%, 16% of the women remained incontinent and 13% failed. Failure was significantly associated with previous repairs, amount of fibrosis and fistula size. Incontinence was significantly associated with previous repairs, amount of fibrosis and fistula location. Iatrogenic fistulas had a better outcome, mostly explained by fistula attributes. The success rate for fistula closure for patients with no previous surgeries was 90,7% with 11,5% remaining incontinent. 5 Conclusion: Obstructed labor was the main cause of fistula. A disturbing high percentage of the fistulas were caused by medical mismanagement, indicating a need for more training and regulation of obstetric services and a call for re-emphasizing the role of midwifes in assisted deliveries. Fistula as a direct result of rape is rare. Age at fistula development was older than most studies which may be indicative of poorly assisted deliveries and lack of access to emergency obstetric care. Treatment delay was also longer than most studies and there is a need to improve fistula awareness and available treatment. Fistulas should be repaired by qualified surgeons only.