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  • Title: [Vesico-vaginal fistulas].
    Author: Leclerc Du Sablon M.
    Journal: Dev Sante; 1990 Apr; (86):8-11. PubMed ID: 12283172.
    Abstract:
    A vesicovaginal fistula is an abnormal passage between the bladder and the vagina. It is a hole in the lower posterior wall of the bladder and sometimes the urethra through which urine continuously drips toward the vagina, without possibility of control. Since women suffering from vesicovaginal fistulas are commonly infertile, the problem affects their entire social, family and gyneco-obstetrical lives. Fistulas are a complication of difficult deliveries and occur frequently in some rural and isolated regions of Africa insufficiently served by maternity hospitals. Fistulas develop in the course of deliveries prolonged by any cause when the baby's head presses against the bladder wall, causing necrosis of the wall by ischemia. The fistula appears several days after delivery of an usually stillborn infant. Fistulas are most commonly seen in young women, over half of whom are primiparas. Risk factors include small stature with narrow pelvis and excision. But the lack of obstetric care and midwives in rural zones and the difficulty of transfer to a hospital are the major factors. The fistula may measure several mm to several cm in length. The bladder has a reduced capacity because of sclerosis. The fistula may affect the urethra, uterus, vagina, and in very severe cases the rectum. Continuous local and urinary infection is almost always present. Early diagnosis is important because treatment is simpler, but it is more difficult than later diagnosis and symptoms may be masked by postpartum incontinence caused by trauma to the perineum which usually regresses spontaneously. An evaluation of the size and exact location of the fistula and the condition of the bladder and other affected organs is necessary before corrective surgery can be planned. 1 or 2 weeks of preoperative preparation may be needed to treat anemia, parasites, urinary infections, and cutaneous lesions. Treatment may require from several weeks to several months. Numerous surgical procedures are possible. The choice depends on the lesions and the habits of the surgeon. Curative surgery may not be possible in the most severe cases. Palliative surgery requires careful longterm follow-up that is seldom possible in Africa. When the final outcome is good, the patient must be carefully advised that hospital care is imperative during any subsequent pregnancies to avoid another fistula. Prevention in the form of screening of difficult deliveries and transfer to the nearest hospital at any moment is the best form of treatment for this condition.
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