Re: Obstetric fistula: a public health issue, O&G Magazine Vol 19;No 3:p 60.
For over 20 years, I have spent much time in Africa and Asia treating women with obstetric fistula (OF), and have just returned from remote far western Uganda as a medical volunteer. I have lived in Ethiopia for over a year, spending most of my time there at the Addis Ababa Fistula Hospital, working as a fistula surgeon.
The paragraph on ‘future directions of OF detection’ is objectionable. At present, we can detect 100 per cent of fistulas from the urethra/bladder to the vagina (and recto-vaginal fistula) by clinical assessment alone. Imaging is useful in ureteric fistulas. In many parts of Africa, ultrasound is not available. It is too expensive, there is no training in ultrasound use and electricity is unreliable, with power surges damaging equipment. There is also a paucity of biomedical engineers to service or repair equipment.
At the hospital in remote western Uganda, the x-ray tube is many decades old with no funding for another, let alone an ultrasound. There is no blood for transfusion and very basic blood tests (that is, only haemoglobin, test for malaria, HIV and extremely difficult to obtain basic electrolytes).
In many low-income countries in Africa and Asia, healthcare is not free. Every visit and every investigation adds to the cost. Many cannot afford to come to the clinic, let alone pay for investigations. For a woman with a fistula, history and examination +/- dye test is all that is required. A dye test is not required for the majority as the fistula is large and therefore easily palpable or seen on examination. Clinical hands-on examination also allows the clinician to inspect the vagina for other pathology, other fistulas (rectovaginal or more than one genito-urinary fistula) and vaginal scarring. It also allows the clinician to assess and plan for the route of surgery – vaginal repair or abdominal. This is very important in many low-income countries as spinal anaesthesia is safer and preferable to general.
For the ‘pinhole’ fistula, a dye test will allow the clinician to locate the fistula and, again, vaginal examination enables assessment of the vagina/rectum. The dye test is low cost, available anywhere, requires little training and extremely accurate in diagnosing a fistula. It does not add to the burden of healthcare costs.
The article quotes Nolsoe1 who discusses perianal fistula, which is completely different (with different aetiology) to the obstetric fistula. This reference also admits that ‘gold standard’ for diagnosis of the obstetric fistula was surgery, in other words, clinical examination. Thus, an ultrasound scan is of little benefit and only adds to the cost of healthcare.
Therefore, as an experienced fistula surgeon, I disagree that ultrasound is required to detect obstetric fistulas and advocacy for expensive equipment with little scope for training or servicing of equipment is not helpful in low-income areas.
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Within the anus, there are glands that create fluid. Sometimes these can become blocked and infected, creating what is called an abscess. This is the most common cause of a fistula, although fistulas can sometimes be caused by other conditions as well, such as Crohn’s disease, sexually transmitted diseases, or cancer.