Obstetric fistula is commonly caused by an injury during natural childbirth where a tear occurs in the birth canal. This tear leads to faecal matter leaking through the vagina, causing complications and severe distress for the mother.
These symptoms are what a woman in Singapore experienced after a childbirth injury that was in the news earlier this month.
The incident raises a question: How can these deeply distressing symptoms develop after childbirth? The faecal leakage can go on for months after childbirth and the patient has no control over it. Nor can she stop it.
In general medical terms, a fistula refers to an abnormal connection between two body parts or structures, said Dr Melvin Look, consultant surgeon and director of PanAsia Surgery.
An obstetric-related fistula is an abnormal opening that forms between the birth canal and the rectum, anal canal or urinary tract, due to childbirth trauma. This can cause faecal matter and gas to leak into the vagina.
For example, a rectovaginal fistula forms between the rectum (lower part of the large intestine where stools are stored) and the vagina. An anovaginal fistula forms between the anal canal (which connects the rectum to the anus) and vagina. Both types of fistulas may develop as a result of childbirth-related injuries.
The rectum, anus and vagina are distinct structures but are close in proximity. (Photo: iStock/nmfotograf)
Dr Look explained that while the lower part of the intestine – the rectum or anus – and the vagina are anatomically distinct, they are close in proximity.
“The vault of the vagina lies in front of the rectum, separated by elastic connective tissue. Although this tissue is usually strong, it is only a few millimetres thick and can sometimes be damaged by disease or injury,” he said.
A common cause of damage is an obstetric injury during natural childbirth. This can happen when a tear occurs during the delivery of the baby along the birth canal, said Dr Look.
A childbirth injury can happen when a tear along the birth canal happens during delivery. (Photo: iStock/Fly View Productions)
Dr Cheryl Lau, a senior consultant surgeon specialising in colorectal surgery, at Aeon Surgery, Colorectal Surgery and Endoscopy Clinic told CNA Women that a vast majority of obstetric-related fistulas are anovaginal fistulas. In developed countries, they are rare and occur in about 1 to 3 per 10,000 deliveries.
Globally, there are an estimated 100,000 cases of obstetric fistulas per year, according to Professor Christopher Chong, a urogynaecologist, obstetrician and gynaecologist at Gleneagles Hospital. However, he added that such cases are less common in Singapore and other developed countries.
During childbirth, certain factors can increase the risk.
Prof Chong explained that the perineum – area between the vagina and anus – is generally shorter in Asian women, and the vaginal opening is small compared with the baby’s head.
“The foetal head coming through the vagina typically causes tears, which is why very often, especially for first delivery in Asian women, the obstetrician makes a cut called episiotomy (commonly away from the anus). This serves to deviate the tear away from the anus and minimise ragged and erratic tears,” he said.
However, an obstetric fistula can still occur due to complications, such as delivering a big baby, a baby with a large head, an instrumental delivery (for example, use of forceps), a very rapid labour or a prolonged one, or when the baby is delivered in a non-optimal position.
Delivering a big baby or a baby with a large head, rapid or prolonged labour, and poor healing of the episiotomy wound can increase the risk of obstetric fistula. (Photo: iStock/globalmoments)
Poor healing of episiotomy wound, especially if infection occurs, can also lead to the elastic connective tissue between the vagina and rectum or anal canal breaking down, said Prof Chong.
Dr Look said that tears that occur during childbirth are usually repaired by the obstetrician after the baby and placenta are delivered. However, surgical repair can be “complicated” when severe tears damage the rectum and anus, he added.
Prof Chong said that he sees an average of one to two cases of obstetric-related fistulas a year – usually referrals from other doctors. “In my own hands, I had one case in the last 20 years – a first delivery. The patient was repaired and was well, and went on to have a second baby – this time, by C-section”, he said.
Colorectal surgeons also see rectovaginal and anovaginal fistulas
It can also happen in patients with severe infections and abscesses, or advanced inflammatory bowel disease, a group of intestinal disorders that cause prolonged inflammation of the digestive tract.
Dr Lau said: “It can also occur following difficult hysterectomies (surgery to remove the uterus), especially those performed for severe endometriosis.”
Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus, sometimes affecting nearby organs.
For patients, the condition is “very distressing” as they have to deal with leakage of faecal matter into the vagina, said Dr Look. There is no telling how often it will happen; it can be a constant or intermittent leak of solid, soft or even liquid faecal matter.
“The fistula may also cause pain, especially during sexual intercourse. Sometimes, the symptoms can be very subtle if the fistula is a small one,” Dr Look added.
Symptoms of obstetric fistula include a foul-smelling discharge, faecal matter passing through the vagina, and pain, especially during sex. (Photo: iStock/Alina Prokudina)
Patients also struggle with stigma, which delays proper diagnosis and treatment. “Some affected patients believe their symptom is a result of poor hygiene and do not seek medical help,” said Dr Lau.
Usually, the first symptom is an abnormal, foul-smelling vaginal discharge. The characteristic symptom is the passing of gas or stool through the vagina, said Dr Lau. This happens because the abnormal tract allows faecal matter or gas to pass from the anal canal into the vagina.
Sometimes, there may be recurrent vaginal or urinary tract infections, or irritation and swelling at the vagina and perineum. This is due to bacteria contamination from stools, she explained.
Dr Lau advised seeking medical attention if any of these symptoms occur. “If it's left untreated, recurrent infections from these abnormal tracts can lead to tissue damage at the perineum – or worse, sepsis and incontinence,” she warned.
Treatment for obstetric fistulas may look different from patient to patient. When surgical repair is required, the type of surgery varies based on the cause of the fistula, its location, size, quality of the surrounding tissue as well as the patient’s medical history, said Dr Lau.
Dr Look explained that a small fistula that develops after childbirth may heal on its own with time with proper wound care and nutritional support.
“However, large fistulas can be difficult to manage and are best dealt with by an experienced colorectal surgeon. Surgery to repair the fistula may be required, and sometimes multiple surgeries may be necessary,” he said.
The symptoms can be distressing and stigmatising for women, who are also struggling to cope with the challenges of caring for a new baby. (Photo: iStock/kieferpix)
For patients with infected fistula sites, the first step often begins with controlling the infection.
For example, initial management for a patient with an infected obstetric fistula may include oral antibiotics and wound care. Some patients may be placed on a low-residue diet, which limits high-fibre foods to reduce frequency and amount of stools passed. This reduces the risk of the wound coming into contact with liquid stools.
“Any definitive attempt at surgical repair is usually deferred until all signs of infection and inflammation subsides,” said Dr Lau.
Dr Look said that around three in four patients will eventually heal completely following treatment. However, for women who have previously developed an obstetric fistula, a caesarean section is usually advised for subsequent births, added Prof Chong.
Dr Lau emphasised the importance of early detection and treatment. “Early detection increases the success rate of surgical repairs, before scarring of the surrounding tissues from repeated infections and inflammation set in,” she said.
CNA Women is a section on CNA Lifestyle that seeks to inform, empower and inspire the modern woman. If you have women-related news, issues and ideas to share with us, email CNAWomen [at] mediacorp.com.sg.
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These symptoms are what a woman in Singapore experienced after a childbirth injury that was in the news earlier this month.
The incident raises a question: How can these deeply distressing symptoms develop after childbirth? The faecal leakage can go on for months after childbirth and the patient has no control over it. Nor can she stop it.
In general medical terms, a fistula refers to an abnormal connection between two body parts or structures, said Dr Melvin Look, consultant surgeon and director of PanAsia Surgery.
An obstetric-related fistula is an abnormal opening that forms between the birth canal and the rectum, anal canal or urinary tract, due to childbirth trauma. This can cause faecal matter and gas to leak into the vagina.
For example, a rectovaginal fistula forms between the rectum (lower part of the large intestine where stools are stored) and the vagina. An anovaginal fistula forms between the anal canal (which connects the rectum to the anus) and vagina. Both types of fistulas may develop as a result of childbirth-related injuries.
The rectum, anus and vagina are distinct structures but are close in proximity. (Photo: iStock/nmfotograf)
Dr Look explained that while the lower part of the intestine – the rectum or anus – and the vagina are anatomically distinct, they are close in proximity.
“The vault of the vagina lies in front of the rectum, separated by elastic connective tissue. Although this tissue is usually strong, it is only a few millimetres thick and can sometimes be damaged by disease or injury,” he said.
CHILDBIRTH INJURIES: A COMMON CAUSE
A common cause of damage is an obstetric injury during natural childbirth. This can happen when a tear occurs during the delivery of the baby along the birth canal, said Dr Look.
A childbirth injury can happen when a tear along the birth canal happens during delivery. (Photo: iStock/Fly View Productions)
Dr Cheryl Lau, a senior consultant surgeon specialising in colorectal surgery, at Aeon Surgery, Colorectal Surgery and Endoscopy Clinic told CNA Women that a vast majority of obstetric-related fistulas are anovaginal fistulas. In developed countries, they are rare and occur in about 1 to 3 per 10,000 deliveries.
Globally, there are an estimated 100,000 cases of obstetric fistulas per year, according to Professor Christopher Chong, a urogynaecologist, obstetrician and gynaecologist at Gleneagles Hospital. However, he added that such cases are less common in Singapore and other developed countries.
WHO IS AT RISK
During childbirth, certain factors can increase the risk.
Prof Chong explained that the perineum – area between the vagina and anus – is generally shorter in Asian women, and the vaginal opening is small compared with the baby’s head.
“The foetal head coming through the vagina typically causes tears, which is why very often, especially for first delivery in Asian women, the obstetrician makes a cut called episiotomy (commonly away from the anus). This serves to deviate the tear away from the anus and minimise ragged and erratic tears,” he said.
However, an obstetric fistula can still occur due to complications, such as delivering a big baby, a baby with a large head, an instrumental delivery (for example, use of forceps), a very rapid labour or a prolonged one, or when the baby is delivered in a non-optimal position.
Delivering a big baby or a baby with a large head, rapid or prolonged labour, and poor healing of the episiotomy wound can increase the risk of obstetric fistula. (Photo: iStock/globalmoments)
Poor healing of episiotomy wound, especially if infection occurs, can also lead to the elastic connective tissue between the vagina and rectum or anal canal breaking down, said Prof Chong.
Dr Look said that tears that occur during childbirth are usually repaired by the obstetrician after the baby and placenta are delivered. However, surgical repair can be “complicated” when severe tears damage the rectum and anus, he added.
Prof Chong said that he sees an average of one to two cases of obstetric-related fistulas a year – usually referrals from other doctors. “In my own hands, I had one case in the last 20 years – a first delivery. The patient was repaired and was well, and went on to have a second baby – this time, by C-section”, he said.
OTHER CAUSES OF FISTULA
Colorectal surgeons also see rectovaginal and anovaginal fistulas
It can also happen in patients with severe infections and abscesses, or advanced inflammatory bowel disease, a group of intestinal disorders that cause prolonged inflammation of the digestive tract.
Dr Lau said: “It can also occur following difficult hysterectomies (surgery to remove the uterus), especially those performed for severe endometriosis.”
Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus, sometimes affecting nearby organs.
THE EMOTIONAL TOLL, SIGNS NOT TO BE IGNORED
For patients, the condition is “very distressing” as they have to deal with leakage of faecal matter into the vagina, said Dr Look. There is no telling how often it will happen; it can be a constant or intermittent leak of solid, soft or even liquid faecal matter.
“The fistula may also cause pain, especially during sexual intercourse. Sometimes, the symptoms can be very subtle if the fistula is a small one,” Dr Look added.
Symptoms of obstetric fistula include a foul-smelling discharge, faecal matter passing through the vagina, and pain, especially during sex. (Photo: iStock/Alina Prokudina)
Patients also struggle with stigma, which delays proper diagnosis and treatment. “Some affected patients believe their symptom is a result of poor hygiene and do not seek medical help,” said Dr Lau.
Usually, the first symptom is an abnormal, foul-smelling vaginal discharge. The characteristic symptom is the passing of gas or stool through the vagina, said Dr Lau. This happens because the abnormal tract allows faecal matter or gas to pass from the anal canal into the vagina.
Sometimes, there may be recurrent vaginal or urinary tract infections, or irritation and swelling at the vagina and perineum. This is due to bacteria contamination from stools, she explained.
Dr Lau advised seeking medical attention if any of these symptoms occur. “If it's left untreated, recurrent infections from these abnormal tracts can lead to tissue damage at the perineum – or worse, sepsis and incontinence,” she warned.
HOW OBSTETRIC FISTULA IS TREATED
Treatment for obstetric fistulas may look different from patient to patient. When surgical repair is required, the type of surgery varies based on the cause of the fistula, its location, size, quality of the surrounding tissue as well as the patient’s medical history, said Dr Lau.
Dr Look explained that a small fistula that develops after childbirth may heal on its own with time with proper wound care and nutritional support.
“However, large fistulas can be difficult to manage and are best dealt with by an experienced colorectal surgeon. Surgery to repair the fistula may be required, and sometimes multiple surgeries may be necessary,” he said.
The symptoms can be distressing and stigmatising for women, who are also struggling to cope with the challenges of caring for a new baby. (Photo: iStock/kieferpix)
For patients with infected fistula sites, the first step often begins with controlling the infection.
For example, initial management for a patient with an infected obstetric fistula may include oral antibiotics and wound care. Some patients may be placed on a low-residue diet, which limits high-fibre foods to reduce frequency and amount of stools passed. This reduces the risk of the wound coming into contact with liquid stools.
“Any definitive attempt at surgical repair is usually deferred until all signs of infection and inflammation subsides,” said Dr Lau.
Dr Look said that around three in four patients will eventually heal completely following treatment. However, for women who have previously developed an obstetric fistula, a caesarean section is usually advised for subsequent births, added Prof Chong.
Dr Lau emphasised the importance of early detection and treatment. “Early detection increases the success rate of surgical repairs, before scarring of the surrounding tissues from repeated infections and inflammation set in,” she said.
CNA Women is a section on CNA Lifestyle that seeks to inform, empower and inspire the modern woman. If you have women-related news, issues and ideas to share with us, email CNAWomen [at] mediacorp.com.sg.
Continue reading...