The latest obstetric fistula research summarized for you in one place.
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November 2017


Fistula Research Update


Presented by Texas Children's Hospital® Global Women's Education, Research and Care Program

Patients at the FfFF Fistula Care Center, Lilongwe, Malawi. Photo Credit: Smiley Pool
Welcome back to the Fistula Research Update! This newsletter is created for researchers, fistula surgeons, medical providers, nurses, social activists and advocates. We hope that it is shared widely and that it will help us all to reach the collective goal of ending fistula.
-Editors Rachel Pope, MD, MPH & Jeffrey Wilkinson, MD  
Baylor College of Medicine 
Texas Children's Global WERC
This edition has many exciting new publications on a wide variety of OF care topics. We have expanded our editorial team, so be sure to check out their profiles below. We will begin with surgical optimization, and end with social reintegration and the effects on families. We hope you enjoy our review! /rp

     This paper by Shepherd et al. focused on a hypothesis that fistula patients with HIV have poor surgical outcomes with high cases of complications. The paper finds that VVF outcomes for the HIV-positive group differed from the HIV-negative group but not for ureterovaginal fistula and/or RVF. Among all VVF surgeries, those in the HIV-positive group were more likely to have a failed repair than those in the HIV-negative group.  It further grouped VVF into high, low and large. Among surgeries for large VVF, women in the HIV-positive group were more likely to have failed repair than those in the HIV-negative group and low VVF did not demonstrate a failure by HIV status but the likelihood of achieving continence was lower among HIV-positive women than HIV-negative women. In conclusion, HIV influences the outcomes of OF surgical repair and closure of fistula is more likely to fail among HIV-positive women with VVF. –Sperecy Chigwale
Future studies including viral loads and/or CD4 counts in relation to outcome could be useful for optimizing patients prior to surgery. /rp

    Our research group has published on our experiences using a fasciocutaneous flap maintaining its vascular supply in vaginal reconstruction for women with obstetric fistula and vaginal stenosis. We found that the use of the Singapore flap was not only safe and possible in a low-resource setting, but also resulted in functional outcomes for our patients. After the postoperative healing, women used silicone dilators and while most of the patients previously experienced sexual dysfunction, those who have become sexually active do not. This small cohort of work is a result of collaboration between gynecological surgeons and plastic surgeons at our institution. Plans are to evaluate a larger sample of patients in the future. /rp
     Browning et. al. also expound upon the utility of the Singapore skin flap as a way to restore vaginal elasticity. They describe the “Integral Theory,” that scarring creates an oppositely-acting force on the urethra, keeping it from closing and functioning normally. Therefore, the skin flap reduces this force in patients with Goh type 4 cases, specifically, 46% (n=45) patients gained continence compared to an expected 19% for this population. /rp
While much research remains to be done in terms of skin and muscle flaps for improving outcomes for fistula patients, the Singapore flap appears to be one of the most promising surgical techniques in a long time to complement routine fistula surgery.  /jw

Raassen and colleagues perform a retrospective review of ureteral injuries following obstetric and gynecologic surgeries in Africa and Asia. This is essentially a descriptive study, but the largest one in the literature addressing this topic in low resource settings. Most of the injuries occurred after obstetrical surgery.  Most injuries occurred in the left ureter but occasionally in both ureters.  Women in the obstetrical surgery injury group were younger and waited longer for their repair.  There was a high success rate for treatment of the ureteral injuries, despite these being repaired in low resources settings.  The authors discuss a number of potential factors that may impact the formation of ureteral injuries at the time of obstetrical or gyecological procedures.  

Raassen and colleagues examine findings from a large series of women with ureteral injuries in low resource settings.  Their results are not unexpected and the teaching points highlighted in the paper are worth noting, specifically, the importance of careful technique, independent of the setting. /jw
Ekwidgwe et al. performed a retrospective analysis on 133 patients in a one year period between 2015-2016. Patients with RVF or requiring high doses of analgesia were excluded from the study. Of the cohort, 45.1% of patients experienced post-surgical bladder spasms. Bladder spasms were associated with fistula repair (p=0.044); in other words, patients with an unsuccessful fistula repair were more likely to have bladder spasms (68.4%). The authors suggest two theories - 1) bladder spasms can may result in poor surgical outcomes, or 2) breakdown in the suturing site result in bladder spasms. However, this paper only suggests a correlation between bladder spasms and fistula repair outcomes and the data does not prove causation. 
    Patients with bladder spasms were treated with anticholinergic drugs (hycosine and tolterodine) for a maximum of 9 days; all cases of spasm resolved prior to discharge. Given the high incidence of bladder spasms after fistula repair, and the need for continuous bladder drainage with a urinary catheter, it is reasonable to prophylactically use anticholinergics for the prevention of bladder spasms. -Olivia Chang
This study should encourage a randomized controlled trial which would examine anticholinergics vs placebo in post-operative fistula patients. /jw

A nurse-delivered mental health intervention for obstetric fistula patients in Tanzania: results of a pilot randomized controlled trial
Researchers in Tanzania (Watt et al.) conducted a pilot feasibility randomized control trial of a psychological intervention to improve mental health for obstetric fistula patients – the first of its kind to test a specific mental health intervention in fistula patients.  Over a 2-year period, patients admitted for fistula repair were randomized to either a standard of care control arm or a treatment arm, which included six individualized psychotherapy sessions conducted by a trained nurse facilitator.  Both groups received pre-operative and pre-operative mental health assessment, and 85 % of women met criteria for mental health dysfunction at enrollment. Overall, the intervention was positively received by participants, and was well-integrated and faithfully administered by the trained nurse facilitator.  Post-treatment assessment demonstrated improvement in depression, anxiety, and PTSD measures.   
    As a feasibility study, however, there were not enough participants to determine whether the intervention had a significant effect in improving mental health beyond surgical repair of the fistula and the standard of care, and a larger-scale RCT will be needed to determine this. Finally, as previous studies have indicated, mental health outcomes may be largely determined by the success or failure of the repair to cure incontinence.  A larger trial should consider whether additional interventions would particularly benefit such women with unsuccessful surgeries. -Mary Stokes
Compared to the ‘standard of care’ for mental health in women with obstetric fistula, one could imagine many interventions that could be helpful.  In any other setting where someone had experienced the degree of trauma and loss that fistula patients experience, the need for mental health interventions would be assumed.  This will certainly involve further study on which interventions are most helpful and inevitably these will need to be individualized to patients according to their specific problems. /jw

Reintegration of Women Post Obstetric Fistula Repair: Experience of Family Caregivers

Although OF can be surgically corrected, life beyond the repair can have intense emotional, social, and economic ramifications for women and their families. Family support is essential to assist women in reintegrating. A critical ethnographic study conducted by Jarvis et al, which explores a culture of reintegration in Ghana found out that many family members expressed a sense of relief and joy once a woman with OF was successfully treated and returned home. A woman recovering from an OF repair and reintegrating might be exempt from her family and social responsibilities, thus displacing her duties on other family members.
    The psychological distress for family members who provide care and support for persons recovering from OF can be overwhelming. Economic hardship and financial strain occur because the physical restrictions needed for recovery and the subsequent limitations in contributing to family life and resources. Many families post OF are increasingly impoverished because of the cost incurred in seeking treatment, and the loss of an income earner within the family. Family members expressed feelings of shame and remorse during reintegration. Many family caregivers along with the women they cared for post OF repair were transitioning from dealing with a chronic condition to a phase of rehabilitation and reintegration. In addition, family caregivers who were husbands or partners commented that they felt emotionally disconnected from their wives because health care providers advised couples to abstain from sexual intercourse for 3 to 6 months after OF repair. Support for family members who care for women post OF repair in Ghana should be directed toward encouraging women and families to set realistic reintegration goals and expectations, and to be engaged in discharge planning prior to returning home post OF repair. -William Nundwe
Due to the nature of OF repair, families are often left out of the equation. This study offers a compelling argument to make an effort to include family to assist women with OF reintegrate. /rp
New Members of the Research Team:
Olivia Chang is an OB/GYN junior faculty member newly stationed in Lilongwe. She manages an obstetric emergency program and is also training in obstetric fistula care as she plans to go on to a fellowship in Female Pelvic Medicine and Reconstructive Surgery.
Sperecy Chigwale is a new research assistant with our team. Having recently completed a degree in medical anthropology, she brings a unique perspective of culture and healthcare to the group.
William Nundwe is our senior research assistant, who has traversed Malawi, interviewing women with obstetric fistula and has witnessed long-term outcomes after surgery.
Mary Stokes is an OB/GYN global women’s health fellow in Malawi coming to us from Miami, Florida. She is busy with clinical work preventing fistulas and learning how to repair them.
Special thanks to Freedom from Fistula Foundation  

and One By One
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