CHARACTERIZING URINARY INCONTINENCE AFTER OBSTETRIC FISTULA REPAIR: - - PowerPoint PPT Presentation

CHARACTERIZING URINARY INCONTINENCE AFTER OBSTETRIC FISTULA REPAIR: THE UGANDA EXPERIENCE

Rahel Nardos, MD, MCR, FPMRS Oregon Health& Science University/ Kaiser Permanente Northwest

DISCLOSURE

• I have no relevant financial relationships to disclose

BACKGROUND

• Uganda has one of the highest prevalence of obstetric vesicovaginal

fistula in the world, estimated at 2.6% (1)

• Many women continue to have persistent incontinence after their

fistulas have been successfully closed

• Estimates of persistent incontinence range from 7-40% (2-3)
• The etiology of persistent incontinence is likely multifactorial

1. McCurdie FK, Moffatt J, Jones K. Vesicovaginal fistula in Uganda. J Obstet Gynaecol. 2018;38(6):822-827. 2. Browning, A., & Menber, B. (2008). Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment. BJOG : An International Journal of Obstetrics and Gynaecology, 115(12), 1564–9 3. Gutman, R. E., Dodson, J. L., & Mostwin, J. L. (2007). Complications of treatment of obstetric fistula in the developing world: gynatresia, urinary incontinence, and urinary diversion. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 99 Suppl 1, S57–64

OBJECTIVE

• Characterize persistent urinary incontinence after fistula
• Type
• Severity
• Assess the impact of post-fistula incontinence on
• Quality of life
• Psychological wellbeing
• Raise awareness to the ongoing chronic medical needs of obstetric fistula

patients.

METHODS

• IRB obtained from Makerere University and Oregon Health & Science University
• Enrolled women ages 18-80 with a history of obstetric fistula
• With persistent incontinence (Cases: N=36)
• Without persistent incontinence ( Controls: N=52)
• Data collected from patients in Central and Eastern Uganda from 2017-2019
• Project conducted in partnership with Terrewode, an NGO in Uganda that provides post-fistula

reintegration program.

• Exclusion Criteria: current pregnancy or obstetric fistula

ASSESSMENT TOOLS

• Semi-structured questionnaire
• Demographics
• Psychological, medical, economic and treatment seeking behavior
• Severity of incontinence assessed using:
• Post-Fistula Incontinence Severity Scale (PFISS)
• International Consultation on Incontinence Questionnaire Short Form

( ICIQ-SF)

• 2-hour Pad test
• Bladder diary : Color coded paper strips
• Impact on quality of life assessed using:
• ICIQ-QOL
• Exam: Dye test and Cough stress test

1 2 3 4 5 6 7

METHODS

RESULTS

Demographics Controls (n=52) Cases (n=36) P-value Age 30.32 ± 9.86 34.68 ± 11.82 0.06 Age at first Marriage 17.50 ± 2.81 17.51 ± 2.57 0.98 Age at first Delivery 18.13 ± 2.35 17.68 ± 2.80 0.42 Age at first fistula 24.78 ± 7.46 20.28 ± 5.84 0.003 Number of fistula surgeries <2 >2 51 (98%) 1 (2%) 13 (36%) 23 (64%) 0.001 No of Deliveries before fistula None >1 19 (37%) 33 (63%) 22 (63%) 13 (37%) 0.02 Marital status Married Widowed/Separated Never married 30 (58%) 15 (29%) 7 (13%) 15 (42%) 19 (53%) 2 (5%) 0.08

RESULT

Type of incontinence Stress 67% Urgency 47% Mixed 71% Post-void dribbling 31% Leaks all the time 53%

• Clinical assessments
• 97% of cases had positive cough stress test
• 86% of cases had 2 hour Pad weight of >4

grams

• Bladder diary
• Average leaks/day: 20
• Average bladder capacity : 150ml
• Average voids/day: 13.6

RESULTS

• Significant psychological burden
• 33% of controls and 42% of cases have had frequent suicidal ideation
• 8% in each group ( cases and controls) have attempted suicide
• 17% of controls and 25% of cases have had plans for suicide
• Severe urinary incontinence
• 83% Cases perceived their incontinence to be severe (ICIQ-SF 13-18) or very severe ( ICIQ-

SF 19-21).

• Moderate positive correlation between ICIQ-SF and PFISS (cc =0.47)
• Significant Impact on quality of life
• Mean ICIQ-QOL score of 62.8+12.8 (scores normally range from 19-76)
• Moderate positive correlation between ICIQ-SF and ICIQ-QOL (cc=0.60)

CONCLUSION

• Persistent incontinence after obstetric fistula is associated with
• A younger age at first fistula
• A history of more than two obstetric fistula
• Most post fistula incontinence is mixed (71%), characterized by urgency (47%) and stress( 67%)

incontinence.

• Women who have persistent urinary incontinence after fistula have severe incontinence that has

high negative impact on their quality of life and psychological wellbeing.

• Our model of Obstetric fistula care should be expanded to address the more chronic and

debilitating medical condition of persistent incontinence

LIMITATIONS

• Unable to make clinical correlations such as stage of fistula, surgical

history, obstetric history etc.

• Not able to perform more complex bladder evaluations such as

urodynamics

ACKNOWLEDGEMENT

• Worldwide fistula fund
• OHSU Global Health Student Fund
• Terrewode ( Fistula Reintegration Program in Uganda)
• Alice Emasu, MSW
• Bonnie Ruder, PhD
• Katie Cobb