1. Five year review of rectovaginal fistulas
at Addis Ababa Fistula Hospital
Professor Gordon Williams
Dr Habtemariam Tekle
Mary Venn

2. Introduction Incidence: 3.3% - 15%
Primarily caused by prolonged obstructed labour
No standard classification

3. Objectives To identify Aetiology Patient characteristics
Extent of rectovaginal injury
Patients requiring a colostomy
Outcomes

4. Methods 5 years retrospective data from 2004 –2009
Operation register & patient cards reviewed
Information recorded on a prepared questionnaire

5. Causes of Rectovaginal Fistula
Number (%)
Child birth
Mean duration of labour 3.8 days
282 (89.5)
Post coital
22 (7)
Accidents
8 (2.5)
Other
3 (1)
Total
315
210VD ,26CS, 12DD, 34ID
POSTCOITAL = 14
RAPE = 8
ACCIDENTS 8 INCLUDING OX INJURY,FALLACCIDENT,FIGHT,
OTHERS: ABORTION,LESION,HERBAL

6. Characteristics of All Rectovaginal Fistula
Type
High (35.2%)
Mid (28.6%)
Low (23.3%)
Circumferential (11.4%)
Combined (8.9%)
REPEAT COUNT(DOUBLE COUNT) = 351
ALL CIRCUMFERENCIAL DUE TO OBSTETRIC CAUSES = 36(97.2% following obstructed labour: 28 VD, 4 CS, 3 ID, 1 accident)

7. Characteristics of Obstetric Rectovaginal Fistula (N = 282)
Primiparous (70.9%)
Multiparous (29.1%)
Concurrent VVF (85.1%)
Position of fistula
High (38.3%)
Mid (31.2%)
Low (20.6%)
Combined (9.9%)
ALL CIRCUMFERENCIAL DUE TO OBSTETRIC CAUSES = 36(97.2% following obstructed labour: 28 VD, 4 CS, 3 ID, 1 accident)

8. Characteristics of Post-coital Fistula
N = 22
Parity
nulliparous
Age
Mean
Type
Low (90.9%)
3PRIMI, 4MULTI
Age range 8-60 years (NB 60 year old sustained injury aged 12) median and mode 23 years, mean 24.5 years, or 23.3 years excluding patients <16 and >30 years old
Position of fistulae; 90.9% low (n=20) 1 mid (4.5%) 1 high (4.5%)

9. Associated Injuries N = 315 Stricture 6 (2%)
Concurrent VVF (77.5%)
Concurrent tear (6%)
None (14.5%)
6 strictures, all following obstructed labour, all with VVF. All with high fistulae, half circumferential, same half had colostomy. 5 cures at first attempt, remaining pt died of sepsis.
Concurrent VVF240 caused by obstructed labour, 1 rape, 3 accidents

10. Colostomy Colostomy 67 (21%) Colostomy not closed: 6 AAFH: 51
Elsewhere: 16
Needed revision: 2
Time from opening to closure of colostomy: 5 months
Colostomy not closed: 6
Lost to follow up: 3
RVF not closed: 2
Patient died: 1
Aetiology: 47 VD (70.1%) 10 CS 2 DD 5 ID 2 post-coital 1 accident
Positions: 43 high (64.2%) 5 mid 4 low 8 mid-high 7 mid-low
Circumferential: 24 Yes (35.8%) 43 No (64.2%)

11. Cure & Surgical Technique: First time surgery
Single layer closure 9/14 Two layer closure 245/261 Abdominal approach 1/1 End to end anastomosis 16/21 Unspecified 5
Total cure at 1st repair =276

12. Outcomes Overall closure success 294 (93%) 1st operation 276 (88%)
2nd operation
3rd operation
4th operation
7th operation
Breakdown of Operation 1 Sub-optimal Outcomes(n=39)
27 first ops were broken  11 cured at second op, 2 at third, 1 at fourth, 1 at seventh, =15
9 no f/u after first failed op, 1 no f/u after 4x failed attempts, =10
1 never closed after 6 attempts at AAFH, 1 pinhole after three ops
2 first ops repaired BUT pinhole remained after first op
5 first ops abandoned  1 closed at second op, 1 at third,
3 holes remained (not re-attempted)
1 RVF repaired but incontinent, required perineal reconstruction then cured after second op
2 RVF closed but poor sphincter tone, leaking
1 pt died
1 no f/u

13. Outcomes of Concurrent VVF in Patients with RVF (N = 240)
Closed at 1st attempt 169 (70%) Broken 63 Abandoned 6 Died 1
Concurrent VVF in 240/282 obstetric cases (85.1%)
Only 169 VVF closed at first attempt (70.4%)
66 closed and dry
45 closed, mild stress
29 closed, moderate stress
18 closed, severe stress
2 closed, urge incontinence
2 closed, mixed incontinence
7 urine retention, self-catheterisation
63 broken
6 abandoned, 2 other (1 patient died, 1 patient’s ureter could not be re-implanted at initial op, dry following later re-implantation)
NB of the 4 non-obstetric VVF, all closed and dry. Total rate of VVF closure at first attempt 70.9%.

14. Outcomes for Colostomy Patients
Cured
1st operation (77%)
2nd operation
3rd operation
7th operation
No Follow up
Pin hole remained
Could not be repaired
Died

15. Conclusions
RVF is mainly caused by childbirth and long duration of labour in primiparous
Patients who had colostomy had an obstetric cause & were high & circumferential RVF’s
Patients with concurrent VVF & RVF had less success
Standard classification needed for prediction of outcome
Criteria for colostomy have to be settled