Obstetric Urinary Fistulas in KwaZulu-Natal - What is the Extent of this Tragedy?

Background. This study describes the demographics and clinical characteristics of women with obstetric fistulas attending the urogynaecological unit at King Edward VIII Hospital (KEH); KwaZulu-Natal (KZN); South Africa. Method. A prospective clinical review of all women admitted with the diagnosis of an obstetric fistula at KEH from 1999 to 2003. Results. A total of 41 cases from the rural areas of KZN and the Eastern Cape were identified. The mean age was 29 years (range 15 - 51 years); and 21 were primi- gravidas; 14 of whom had unplanned pregnancies. All were from low socioeconomic backgrounds and had limited or no access to antenatal care; either due to their social cir- cumstances or to lack of health care facilities. The duration of labour was prolonged in all; there were 5 live births; and 2 neonatal deaths. Conclusion. Obstetric fistulas are still common in KZN and the Eastern Cape; and occur mainly in women from rural areas

Ventral pre-public herniation of bladder following incontinence surgery

Objective: Ventral pre-pubic herniation of the bladder through an incisional hernia is an uncommon condition and reports in the literature are confined to one or two cases. We describe nine patients who presented with this condition 1 to 5 years after undergoing Burch colposuspension operations for stress urinary incontinence [SUI]. Patients and Method: All patients developed the condition following Burch colposuspension operations for stress urinary incontinence. Their non-specific presenting symptom complex is described and emphasized. The incisional hernias were difficult to diagnose on initial clinical examination and easily missed; unless the patient was examined in the erect position with a full bladder. Lateral cystography was the definitive diagnostic imaging modality. CT findings were dramatic and informative but not essential for the diagnosis. On urodynamic investigation bladder pain and urgency on low volumes were found; but no abnormal contractions were seen. Cystoscopy was essential to exclude other intravesical pathology and the specific findings are described. As these patients had intractable bladder symptoms; surgical repair was performed. The anatomical defect in the anterior abdominal wall was always more extensive than anticipated and closure incorporating Prolene mesh and sutures was performed. Co-morbid vaginal prolapse was repaired 4 to 6 months later. Recurrent stress urinary incontinence in one patient was preferably treated with a transobturator suburethral tape. Results: Two patients developed recurrent incisional hernias within the first year. Our first patient who had a primary closure only; had a subsequent successful closure with Proline mesh. One other patient developed a recurrence in the upper part of the wound. The other patients were all symptomatically satisfied with their results at 6-month follow-up. The symptoms of bladder overactivity had reduced dramatically to satisfactory levels and clinically the repairs were secure. The subsequent vaginal repairs of their recurrent cystoceles and rectoceles in three patients seemed successful on short follow-up. The patient who had the transobturator suburethral tape placed is clinically continent. Conclusion: The condition is probably more common than realised and significantly under diagnosed. It should be considered and actively excluded in patients with symptoms of bladder irritability and pain after previous suprapubic incontinence or prolapse surgery. Surgical repair utilising Prolene mesh is recommended and co-morbid urogenital prolapse or recurrent stress urinary incontinence can be adequately treated 4-6 months later