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How Events That Occur Before Birth and in Early Life Influence the Development of a Vesicovaginal Fistula (Vvf) -Part I

Updated on May 23, 2020
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Chioma is a Medical Doctor and Public Health practitioner based in Gombe state Nigeria, with years of experience working in rural settings.

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Introducing the "Life Course Perspective" of the Vesicovaginal Fistula (Vvf)

Ever wondered if the sum total of a person's actual experiences were the result of a sequence of socially defined roles, events and decisions that an individual makes over time? Well, it is possible to examine an individual's life history and from it deduce how events before birth and in early life influence future choices, events and even the development of disease.This is known as the life course perspective, also referred to as the life course approach or life course theory (I'll be using these terms interchangeably). In this article which is the first of a two part series; we'll be laying the ground work for the analysis of the life course perspective of the VVF which we will study in detail in part two of this series.

Ever wondered if the sum total of a person's actual experiences were the result of a sequence of socially defined roles, events and decisions that an individual makes over time? Well, it is possible to examine an individual's life history and from it deduce how events before birth and in early life influence future choices, events and even the development of disease.

Getting Started

To get a head start on this topic, we need to be clear on some terminologies and understand why the VVF is fit to be looked at from a life course perspective. When reading various literature on VVFs, you may notice a number of terminologies being used interchangeably; these include: “vesicovaginal fistula”, “obstetric fistula” , “genitourinary fistula” or simply just “fistula”. Given that our focus is on VVFs that result specifically from obstetric events; it is imperative that we make a clear distinction between each of these terms.

Definition of Terms

Fistula: This is an abnormal connection between two hollow organs.

Obstetric Fistula: An abnormal opening between a woman’s genital tract and her urinary tract or rectum.

Genitourinary Fistula: Sometimes referred to as a urinary fistula, is an abnormal connection or passageway between the urinary and genital structures.

Vesicovaginal fistula: An abnormal opening between the bladder and the vagina that results in uncontrollable leaking of urine through the vagina.

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How Common are They?

VVFs although once common in Western Europe and the United States, are generally more prevalent in developing countries where most cases are as a result of injuries sustained during childbirth.The difference in prevalence is not merely because of the efficient and effective systems of maternity care that provide access to emergency obstetric services for women who develop complications during labor; but also because of the shift of these industrialized nations from the determinants that lead up to the development of the VVF.

VVFs although once common in Western Europe and the United States, are generally more prevalent in developing countries where most cases are as a result of injuries sustained during childbirth.

Etiology/Cause of Vesicovaginal Fistulas (Vvfs)

VVFs chiefly result from obstetric and operative injury, malignancy, radiation, trauma, and infections.They are rare in developed countries were they arise as complications of either radiation therapy and/or surgery. However, in developing countries, it is the commonest type of genitourinary fistula, with eighty to ninety percent of VVFs resulting from obstetric injury. In this article, we are focused on the life course approach of VVFs that are a sequel to prolonged obstructed labor; or in other words the “obstetric fistula” (given its obstetric cause) which has a rich history of events that culminate in its occurrence and hence can be addressed from a life course perspective.

Vesicovaginal fistulas chiefly result from obstetric and operative injury, malignancy, radiation, trauma, and infections.

Brief Historical Background

It would be impossible to discuss the life course perspective of the vesico-vaginal fistula without a brief look into the historical background of this condition.The wealth of history that underlies the obstetric fistula is absolutely breathtaking.The oldest evidence of a VVF is found in the remains of Queen Henhenit, the wife of Egypt’s ruler around 2050 BC. An extensive anatomical review found a defect in the bladder communicating directly with the vagina. A closer examination also indicated that the pelvic bone was abnormal in shape, approximating that of apes, and considering the width of the pelvis; the examiner believed that it was too narrow to allow the passage of a fetal head. It has been hypothesized that the severe damage to Queen Henhenit’s bladder and vagina occurred at the time of parturition likely resulting in her death. As it has been noted: “to Queen Henhenit belongs the dubious honor of having suffered the most antique vesicovaginal fistula documented.”

The oldest evidence of a VVF is found in the remains of Queen Henhenit, the wife of Egypt’s ruler around 2050 BC. As it has been noted: “to Queen Henhenit belongs the dubious honor of having suffered the most antique vesicovaginal fistula documented.”

Early Analysis of Vesicovaginal Fistulas (Vvfs) Within Structural, Social and Cultural Contexts

In the 11th century, the Arabo-Persian Physician named Avicenna was the first individual to make a connection between obstructed labor and vesicovaginal fistulas.Though not following a conceptual framework, in an attempt to achieve the aforementioned, Avicenna unwittingly pointed out a determinant in the life course approach of this condition. He noted that “In cases which women are married too young, and in patients who have weak bladders, the physician should instruct the patient in ways of prevention of pregnancy. In these patients the fetus may cause a tear in the bladder that [will] result in incontinence of urine.The condition is incurable and remains so until death.”

It is interesting to note that though a physician, Avicenna actually looked beyond the scope of his field to discover a determinant which he believed to be critical to the development of the vesicovaginal fistula -"women who marry at an early age"; that he mentions it first before what was clinically obvious - “the weak bladder” in women he examined. This in my opinion is remarkable and probably the first attempt at a life course perspective of the vesicovaginal fistula.

Portrait of Ibn Sina or Avicenna (980–1037 CE). 
Portrait of Ibn Sina or Avicenna (980–1037 CE).  | Source

In the 11th century, the Arabo-Persian Physician named Avicenna was the first individual to make a connection between obstructed labor and vesicovaginal fistulas.

Closing Remarks

In part two of this series, we will take an in depth look at the VVF from a life course perspective. Here we will consider the long term effects of physical and social exposures on the risks of VVFs before an individual is conceived, right until adolescence. We will also discuss the biological, behavioral and psycho-social pathways that operate across lineages and an individual’s life to influence the development of a VVF.

Finally, in this article, we focused primarily on enhancing our general understanding of VVFs and associated terms. By providing a brief structural, social and cultural context to VVFs; I am hopeful that persons who are familiar with the clinical aspect of this disease condition are gaining a broader perspective of the disease. For those who are not familiar with VVFs, or have never heard of them, now is a great time to do your own research.

Sources

    1. Cron J. Lessons from the Developing World: Obstructed Labor and the Vesico-vaginal Fistula. Medscape General Medicine. 2003; 5(3).
    2. Wall LL, Arrowsmith SD, Briggs ND, Browning A, Lassey A. The Obstetric Vesicovaginal Fistula in the Developing World.
    3. Homaira R, Khatun S. A Study on Different Surgical Methods Used for Repair of Vesicovaginal Fistulas in Dhaka Medical College Hospital. Medicine Today. 2010; 22(01):12-14.
    4. Dutta DC. Obstructed Labor. In: Konar H, editor. Textbook of Obstetrics. 5th ed. Calcutta: Central Book Agency, 2001:434-436.
    5. Moir JC. Vesicovaginal Fistula as Seen in Britain. J Obstet Gynaecol Brit Commonw. 1973; 80:598-602.
    6. Langkilde NC, Pless TK, Lundbeck F, Nerstrom B. Surgical Repair of Vesicovaginal Fistulae: A ten-year Retrospective Study. Scand J Urol Nephrol. 1999; 33:100-3.
    7. Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv. 1995; 51:568-574.
    8. Shlomo YB, Kuh D. A Life Course Approach of Chronic Epidemiology: Conceptual Models, Empirical Challenges and Interdisciplinary Perspective. International Journal of Epidemiology. 2002; 31:285-293.
    9. UC Irvine, Department of Urology. Genitourinary Fistula.
    10. World Health Organization (WHO). Obstetric Fistula.
    11. Michael S, Constantina S,Theodora S, Konstantinos K. Vesicovaginal Fistula: Diagnosis and Management. Indian J Surg. 2014 Apr; 76(2): 131–136.
    12. Diana K, Yoav B. A Life Course Approach to Chronic Disease Epidemiology. Oxford: Oxford University Press. 1997

    13. Janet ZG, Glen H.E Jr. Methods of Life Course Research: Qualitative and Quantitative Approaches, Sage Publications 1998.






This content is accurate and true to the best of the author’s knowledge and is not meant to substitute for formal and individualized advice from a qualified professional.

© 2020 Ejeagba Chinonso Chioma

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