Healthcare Delivery Systems in Rural Areas

*Ankeeta Menona Jacob*

#### **Abstract**

Health care is a fundamental right of every human being. About half of the world's population (An estimated 3.4 billion of the world's 7.6 billion in 2018) lived in rural areas. Individuals in rural areas often have poor access to healthcare because of poor accessibility and availability of standard healthcare systems and socio-cultural factors affecting their perception of health compared to the urban population. Though there is a projected decrease in the absolute percentage of the world's population dwelling in rural areas by 2050, there is also a projected increase projected increase needing of prioritizing rural health. This chapter shall discusses the critical factors that disadvantage the rural population. It also considers the methods used to work out rural healthcare delivery strategies to decrease this disparity in rural areas' health care facilities.

**Keywords:** Rural Health services, Telemedicine, Health services accessibility, Telemedicine, Health Policy

#### **1. Introduction**

Healthcare is a fundamental right of every human being and everyone's responsibility [1]. When healthcare is viewed as a right and a responsibility, the state's active role in maintaining its people's health becomes even more pro-active more pro-active. This remedies the often-neglected individual's responsibility toward his/her health. There has always been an inverse distribution of healthcare services in rural when compared to the urban population, which is often referred to as the inverse care law or Pareto's Law. Pareto's law of distribution applied to healthcare (according to the British General practitioner Julian Hart in 1971) hypothesized that those in the greatest need of medical services in healthcare get the lowest quality possible healthcare and at the very end [2].

The term rural population also differs from country to country and is defined by the country's statistical office. In 2019, the world bank estimated that about 3,397,467,990 individuals were residing in rural areas globally. However, the global increase in rural population has been less than 1% per annum [3]. Even though these population growth rates in rural areas are minuscule there is also a projected increase in population. The existing deficiencies in the healthcare delivery system rural areas will only compound the problems with further urbanization and the healthcare policies favoring healthcare privatization [4]. There is also a growing need to create rural communities which are healthy and at par with healthcare facilities in urban areas [5]. Therefore, prioritizing rural health is imperative and will be a dire necessity for the future.

#### **2. Definitions in rural healthcare**

Rural healthcare delivery systems are often deficient in human resource, infrastructure structure, equipment, and financial support. These are essential to provide quality clinical and community healthcare services to the population they cater to. Some countries define healthcare services provision in areas (or communities) that are at a distance of more than 80 km or more than one hour by road from a designated healthcare facility (providing round the clock anesthesia, surgical and obstetrical facilities) [5]. This phenomenon, however, is relative to urban healthcare delivery systems and not an absolute absence of healthcare facilities. The services providers in rural areas are mainly the state or the government. The rest of the health care providers in rural regions are primarily indigenous systems of medicine with or without formal training in healthcare provision.

Remote healthcare is a term often used interchangeably with rural healthcare. Remote healthcare refers to hard to reach areas geographically. This happens mainly in the rural areas where access via roads are challenging [5, 6]. These areas may benefit from a remote health monitoring system, especially for health conditions and diseases that need long-term healthcare. These regions, however, would be significantly helped by the use of Telemedicine, given information and communication technology widely available. Whenever access to healthcare for an emergency or serious condition is required, these remote areas would need referral-service access to a secondary or a tertiary healthcare facility.

Rural Healthcare access is the ability of rural communities (or individuals residing in such communities) who can be promptly approached for health promotive, preventive, curative, and rehabilitative services. This works on the tenets of availability, utility, acceptability, feasibility, and equitability [7].

Barriers to healthcare access are systematic hindrances that may interfere with access to healthcare systems. In rural health systems, they could be broadly classified as structural (Infrastructure, human resources and time-related inadequacies), financial (leading to catastrophic expenditures, unaffordability of medical aid, or lack of completeness in treatment due to inability of money) or personal or socio-cultural (Physical and/or physiological hindrances, sociocultural inappropriateness) [8].

Social Acceptability of rural health services may be defined as the individual's subjective-attitudinal perception of health care service provision and providers [9]. Acceptability may also refer to the pertinent interaction and client satisfaction accompanying service provision in the socio-cultural context of the rural areas [10].

#### **3. History of rural healthcare delivery systems**

**China:** An excellent example of a rural healthcare delivery system was the "Barefoot doctors" of China. In 1965 Urban doctors trained young farmers in Shanghai's Chiang Chen Province in primary medical care. These later formed the backbone of China's medical aid services [11, 12]. After a training period of three to six months and regular skill up-gradation with in-service and apprenticeship programs, these part-time healthcare providers. The healthcare provision in these areas enjoyed the local Chinese population's support [12]. They were trained in preventive, promotive, and rehabilitative healthcare provision in traditional Chinese and Modern (or Western) Medicine, alongside providing medical care. These part-time healthcare providers, also developed a robust system for referral for complex medical and surgical cases to a secondary or tertiary healthcare facility [4]. The financial support for such healthcare providers was both from a collective and mutual aid

#### *Healthcare Delivery Systems in Rural Areas DOI: http://dx.doi.org/10.5772/intechopen.98184*

basis. However, in 1978 major health reforms in China heralded a new breed of barefoot doctors to medically more qualified "Village health Doctors" and medically lesser qualified "rural health workers" (through an annual assessment) that led to the downfall of this system [13].

The financial moratorium also changed from a collective and mutual aid basis (through a rural cooperative medical system) to a paid service model. The new system in China rolled back many positive health reforms. These reforms included reduced mortality, improved life expectancy for almost three decades and most importantly widening the already existing urban and rural health disparity [14].

**India**: The concept of Community Health Worker (C.H.W.) was introduced under the "National Village Health Guide Scheme" much before the idea of primary Healthcare (through the Alma Ata declaration at Kazakhstan in 1978) was proposed [15]. However, lack of affiliation to a formal health system, poorly defined job responsibilities, and poor financial remuneration plagued the Village Health Guide scheme's success.

In India, maternal and child health, especially midwifery and childbirth assistance, was mainly through the "Traditional Dai" system. However, lack of formal training in midwifery and safe delivery practices led to significant mortality and morbidity among mothers and infants. Training of these traditional birth attendants in 2006 under the National Rural Health Mission (NRHM) was an essential step toward providing trained birth assistance and improving mothers and newborn health in rural areas.

The paradigm shift in India's healthcare provision was through the National Rural Health Mission effort in health activism through ASHA (Accredited Social Health Activist). Through local community participation, an ASHA worker proficient in various aspects of preventive, promotive, rehabilitative services largely concentrated in maternal and child health through local community participation. The ASHA worker also collaborates with local rural bodies to improve health, sanitation, and nutrition in India's rural communities, a bottom-up approach [16].

The healthcare system in India had stressed the need for primary healthcare right from the pre-independence era (The Joseph Bhore Committee report in 1946) [17]. The Health Survey and Development Committee report (or the Bhore Committee Report) laid down the blueprint for a three-tier system to deliver healthcare at centers in India before the first national health policy, in the year 1983. The unique nature of the Indian healthcare sector is the blend of traditional(commonly called the AYUSH system- made up of Ayurveda, Yoga, Unani, Siddha and Homeopathy medicine) and allopathic medicine that is made available through a myriad of public and private healthcare providers. However, these healthcare services are also negatively skewed toward the rural areas where more than 60% of the population resides.

The three-tier healthcare system is divided into the primary or first point of contact of healthcare through the sub-centers that cater to a population of 3000 to 5000 [17]. The sub-centers are then linked to the Primary Health Centers (P.H.Cs.) established in the rural and urban areas for a population of 30,000 in plains and 20,000 in hilly and tribal areas. The first point of referral for the Primary health centers in the Community Health Centers (C.H.C.) is set up for every 1,20,000 population in plain areas. Every 80,000 people in hilly, tribal areas form the second tier of the public health system in India. The third tier of healthcare providing tertiary healthcare is the First Referral Units (F.R.U.)s that are set up at district or sub-district levels with round- the-clock services for healthcare. These public healthcare centers were plagued with human resource and infrastructural deficiencies. They suffered a vital mechanism for referral of patients and follow-up from higher level healthcare centers, with less than 11.5% seeking healthcare at these centers [18]. However, the private

healthcare sector and the non-governmental healthcare agencies also contribute to addressing the population's healthcare needs. Because of financial and other infrastructural strengths, these healthcare facilities are often beyond the reach of many, especially in rural areas [18]. Under the country's National Health Mission (N.H.M.), through the National Health Policy of 2017, recommended the establishment of "Health and Wellness Centers (H.W.C.)" for delivery of Comprehensive Primary Healthcare (CPHC) by up-gradation of sub-centers and Primary Health Centers as shown in **Figure 1**. The deficiencies seen in the implementation of rural healthcare seen earlier would now be overcome by improved spending to up to 70% of the budgetary allocation, institutional and governmental mechanisms under the flagship of National Health Mission (N.H.M.) for Primary Health care for Universal Health Coverage (UHC) in India and the Pradhan Mantri Jan Arogya Yojana (PMJAY).

**Australia:** The Australian Whitlam Labour government in 1972 pioneered setting up policies for the rural and remote regions of Australia, especially those residing in Australia's suburban areas. The Hawke Labour government of 1982 renewed its commitment to healthcare services' access and equity in Australia's remote and rural areas. The national conference at Toowoomba to design and set up a policy of initiatives for rural health in the late 1980's paved the way for the National Rural Health Strategy of 1994 that the Australian Health Ministers Council promulgated.

**Figure 1.**

*Re-organization of public healthcare facilities for Rural India under the Ayushman Bharath scheme in India [18].*

#### *Healthcare Delivery Systems in Rural Areas DOI: http://dx.doi.org/10.5772/intechopen.98184*

The National Rural Health Strategy through the RHSET programme, the Rural Incentives Program and the collective efforts of the doctors, nurses, Allied health professionals' associations worked toward healthcare service delivery in the remote and rural areas of Australia along with a Non-governmental rural health body called the National Rural Health Alliance. Although these efforts were primarily focused on incentivizing doctors and other paramedical staff of rural and remote Australia, it was ineffective in satisfying the rural health concept. This was because of issues of financial, infrastructural resource allocation to this programme, as indicated by the performance indicators measuring the remote and rural Australians' health.

The Australian rural and remote health program underwent a radical change through a dedicated policy framework improvement keeping in mind the provision of health services in these areas by 2008 and Healthy Horizons. This programme currently supports the implementation of local programs that are culturally sensitive, practical forging partnerships in the community and the health care providers by equipping the physical and social capabilities of rural and remote health care service centers in Australia [5].

**United States of America** -through rural public health began to rise in the early 1700s, the focus was more on improving and maintaining water supplies and sanitary conditions. However, in the late 1800s, with the spread of diseases from urban to rural communities, the focus shifted to improving rural health facilities from 1908 to the end of World War II. The Hill-Burton Act of 1945 promoted healthcare delivery access in rural areas via rural community hospitals [19].

**Mexico**: The social service year reform of 1930 was sponsored by President Lazaro Cardenas, where medical students had to compulsorily put in 5 months of rural healthcare service as part of their graduation. This helped bridge the health-related gaps in rural areas. Though there was a significant improvement in rural health, a lack of cultural impressionability caused setbacks in the desired outcome as anticipated by the medical graduates. Influenced by the Alma Ata declaration of 1978, the Coplamar system, a Social Protection of Marginal Groups program, was launched, wherein community-based health practitioners were trained in maternal and child health by ensuring community participation in rural communities. However, within years of introduction, the scheme suffered significant losses in funding and the scheme lost its popularity. The Coplamar system was later re-christened as the Opportunities program, a conditional cash-based transfer system that continues to function in rural Mexico [20].

#### **4. Definition of rural health and its impact on health-seeking behavior**

The World Health Organization (WHO) defines health as "The state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". Perception of health was considered "working hard, staying busy, exercising, drinking water and eating well". Being healthy often referred to a more subjective consciousness of self-dependence to carry out their daily living activities in rural areas. A relative inability to carry out Daily activities to maintain a household or to perform farm-related chores was considered ill health. This perception of subjective health and wellbeing is particularly true in rural elderly. Physical, mental, social, and spiritual wellbeing are knitted into a mosaic of the everyday life fabric of rural elderly [21]. There is a distrust, especially in seeking professional help for mental health-related issues. The presence of indigenous systems of healthcare usually handles the burden of preventive and promotive health services. However, they are generally not trained or qualified in managing emergency medical conditions and have an inadequate system for referral for these conditions.

The intuitive feeling of health compounded with a low level of trust in the medical healthcare system, decreased demand for services for the "non-urgent" health issues" by healthcare providers, long waiting periods at hospitals for health-related issues. These factors often translate to neglect and apathy toward health-seeking at in the health care institutes in rural areas [21]. This perception of health and disease in rural residents goes a long way in planning healthcare service provision in rural areas [21].

#### **5. Situational analysis of rural healthcare delivery system**

Disparities exist among urban and rural healthcare delivery systems, but within the healthcare systems, there exist socio-cultural and ethnic differences in the accessibility and utilization of healthcare facilities [22]. The situational analysis will focus on aspects of any healthcare system, i.e., accessibility, utilization, acceptability, feasibility, and equity.

#### **5.1 Differences in urban and rural healthcare service delivery systems**

#### *5.1.1 Accessibility*

Healthcare services in rural areas are less accessible than the urban areas, which could be attributed to the topographical differences [5, 23]. Studies from the Indian subcontinent show that the bed population ratio, percentage of trained medical practitioners, and healthcare provision infrastructure are substantially lesser in rural areas compared to urban areas [4]. Even with a sharp increase in the need for emergency services for rural residents when compared to the incremental rise among urban residents in need of emergency services [24], more trained emergency physicians were present in urban areas than rural areas [25]. The number of healthcare professionals and availability of medical services in remote areas is sparse [5]. The problems with transport facilities and communication technologies further compound the problem of poor healthcare accessibility [23].

#### *5.1.2 Utilization*

The factors that enabled healthcare service utilization in Africa's urban areas were motivational benefits, the individuals' current health status, and services availability. However, in rural areas, geographical adjacency, free or low-cost healthcare availability, health insurance, ethnicity, and and family income, influence the rural residents' health services utilization [26]. In general, the individuals would preferred to be treated by healthcare personnel of the local areas, though often under-staffed or resource-constrained [23]. The underutilization has also been attributed to the lack of quality-assured healthcare services sensitive to people's health needs in rural areas [27].

#### *5.1.3 Acceptability*

The concept of acceptability has frequently been intermingled with availability and affordability of healthcare service provision and patient satisfaction [10]. The concept of trust in the healthcare provider, endorsement of the provider by leaders in the rural community in addition to early community interaction and home visits were found to improve the acceptability of maternal and child healthcare services in rural Uganda [28]. In rural northeast India, facilities for safe and sound quality healthcare services were linked to healthcare service acceptability [29].

#### *Healthcare Delivery Systems in Rural Areas DOI: http://dx.doi.org/10.5772/intechopen.98184*

#### *5.1.4 Feasibility*

The availability of healthcare-related services was substantially lesser in institutes providing rural healthcare vis a vis with their urban counterparts [30].

#### *5.1.5 Equity*

Equity in healthcare within rural areas also play an essential role in the rural healthcare delivery system. In the Republic of Suriname, a study conducted showed that equitable resource distribution for primary healthcare services was comparable in rural and urban areas. However, factors like perceived need, female gender, and socioeconomic status contributed to inequity for services related to chronic healthcare-related issues within the Republic of Suriname's rural areas [31].

Provision and upgrading healthcare-related insurance schemes and policies positively contributed to reducing the inequitable distribution of healthcare services [31]. The Development of tailor-made healthcare services addressing these principles to provide timely, socio-culturally appropriate, economically sustainable and equitable services in rural areas is necessary [5, 32].

#### **6. Challenges in healthcare delivery in rural areas**

The healthcare facilities in rural and remote areas are often deficient in core or essential health services, especially for support and local outpatient basis treatment [33]. The problem of shortages in trained global healthcare force and support, provision of geriatric and mental health services, infrastructure for timely healthcare services have affected rural healthcare services more than urban services [5]. The lack of healthcare insurance and the treatment costs incurred compounded with the insufficient healthcare expenditure of Gross National Product (G.N.P.) on health has worsened this situation [34]. The rural population of elderly, sick, uninsured and suffering from chronic diseases is significantly higher than its urban counterpart, which need to be addressed [33].

#### **7. Ideal system of rural health service delivery**

Planning rural healthcare services need an optimum mix of primary and secondary healthcare services at the community and individual levels. An ideal system delivering rural healthcare services should focus on "core healthcare services" or basic health-related amenities for maternal, child health, oral health. This must also include primary health care providers and emergency services for stabilizing patients needing urgent medical care with a timely referral system that provides a continuum of care [35]. The health systems should be locally sourced through community-based organizations, depending on the rural community's health care needs through a formal inquiry vide community- healthcare- needs assessment [35]. The aim of delivering healthcare in rural areas should not be limited only to improve the quantum of services provided but also the quality of healthcare services [35]. The Institutes of Medicine (I.O.M.) quality in healthcare can be approached through an integrated prioritized public health intervention at individual, family, community levels [29]. There should be provision for a support system for the healthcare service delivery personnel and the communities they serve through appropriate education, financial incentives, human resource, and infrastructural capacity. The feasibility and acceptability of Information and

Communication Technology (I.C.T.), especially for diagnostic emergencies like Acute abdomen, Myocardial infarction, Stroke etc., should be explored, especially in remote areas [34]. These systems of I.C.T., if feasible and planned correctly, can be used for monitoring of chronic that arise in Non-communicable and communicable diseases [34]. Leveraging the concept of a "healthy village" like the RURBAN initiative in India needs to be looked at while planning services in these areas [27].

A health care team providing these services, which are community-based with sustainable financial sourcing, can ensure healthcare facilities from seemingly simple medical issues to complex health conditions needing sophisticated tertiary care health system interventions, need to be planned too. The rural health care services need to be backed up by community participation with leaders and members of both health and non-health-based organizations in the rural community. The above system would also need to be socio-culturally sensitive and appropriate, catering to the rural community's health needs. This healthcare provision will depend on the healthcare funding through the nation's allocation of funds for health for rural and urban areas [28, 29].

#### **8. Devising a rural healthcare delivery system**

As emphasized by the Alma Ata declaration of 1978 in Kazakhstan, any healthcare system's precept should be based on primary healthcare [36]. Scarce resources are allocated in terms of human resources, infrastructure, and money for rural healthcare delivery, equitable healthcare provision can be made possible only by improving accessibility and acceptability of healthcare services among rural communities [18]. Sustainable healthcare delivery in rural areas can be possible only if the focus is shifted from providing healthcare service to providing a continuum of care in rural areas [6].

The Continuum healthcare delivery should be planned through a three-tier system of primary, secondary, and tertiary healthcare. This can be coordinated through collaboration and socially accountable healthcare institutes in these areas. In a consultation forum with Australia, Brazil, South Africa, Nepal, and India on A consultation forum with Australia, Brazil, South Africa, Nepal, and India on delivery of rural-primary healthcare, showed that geographically accessible, socio-culturally acceptable, family-centered healthcare needs to be developed. Integrating these concepts based on preventive, promotive, and curative, sensitive to the perceived requirements of the rural communities, need to be crafted. Creating a rural healthcare delivery system should begin with community healthcare needs and demands assessment that identifies potential strengths, weaknesses, threats, and opportunities in terms of human resource, infrastructure, and costs in building a sustainable rural healthcare delivery system sensitive to local healthcare needs. Once the healthcare-related needs are identified, prioritizing these needs based on either a nominal group technique or the Hanlon's basic priority rating system, or an intervention mapping can be employed. Implementing a healthcare system engaging community partners, a community-based organization ensuring the fullest community participation in making healthcare decisions through sustainable healthcare and financial incentivization schemes would be the next challenge to overcome.

When appropriate linkages being forged with referral systems, higher budgetary spending on healthcare by the states, healthcare insurance that improves affordability to build and empower healthcare teams providing rural healthcare [32]. With a shortage of trained rural healthcare professionals on health emergency and maternal and child health, individuals sourced from the local rural communities like the ASHA workers in India [16], Barefoot doctors in China [6, 12] could be looked at as potential bridges to the healthcare-related gap in rural areas. However, adequate and

#### *Healthcare Delivery Systems in Rural Areas DOI: http://dx.doi.org/10.5772/intechopen.98184*

regular training and accreditation of rural healthcare providers who are sensitive to the family-centered practice of evidence-based medicine are paramount [32].

A concept of extended-community-care team sourced from trained staff of urban social and healthcare professionals who provide their skill and expertise prevalent in Scotland's remote and rural areas [6]. Research models for developing such extended healthcare teams in rural and remote with evidence through health impact assessment can ultimately translate to advocacy for policy-orientation prioritizing rural health.

Dissemination of information in rural healthcare delivery systems in research is also paramount for other rural communities to develop or adapt such models to achieve the best healthcare-related outcomes.

#### **9. Role of telemedicine in rural healthcare delivery**

Telemedicine has leveraged the benefits of advanced telecommunication and computer technologies, which can provide diagnostic and therapeutic support to patients residing in remote and rural areas [6, 37, 38]. Modern technology like Clinical Decision Systems (C.D.S.), Picture Archiving and Communication Systems (P.A.C.S) that capture, store, and disseminate health-related information from patients in rural and remote areas to healthcare providers on a realtime basis. These systems can help in making immediate and urgent healthcare decisions in these areas [37]. Information and Communication technologies improve accessibility to primary health care needs, maximizes service delivery, transfer and sharing of appropriate technology for instruction, training, continued education of healthcare service providers is also maximized in rural and remote areas [39, 40].

The characteristics of a programme that supports information and communication technology in remote and rural healthcare systems (which helps in return to improve health especially in developing countries are as follows:


The three-pronged benefits that can be reaped by use of Information and Communication Technology (I.C.T.) would be in


The information and communication technology can also aid in lifelong learning, improvement and retraining in healthcare delivery system's accountability [38]. The establishment of electronic health records using barcoding and other such indexing systems for an individual also helps in maintaining the patients' continuity of care [37]. The WHO e-health strategy envisages, e- health-solutions exploration by identifying and addressing needs, innovative methods and research. This provides evidence, information, guidance, best practices and management of such solutions in rural and remote areas [40].

The challenges in implementation of Information and Communication technology like telemedicine, e-health include:


#### **10. Conclusions**

Rural and remote healthcare delivery is essential to achieve a "Healthy Nation" through quality-assured core or basic healthcare centered on preventive, promotive, curative and rehabilitative service delivery. The healthcare- delivery system's focus on a constraint resource setting, lies in developing tailor-made models for the sustainable provision of healthcare facilities in rural and remote areas. Healthcare research into factors affecting accessibility, utilization, the feasibility of healthcare delivery models in rural areas should be encouraged to provide advanced insights into what works and what does not work in rural areas. The opportunities offered by information and communication technology, (including Telemedicine) bridge the gaps in rural and remote areas.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Healthcare Delivery Systems in Rural Areas DOI: http://dx.doi.org/10.5772/intechopen.98184*

#### **Author details**

Ankeeta Menona Jacob K S Hegde Medical Academy, a Constituent College of NITTE (Deemed to be) University, Deralakatte, Mangalore, Karnataka, India

\*Address all correspondence to: nishankeeta@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[39] Nyasulu C, Chawinga WD. The role of information and communication technologies in the delivery of health services in rural communities: Experiences from Malawi. S Afr j inf manag. 2018 Sep 18;20(1):1-10.

[40] Chetley A, Davies J, Trude B, McConnell H, Ramirez R, Shields T, et al. Improving Health, Connecting People: The Role of ICTs in the Health Sector of Developing Countries- A framework paper. 2006 p. 65. Report No.: Working paper No. 1.

#### **Chapter 3**

### Common Genitourinary Fistulas in Rural Practice: Treatment and Management

*Chineme Michael Anyaeze*

#### **Abstract**

Acquired genitourinary fistulas are common in rural practice. They are pathological communications between the urinary and genital tracts, or between either of the tracts and gastrointestinal tract or skin. Vesicovaginal fistula is the commonest and most devastating. They may result from prolonged and obstructed labor, injuries during obstetric, gynecologic, pelvic and urologic procedures, circumcision, fall from heights, road traffic accidents and female genital mutilation. They present as urinary leakage with characteristic odor. Diagnoses are mainly clinical and confirmed by dye tests, contrast radiography and endoscopy. Treatment is individualized according anatomic sites and etiology. Timing of repair is of essence; delayed repair for obstetric and early for focal injuries. Multidisciplinary team approach and cooperation is encouraged in the management of some of these cases. The sustenance of the 2 – way referral system is emphasized in cases beyond the scope of rural practice. Repairs when undertaken by skilled compassionate fistula surgeons with attention to principles of fistula management and surgical treatment, success rate can approach 90%. Interposition of vascularized grafts have improved success rate. The burden of this condition will be reduced through integration of rural practitioners in the preventive strategies of health education of the public and girlchild; improvement of healthcare, education and transportation infrastructures.

**Keywords:** Common, Genitourinary, Fistula, Rural, Practice

#### **1. Introduction**

Genitourinary fistulas are abnormal tracts between the genital and urinary tracts. Abnormal tracts connecting the urinary system to any structure of the pelvic floor [1], gastrointestinal tract and the skin are also regarded as urinary fistulas [2]. Obstetric fistula is an abnormal hole connecting the vagina to the bladder (VVF), the rectum (RVF), the ureter (UVF) or a combination of these which leads to uncontrollable leakage of urine or feces or both through the vagina, and resulted usually as a complication of difficult labor. Urinary fistulas are severe physical, social and psychological debilitating conditions [3]. It presents as a surprise, taking the patient and caring physician unawares. The commonest type, vesicovaginal fistula (VVF) is still very common in the rural areas especially in Northern Nigeria, [4] and Ethiopia [5]. Thus, this condition is basically a rural disease. Rural area is characterized by meager earnings, low education and poor infrastructure [6]. In the developing countries the attending healthcare worker may be a Traditional Birth Attendant (TBA), traditional healer, quack, midwife, medical officer, obstetrician and gynecologist, surgeon or urologist. In the context of this work, the rural practitioner is a qualified medical doctor practising in the rural area, and is available and accessible to those who suffer from genitourinary fistulas.

The questions are, "will the integration of rural practitioners in the efforts towards elimination of obstetric fistulas reduce the prevalence and burden of the conditions?" What roles will the rural practitioner play in the treatment and management of genitourinary fistulas?

The true incidence of genitourinary fistulas in the developing countries is not known, [7] but some authors have put rates for VVF at 1–3 per 1000 deliveries [8], 3.5 per 1000 births [9] and 5–10 per 1000 deliveries [10]. In contrast VVF is no longer common in the developed countries as a result of improved obstetrics care; and results mainly as a complication of pelvic surgery, malignancy and radiotherapy [11].

This chapter will dwell on fistulas caused by trauma, including obstetric and iatrogenic, and its aim is to highlight the strategic position of rural practitioners in the prevention of genitourinary fistulas, the benefits that will be derived from their education and training on the subject matter, and to suggest a framework for their roles in the treatment and management of these conditions.

#### **1.1 Objectives**

The objectives of this work are to:


#### **2. Etiology**

#### **2.1 Causes of genitourinary fistulas**

Obstructed labor is the main cause of VVF in the rural areas accounting for between 56 and 97.88% in some series [4, 12–16].

Other causes of genitourinary fistulas in the developing world are well reported, [4, 5, 7, 9, 10, 12–17], and shown on **Table 1**.

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*


#### **Table 1.**

*Etiology of genitourinary fistulas in rural practice.*

**Table 2** summaries the etiology of genitourinary fistulas encountered by the author in rural practice from January 2000 to December 2020. Two of the VVF cases were associated with big vesical calculi; one of them had also vesicocutaneous fistula. Urethrovaginal fistulas are not common as noted in **Table 2**. They were complications of vaginal hysterectomy and consequences of vaginal procedures by quacks and homeopaths.

Rectovaginal Fistulas and other urinary fistulas are less common. RVF resulted from trauma mostly, and when it occurred during obstructed labor, it was associated with VVF. Urethrocutaneous fistulas in infants resulting from circumcision mishaps were not rare. These procedures were performed by traditional health attendants, hospital attendants, nurses, midwives and medical officers. The surgical residents at the Federal Medical Center Owerri, Nigeria perform circumcision under the supervision of team consultants since 2000. The less commonly occurring vesicouterine fistula (VUF) and vesicocervical fistula are complications of difficult cesarean sections (CS) [16], and uterine rupture. When urinary fistula occurs as a complication of treatment the effect is devastating to the trained care giver even though the propensity for medicolegal litigation is very low in the rural areas. The patient often stays isolated, withdrawn, miserable and depressed. The husbands and relatives of patients in my experience have been supportive and cooperative in contrast to other reports especially from northern Nigeria [3–10, 18].

#### *2.1.1 Risk factors*

The risk factors related to the development of urogenital fistulas in the rural areas that appear in the literature, [7, 12, 14, 16–23] are enumerated in **Table 3**. Other factors especially in the developed world include periurethral bulking, Burch Culpo suspension, urethral diverticulum repair, and loop excision of the cervix [24–28]. Endometriosis, gynecologic cancer, pelvic irradiation, schistosomiasis, intrauterine device and neglected pessary have also been reported [12, 14].


*Key: VVF = Vesicovaginal fistula, RVF = Rectovaginal fistula, VUF = Vesicouterine fistula, UVF = Ureterovaginal fistula, VCF = Vesicocervisal fistula, UrVF = Urethrovaginal fistula, RUF = Rectourethral fistula, VRF = Vesicorectal fistula, UrCF = Urethrocutaneous fistula, VCuF = Vesicocutaneous fistula, EVF = Enterovaginal fistula, VEF = Vesicoenteric fistula.*

#### **Table 2.**

*Genitourinary fistulas encountered by the author in rural practice.*

Contributory factors to this burden are poor transport infrastructure, lack of skilled medical personnel and collapsed public healthcare delivery system [6]. Specialists in surgery and obstetrics and gynecology show little interest in fistula surgery, and rarely practice in rural areas. Bad roads prolong the time interval between onset of labor and arrival to hospital or make it impossible for the journey [7, 9].

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*


**Table 3.**

*Risk factors related to the development of genitourinary fistulas in rural areas.*

In southern Nigeria many roads are not passable during the peak of rainy season: July–September. Brain drains affect developing countries seriously as their trained healthcare professionals relocate or emigrate to Europe, America, Canada, Saudi Arabia for greener pastures [29, 30]. In this situation, these hapless young pregnant women turn to the familiar, available and accessible traditional healers, quacks, traditional birth attendants and poorly trained midwives whom they can afford their services for obstetrics care.

#### **2.2 Classification and pathogenesis of genitourinary fistulas**

The anatomic classification of urinary fistulas has been mentioned in **Table 2**. **Figure 1** shows them graphically.

The exact pathological mechanism in the formation of obstetric fistula is not clear. However, the compression of maternal soft tissues of bladder base, urethra, cervix vagina and rectum posteriorly, against the unyielding pubis and sacral spine during prolonged obstructed labor; with the resultant ischemia, epithelial necrosis and subsequent sloughing had been postulated as the pathophysiologic process in the formation of obstetric fistulas by many workers in the developing world [4–10, 14, 16, 20–22, 24].

Arrowsmith et al. described obstetric fistula formation within the spectrum of "obstructed labor injury complex" [20]. Urinary fistulas arising from surgical complications, wounding from accidents and stabbing are focal injuries [7]. Gunshots are more complex as they are associated with the phenomena of "tract cavitation and expansion" injuries [31]. Fistulas resulting from obstetric and high velocity gunshot injuries are larger. Ischemia, erosion and migration maybe responsible for the formation of fistulas by foreign bodies in the vagina, bladder, urethra or retained gauze during vaginal surgery.

#### **Figure 1.**

*(A and B): Anatomic sites of Urinary fistulas. 1-Vesicovaginal fistula, 2-Rectovaginal fistula, 3-Vesicouterine fistula, 4-Ureterovaginal fistula, 5-Vesicocervical fistula, 6- Urethrovaginal fistula, 7- Vesicorectal fistula, 8- Enterovaginal fistula, 9-Rectouethral fistula, 10-Vesicorectal fistula, 11-Urethrocutaneous fistula, Vesicoenteric fistula is not shown.*

#### **3. Clinical features**

#### **3.1 Clinical presentation**

Leakage of urine is the usual complaint. Discharge of feces from the vagina indicates rectovaginal fistula, alone or in association with VVF. The genitourinary fistulas are associated with offensive urine odor. There may be leakage of urine from the vagina, anus or through a hole in the skin depending on the type and location of the fistula. The patient may give a history of prolonged or obstructed labor prior to the leakage by 3 to 10 days in the case of VVF. History of assisted vaginal delivery, before the leakage may indicate VVF [17]. Cesarean section, hysterectomies or any other pelvic surgery may precede the urinary leakage by 10–- 14 days. VVF, UVF, VCF, VUF, VCuF and RUF may result from these obstetric and pelvic surgeries. The differential diagnoses of VVF include stress, urge and over flow incontinence. Pain is not usually associated with VVF, and urinary leakage in VVF may commence immediately after catheter is removed.

VVF may present many weeks after pelvic surgery. A 65 years old lady presented to the author with offensive vaginal discharge and urinary retention 10 weeks after vaginal hysterectomy by a gynecologist. It turned out to be VVF resulting from eroding infected gauge that migrated into the bladder and pointing at the tip of the urethra. The gauze probably used to pack away the bladder must have been forgotten in the wound during the surgery. The patient may present with with a referral letter indicating the definitive or provisional diagnosis. In developing countries difficult urinary fistulas are referred to the urologist or fistula centers. Frequency, urgency, dysuria, vaginal discharge, bleeding or pain during coitus may be present. There may be irritation, rash or dermatitis and whitish crystal formation on the skin surrounding the fistula, **Figure 2**.

History of accidentally falling astride a sharp object, stab, or gunshot injury and sustaining a penetrating injury in the perineum or suprapubic region may be elicited; leakage of urine from the anus may suggest VRF or RUF.

#### **3.2 History**

History from clinical presentation as noted above will guide the clinician towards the likely fistula he/she is dealing with.

#### **3.3 Physical examination**

A general examination should be performed noting nutritional state of the patient and comorbidities. In rural practice nutritional anemia is common and they need to be addressed to enhance wound healing.

#### **3.4 Pelvic examination**

Inspection of the perineum for sinuses, fistulas or associated tears; followed by digital bimanual and bivalve speculum examination which assist in identifying the fistula; and provides the opportunity to note the location, size, number and whether simple or complex. An idea about inflammation, fibrosis and pliability of tissue surrounding the fistula and that of the introitus and vagina are ascertained during the examinations. Stenosis and fibrosis of the introitus and vagina sometimes complicate VVF [7, 32].

#### **Figure 2.** *Vesicocutaneous fistula showing whitish phosphate crystals.*

Ongoing inflammation, infection and induration around the fistula are contraindications for immediate repair.

### **4. Assessment and diagnoses of genitourinary fistulas**

#### **4.1 Dye test in VVF management**

Indications


#### Method

It can be performed in the treatment room or theater. Methylene blue or indigo carmine is mixed with sterile water and instilled into the urinary bladder under gravity without spillage. A sterile gauze or cotton ball is placed at the vault, mid and distal vagina. Patient is asked to walk about and return for inspection after 30 minutes.

Interpretations


#### **4.2 Cystoscopy**

Ideally cystoscopy should be performed for patients presenting with VVF. However, in the setting of rural practice in developing countries of Africa, such necessary services are not always available. The author uses a hand-held batteryoperated portable cystoscope, **Figure 3**, to scope urinary fistula patients whenever necessary in the rural setting. It is very cheap to operate. Apart from visualizing the fistula, it helps in assessing the location, and size, whether simple or complex, and location of the ureteric orifices in relation to the fistulas. This is important in planning and choosing the approach for the repair [2, 32].

**Figure 3.** *Portable hand-held battery-operated cystoscope (TRICOMED Surgical Limited, England).*

**Figure 4.** *Retrograde urethrogram showing a fistulous connection between bulbo-membranous urethra and rectum.*

#### **4.3 Imaging**

Imaging may be needed, but most hospitals in rural practice lack imagine facilities. Patients who could afford contrast studies are referred to facilities that have them to access studies as intravenous urogram, with cystogram in UVF and VVF, retrograde urethrogram (RUG), **Figure 4** and micturating cystourethrogram (MCUG) in RUF, urethrovaginal, urethrocutaneous, and vesicocutaneous fistulas; barium enema, vaginography in RVF, and contrast CT scan. Many of our patients are poor and cannot afford these tests. In the rare situation where the fistulas could not be identified with office procedures despite a suggestive history, Rony A Adam [32] described a process where the patient is given phenazopyridine. (Pyridium) and wear a series of gauze at home over a long period. The gauze balls are placed separately in different plastic bags and brought for inspection later. Patients are instructed on proper conduct of the test in order not to contaminate the gauze during insertion.

#### **5. Prevention**

Urinary fistulas especially obstetric when they occur is associated with misery and isolation, expensive and difficult to treat. Healthcare financing is low in many developing countries [33] and may not be able to accommodate the management of genitourinary fistulas. Nigeria is perceived to bear the world's heaviest burden of obstetric fistulas, followed by Ethiopia, Uganda and Sudan [34]. In Nigeria, 12,000 fresh cases occur annually while 150,000 in the pool await repair [35]. Only 43% of births are attended to by skilled medical personnel in Nigeria [36]. Thus, some of these common genitourinary fistulas are avoidable. Hence some authors, National strategic Framework for Elimination of Obstetric Fistula in Nigeria, Fistula Foundation, and Professional groups recommended preventive strategies for genitourinary fistulas [34, 36]. The rural area is the veritable ground for it, and rural practice is one of the best channels to use.

Three perspectives can be recognized: primary, secondary and tertiary.

#### **5.1 Primary prevention**

The goal is to remove or stop the factors known to cause or contribute to urinary fistula formation. Health education and improvement on community health.

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

Involve community healthcare stakeholders as traditional rulers, village heads, women, youth and religious leaders, teachers and traditional birth attendants, traditional healers and heads of healthcare facilities in this program. Emphasis should be to discourage girlchild marriage, early pregnancy, delivery at home or in the church, conducting labor for a long time before referring to a superior facility, and female genital organ mutilation. Educate the community to embrace the attitude to have deliveries in suitable and efficient healthcare facilities. Encourage the girlchild to go to school and be able to comprehend the dangers in early marriage and pregnancy. Government to upscale health and transportation infrastructures to ensure timely comprehensive emergency obstetric care to all women as is obtainable in developed countries where the condition is eradicated. Effective training of midwives to conduct safe vaginal deliveries, and medical doctors to conduct safe vaginal deliveries, cesarean sections, gynecologic and pelvic surgeries. Regular workshops for public and private primary healthcare staff to monitor and recognize prolonged labor for quick referral. Multidisciplinary team approach for anticipated difficult cases. It can be rewarding to invite an experienced specialist or expert to the local center. The author has been invited by gynecologists and medical officers to join their surgeries in more than 35 instances. Part time or visiting appointments can be offered to such experts.

#### **5.2 Secondary prevention**

The goal is to recognize and repair injuries caused to urinary and genital tracts during surgeries; and to offer early attention and treatment to genitourinary injuries from other causes. The use of appropriate suture material and size in the surgery on urinary tract; and safe surgical conduct. Improved operating light is very important. Many theaters in rural practice use improvised theater lamp [6]. The author uses LED head light gear, **Figure 5** to augment whatever light that is available. It is pertinent for the pelvic surgeon to appreciate the applied anatomy of pelvic structures, and note that the trigone is situated at the anterior aspect of upper 1/3 of the vagina, and the cervical os is at the base of the trigone (inter ureteric ridge).

**Figure 5.** *Rechargeable LED operating headlight gear.*

#### **5.3 Tertiary prevention**

Involves interventions geared towards prevention of complications from urinary fistulas. Treat infections, skin care, nutritional support, correction of nutritional deficiencies and anemia, social support and community reintegration to avert depression, abandonment and divorce. Advocacy for bilateral cooperation and collaboration to sponsor obstetric fistula repairs and training for more fistula surgeons. Repairs should be undertaken by skilled fistula surgeons. Nigeria|Fistula Foundation in her recent report stated that it has provided 9,464 fistula repair surgeries to Nigeria women since 2010 [36].

#### **6. Treatment**

#### **6.1 Principles of fistula management**

In addition to thorough evaluation of the genitourinary fistula patient, the following management principles are important. They should have adequate nutrition, successful treatment of infection, effective urinary drainage, removal or by pass of any distal obstruction and rule out any associated malignancy [2, 32, 37]. Adherence to the principles of surgical repair of urogenital fistulas is paramount to successful repair [2, 4, 5, 7–10, 14, 32, 37]. These include optimal operating light, adequate exposure of the fistula, excision of devitalized and ischemic tissues, removal of foreign bodies from the fistula, careful dissection, keeping to anatomical plane between organ cavities, use of small sized delayed absorbable sutures on small automatic needles, water tight closure, use of well vascularized flaps for repair and support, multilayer closure, non-overlapping tension free suture lines, stenting of urinary tract, adequate drainage after repair, prevention and treatment of infection, and adequate hemostasis.

#### **6.2 Treatment of vesicovaginal fistula**

#### *6.2.1 Conservative method*

Conservative treatment though not popular may be attempted when patient presents early and while waiting for infection and inflammation to subside. The author has recorded success on a few cases that ranged from 0.5 cm – 1.5 cm, **Table 4**. Small fistulas with oblique tracts have been reported to be amenable to conservative management [2].

#### *6.2.2 Surgical repair of VVF*

VVF is commonly classified as vesicocervical, juxtacervical, midvaginal suburethral, VVFs [8]. Other classification methods exist [38, 39].

Fistula repairs should be undertaken by "tutored and trained fistula surgeon" who has passion to ameliorate the suffering of patients. Some medical officers belong to this group [38]. The best opportunity to achieve a successful repair is at the first attempt [2–8]. There should be no room for trial and error. The trainee surgeon should be assisted and monitored by experienced fistula surgeons. In rural surgery for VVF, the best outcomes do not often come from trained specialists as obstetrician and gynecologists; general surgeons, urologists and plastic surgeons.


*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

#### **Table 4.**

*Cases of genitourinary fistulas treated with conservative method.*

#### Timing of repair

In rural practice, obstetric fistula is commonest. Patients arrive late [18–10]. In the case of those who arrive early, we allow 8–12 weeks. If the fistula was iatrogenic or resulted from any other focal injury, we close the fistula as soon as infection is controlled. Controversies surround the timing of repair of VVF [4, 8, 14, 37, 38].

#### Approach

Whoever is undertaking VVF repair must be familiar with both vaginal and abdominal approaches, techniques and maneuvers. One approach may not be suitable for every case [40]. Most surgeons in the developing world use the vaginal approach [4–9, 12, 16, 37, 38].

#### *6.2.2.1 Anesthesia*

Anesthesia should be simple, safe and easy in rural practice. Heavy 0.5% Bupivacaine spinal and intravenous (iv) Ketamine anesthesia; conscious sedation with diazepam and pentazocine injections with local infiltration anesthesia of 1 or 2% lidocaine or lignocaine with or without adrenaline are commonly used. Sometimes iv Ketamine is used to supplement spinal anesthesia in lengthy surgical sessions. Ketamine is safe, 1–2 mg/kg for induction and 25–50 mg iv boluses in titrated doses [41]. Atropine 0.6 mg, diazepam 5 mg stat and given 30 minutes before the start of operation. Atropine prevents secretions and bradycardia, while diazepam prevents dysphoria and psychotomimetic effects during recovery. Bupivacaine spinal anesthesia may last up to 3 hours and is superior to 2% heavy lidocaine spinal

anesthesia which may last for 90 minutes. Endotracheal intubation anesthesia is rarely used in rural practice [6].

#### *6.2.2.2 Tools for VVF-repair*

Tools for VVF repair is shown on **Table 5**. Two assistants are required in prone position. One will be holding up the posterior vaginal wall with a Sim's speculum [37].

#### *6.2.2.3 Preoperative counseling*

It is done in the language she will understand when conservative management has failed. Expectations are discussed, especially that the repair may fail, but hope will not be lost. The need for catheterization for 2–3 weeks, length of hospital stays; possible post-operative frequency, urgency, urgency incontinence for some time after removal of catheter. Patient is counseled thoroughly on informed consent and reminded that challenges may warrant change of plans intraoperatively.


**Table 5.** *Tools for VVF repair.*

#### *Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

#### Choice of suture materials

Small size delayed absorbable sutures ranging from 5/0–4/0, monofilament and braided multifilament from 4/0 to 3/0 with 3/8 and 5/8 atraumatic needles are recommended, **Table 5**. This minimizes the amount of suture material in the wound and still provides adequate closure of wound edges [42].

#### *6.2.2.4 Position for repair of VVF*

This depends on the preference of the surgeon.

#### *6.2.2.4.1 Prone position*

Prone position is used in many fistula centers where skilled and experienced anesthetists will perform cuffed endotracheal intubation inhalation general anesthesia. The specifics of prone position are well illustrated in primary surgery volume one, edited by Maurice King et al. [37].

#### *6.2.2.4.2 Lithotomy position*

Exaggerated lithotomy position with slight head down position, buttocks just beyond the edge of the table.

#### *6.2.2.5 Repairing technique of VVF*

The principal steps are: dissecting out the fistula, mobilizing the vaginal skin from the bladder and precervical fascia, mobilization of precervical (pubovesical) fascia, if possible, attention to ureteric orifices, closure of bladder wall, doing a second layer with the precervical fascia over the first suture layer, placement of vascularized graft when indicated and closing the vaginal skin.

#### *6.2.2.5.1 Steps in vaginal approach*

	- ix. Where possible separate the layer of tissue between the bladder and vagina (precervical fascia) from the bladder wall. This may be difficult in large and fibrotic fistulas. Use suture ligation with 5/0 polyglactin to control bleeding.
	- x. The fistula collar, **Figure 6B**, may or may not be excised depending on the size of the fistula. In large fistulas with repeated repair attempts, conservation is prudent. In the past some workers insist on total excision of fistulous tracts and fibrous tissue [43].

In Latzko technique, the fistulous tract is not excised. It is imbricated into the bladder with interrupted extra mucosal sutures on a small tapered needle [44]. The Latzko technique is versatile, simple and cost effective [45]. Many small and moderate sized vaults and high fistulas can be repaired with various versions of modified Latzko technique [46, 47].

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

#### **Figure 6.**

*(a) Vaginal wall is dissected off the bladder wall. (b) Dissecting out fistula collar. (c) Closed precervical fascia. (d) Closed vaginal skin.*

The vaginal flap technique made popular by Zimmern et al. and Eilber et al., results in four-layer closure when the flap is used [48, 49]. It is well illustrated by Ganabathi K, Sirls L, Zimmern PE and Leach GC [50].

#### *6.2.2.6 Abdominal approach in VVF repair*

Extra peritoneal and intraperitoneal techniques of VVF repairs have been well discussed by Gabanathi K, et al. and Wein AJ et al. [51, 52].

### **7. Post-operative management of VVF repair**


#### **7.1 Adjuncts**


#### *7.1.1 Postoperative counseling*


*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

#### **7.2 Failure of VVF repair**

Failure after repair may result from.


#### **8. Complex vesicovaginal fistula**

These include:


#### **9. Rectovaginal fistulas (RVF)**

#### **9.1 Etiology and clinical presentation**

This is an abnormal connection between the rectum and vagina. The etiology, pathogenesis, clinical presentation and diagnosis of RVF have been discussed in the preceding sections and highlighted on **Tables 1** and **2**. RVF can be classified as low, mid and high vaginal fistula. Low is from the vaginal opening to the hymenal ring, mid from the hymenal ring to the external cervical os, and high from the external cervical opening to the vault of the vagina (area of the cul-de-sac) [32].

#### **9.2 Management**

Conservative management may be tried. Some resulting from penetrating and stab wounds responds to antibiotics, salt bath and fluid diet. Defunctioning colostomy has been performed for some cases. Obstetric RVF will require surgical correction after treating infection and resolution of inflammation.

**Time of repair:** A waiting period of 3–6 months is allowed, and salt bath continues before repair.

#### *9.2.1 Surgical repair of RVF*

A defunctioning sigmoid colostomy may be done.

Assessment under anesthesia as soon as possible to ascertain the location, size and state of the fistula, presence of sloughs, and edema. If the fistula is above 8 cm from the fourchette refer to higher center for repair from above. For mid and low fistulas, repairs can be undertaken from below. If there is associated VVF, it should be repaired first [37].

#### *9.2.1.1 Low fistula*

Spinal anesthesia, prophylactic antibiotics, supine lithotomy position, aseptic technique, transperineal, transvaginal or transanal approach may be used [32, 37]. The tissue around the fistula is infiltrated with adrenalin-normal saline solution as in VVF. An incision along the anterior anal sphincter border or transverse along the posterior fourchette is deepened and dissected proximally separating the vaginal wall from the perineal body, anal sphincter, anal and rectal walls, developing a reasonable dissection of the rectovaginal space proximally, distally and laterally. The fistula is excised, homeostasis achieved, extraluminal closure of the rectum is done using interrupted 3/0 polyglactin and imbricated with seromuscular layer incorporating the internal anal sphincter using interrupted 2/0 polyglactin. Vaginal wall is closed with 3/0 polyglactin. The external anal sphincter if disrupted is repaired end-to-end with interrupted polyglactin O.

#### *9.2.1.2 Mid fistula*

The transvaginal approach is preferred. The principles and techniques are the same. The fistula tract is dissected and excised, wide dissection of the rectovaginal space is done, layered closure of the rectum avoiding the lumen, and interrupted vaginal wall closure with 3/0 delayed absorbable suture.

#### *9.2.1.3 Postoperative care*


#### **10. Ureterovaginal fistula (UVF)**

#### **10.1 Etiology and clinical presentation**

This is a pathological communication between the ureter and the vagina. Etiology includes surgical injuries especially hysterectomy [2, 56]. More cases of UVF are *Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

appearing in rural practice due to increasing rates of cesarean sections performed by unsupervised medical officers working alone. Other causes of UVF have been discussed by Payne CK and Raz S [56].

Vaginal urinary leakage after gynecologic or obstetric surgery is the commonest symptom. Urine may drain from incision wounds and wound drain. When urine collects in the abdomen or retroperitoneum, nonspecific symptoms of flank and abdominal pains, hiccups, fever, abdominal distension, ileus, localized fluctuance and tenderness may occur.

#### **10.2 Diagnosis**

**Confirmation of** the leakage as urine. Oral phenazopyridine hydrochloride (pyridium) is given. Brown coloration of the leakage confirms it is urine. Intravenous indigo carmine can be used. Dye test as described under VVF can be done. Staining of the gauze at the vault confirms UVF. Intravenous urogram (IVU) and micturating cystourethrogram (MCUG) can also be used. The MCUG will diagnose a bladder fistula, confirm or rule out ureteric reflux; while IVU shows the excretion function of the kidneys, site of contrast extravasation, dilatation of upper tract and contrast in the vagina. A postvoid film is needed to assess for a distal fistula. Once the diagnosis is made or suspected, refer the patient to a urologist.

#### **11. Vesicouterine fistula (VUF)**

#### **11.1 Etiology and clinical presentation**

An abnormal communication between the uterus or cervix and the urinary bladder. It is uncommon. The commonest cause is lower segment cesarean section [2, 5, 57]. Other causes include myomectomy [17], vaginal operative delivery, induced abortion and, dilatation and curettage. Presentation is the classical "Youssef's syndrome" of symptom complex: "menouria, cyclic hematuria associated with amenorrhea, secondary infertility and urinary continence" [58]. Diagnosis can be made by a combination of contrast cystogram with voiding cystogram and cystoscopy. Refer to a tertiary healthcare institution for multidisciplinary team management.

#### **12. Urethrovaginal fistula (UrVF)**

#### **12.1 Etiology and clinical presentation**

UrVF is an abnormal connection between the urethra and the vagina. The commonest cause in the developing world is obstructed labor followed by female genital mutilation as 'GISHIRI CUT in Northern Nigeria [8, 15, 37]. In the developed world it occurs as a result of vaginal surgery for incontinence, anterior colporrhaphy, vaginal prolapse and urethral diverticulum [2]. It is often associated with VVF [37]. It presents as urinary leakage from the vagina. A small fistula may produce minimal discomfort, while a large one leaks copiously. Distal small fistulas may be asymptomatic.

#### **12.2 Diagnosis**

The diagnosis is made clinically and confirmed by urethrocystoscopy if available or by micturating cystourethrogram.

#### **12.3 Treatment**

Treatment is by surgical repair. However, some workers recommend that distal urethral fistulas can be observed or managed with an extended meatotomy [59].

#### *12.3.1 Operative repair*

Spinal anesthesia, lithotomy position, aseptic technique is used. Size 16 urethral catheter is passed. The tissue around the fistula is infiltrated with adrenalin normal saline solution 1:100, 000 or plain saline. The fistula tract is encircled with incision. The vaginal skin is dissected free from the urethra all-round the fistula to about 5 mm. An inverted 'U'shaped incision is marked out on the anterior wall of the vagina with the base at the proximal margin of the encircled fistula. The area within the incision is infiltrated with the adrenalin saline solution and dissected off the periurethral fascia as a vaginal wall flap, to a reasonable distance not less than 2 cm. The edges of the fistula are mobilized, reflected over the fistula but not excised. It is closed with interrupted 5/0 monocry (poliglecaprone) or vicryl in the line of least tension. The periurethral fascia is closed perpendicular to the first as a second layer when possible. A Martius flap is raised and tunneled to the repair as an additional layer. The anterior vaginal wall flap is advanced over the closure and sutured with 4/0 vicryl to the distal margin of the wound. This repair technique is well illustrated by Rovner ES, and Leach GE et al. [2, 60]. The repair of UrVF may be very difficult due to relative lack of connective tissues in the mid and distal urethra. Interposition tissue flap is often indicated. Multiple and complex urethrovaginal fistulas should be referred to higher centers for multidisciplinary team approach.

#### **13. Vesicointestinal (vesicoenteric) fistula (VEF)**

#### **13.1 Etiology and clinical presentation**

This is a rare connection between the lumen of small bowel and urinary bladder. The etiology in the rural areas include penetrating and gunshot injuries to the lower abdomen and pelvis; and iatrogenic trauma. In the developed world, it is caused by diverticulitis, malignancy, Grohn's disease, trauma, foreign body and infection [2, 61].

Presenting symptoms include pneumaturia, fecaluria, debritic urine, lower urinary tract symptoms (LUTs), fever, chills, abdominal pain, hematuria, epididymitis, orchitis, and urine from the rectum [2, 61].

Once suspected, the patient should be referred to a higher center for multidisciplinary team management.

#### **14. Enterovaginal fistula (EVF)**

#### **14.1 Etiology and clinical presentation**

A rare abnormal connection between the small bowel and vagina. A complication of hysterectomy in the author's experience, **Table 2**. Elsewhere cases arising from Crohn's disease have been reported [62].

#### **14.2 Treatment**

Refer promptly and accordingly once diagnosed or suspected in rural practice.

#### **15. Rectourethral fistula (RUF)**

#### **15.1 Etiology and clinical presentation**

This distressing acquired abnormal communication between the urethra and rectum is seen in males. The author has encountered only seven cases in 28 years; 4 from gunshot **Figure 7**, two from stab injury and 1 iatrogenic endoscopic injury during endourology procedure, **Table 2**. Other causes in the literature are iatrogenic trauma during prostatectomy, cryotherapy, anorectal surgery, pelvic irradiation, urethral instrumentation, infection and Crohn's disease [2, 63]. The symptoms may include fecaluria, hematuria, LUTs, fever, malaise, urinary tract infection (UTI), nausea and vomiting [64].

#### **15.2 Diagnosis**

Diagnosis is by history, physical examination, urine microscopy and culture; high index of suspicion; and confirmed by retrograde urethrogram (RUG) and MCUG. Urethrocystoscopy and sigmoidoscopy may visualize the fistula.

#### **15.3 Treatment**

#### *15.3.1 Conservative*

Some will heal on conservative management [63, 64]. The author managed the RUF that resulted from iatrogenic trauma during a Direct Vision Internal Urethrotomy (DVIU) procedure with urethral catheterization continuous bladder drainage for 3 weeks, low residue diet and appropriate antibiotics cover.

#### *15.3.2 Surgical repair*

Surgical repair of RUF is beyond the scope of rural practice. Single and staged repairs with or without urinary and fecal (defunctioning colostomy) diversions have been described involving transrectal, transanal and transperineal approaches [64–69].

The York-Mason procedure is a transrectal approach requiring jack-knife prone position and skilled anesthesia. It has been found to be effective with low morbidity [70].

**Figure 7.** *Perineal gunshot injuries resulting in rectourethral fistula.*

#### **16. Vesicocutaneous fistula**

#### **16.1 Etiology and clinical presentation**

An abnormal communication between the urinary bladder and the skin. The commonest variety is the type connecting the bladder and the skin of the lower abdomen or suprapubic region; **Figure 2**. This commonly follows prolonged or neglected suprapubic catheterization. Other sites encountered are perineum and upper thigh. Males are commonly affected. Other causes include gunshot and stab injuries, fall from heights and following pelvic surgery, **Table 2**.

It presents as urinary leakage through the skin.

#### **16.2 Diagnosis**

Diagnosis is clinical and confirmed by MCUG.

#### **16.3 Treatment**

#### *16.3.1 Conservative*

Removal or bypass of distal urethral obstruction will heal some.

#### *16.3.2 Surgical treatment*

Others will require surgical excision of fistulous tract, closure of urinary bladder in layers and wound closure may be primary or delayed depending on its state of cleanliness and contamination.

#### **17. Urethrocutaneous fistula**

#### **17.1 Etiology and clinical presentation**

This is an acquired connection between the urethra and skin. It commonly occurs on the penis, **Figure 8**.

In rural practice, it results commonly as circumcision mishap [71]. There are reported cases following surgery of urethral stricture and diverticulum; and hypospadias repair [72]. Others include paraurethral abscess, gunshot wounds and chronic inflammatory disease.

#### **17.2 Diagnosis**

Diagnosis is clinical.

#### **17.3 Treatment**

There is no standardized surgical repair technique for this condition. Each case should be individualized and treated according to its merit. Urethrocutaneous fistulas should be referred to the urologist.

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

**Figure 8.** *Urethrocutaneous fistula complicating male circumcision.*

#### **18. Role of the rural practitioner and future research**

The roles of the rural practitioner have not been clearly defined in the treatment and management of the genitourinary fistula patient. The following roles are suggested from this study. They should:


It will be worthwhile to determine the degree of involvement of rural practitioners in the treatment and management of genitourinary fistulas at present, and the impact on the burden of the disease when they are fully integrated.

#### **19. Conclusion**

Genitourinary fistulas which occur often in rural practice embarrass the patient and practitioner. The dearth of skilled medical personnel and trained fistula

surgeons in the rural areas, made worse by brain drain, poor transport, education and health infrastructures complicate the burden of genitourinary disease. Thus, the patient will be most grateful to the rural practitioner who promptly guides and refers her to a good fistula surgeon who repairs her fistula successfully. The rural clinician should participate effectively in the preventive strategies, initiate treatment and care as soon as fistula occurs, refer complex and sophisticated ones, and may undertake repair of simple fistulas after adequate training and exposure. Good skill, dedication with passion, attention to the principles of fistula management and surgical treatment will achieve high repair success rate. More efforts in training the rural medical practitioner in fistula surgery, education of the girlchild and the public, deployment of more resources to improve social welfare infrastructures, the treatment and rehabilitation of victims, and regular frequent fistula treatment missions will reduce the prevalence of this condition. It is believed that the realization of these objectives will reduce the burden of genitourinary fistulas.

#### **Author details**

Chineme Michael Anyaeze1,2,3

1 Department of Surgery, Federal Medical Centre Owerri, Imo State, Nigeria

2 Surgery and Urology Unit, Six-C Specialist Clinic, Owerri, Nigeria

3 Mater Misericordiae Hospital, Afikpo, Ebonyi State, Nigeria

\*Address all correspondence to: chinemema85@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Common Genitourinary Fistulas in Rural Practice: Treatment and Management DOI: http://dx.doi.org/10.5772/intechopen.99116*

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Section 3
