Pelvic floor structure and function in women with vesicovaginal fistula

Vesicovaginal fistula is a catastrophic event, especially in areas with poor peripartum care, where most occur. It is usually due to severely obstructed and protracted labor. We assumed that such patients would show evidence of abnormal levator function, eg due to denervation.

In an external audit at Hamlin Fistula Hospital in Addis Ababa, Ethiopia, 95 women were seen for clinical examination and 4-dimensional translabial ultrasound. Patients were examined supine and after voiding. Volume data sets were obtained upon coughing, Valsalva maneuver and pelvic floor muscle contraction.

Women were seen before (22) or after (73) vesicovaginal fistula repair. Mean age was 29.5 years (range 16 to 65) and mean parity was 2.7 (range 1 to 11). Only 2 patients had a significant cystocele (stage 2), 3 had stage 2 uterine prolapse and 13 had a stage 2 rectocele. Levator biometry was done in 92 of 95 women, which showed no evidence of muscle atrophy. Mean hiatal area on Valsalva was 18.8 cm(2) (range 7.7 to 45.9) and only 6 of the 92 women (7%) fulfilled the criteria for ballooning (hiatal distention 25 cm(2) or greater). Levator avulsion was diagnosed in 27 cases (28%), of which 11 were bilateral. Reflex contraction of the levator ani was observed upon coughing in all except 2 patients. Levator contraction upon request could be performed by all except 6 women.

Abnormal levator function and anatomy in patients with vesicovaginal fistula is not uncommon but no more than in unselected urogynecologic patients in the developed world. There was no evidence of permanent denervation of the levator ani.