Other Causes of Vesicovaginal Fistula

Obstructed labor causes the vast majority of genitourinary fistulas.  However, any hospital that cares for women with childbirth injury will see women injured in other ways.  These other causes are real and disturbing.   

Gishiri:    FGM and VVF come the closest together in the area of traditional "medical" practices.  The Hausa people live primarily in southern Niger and northern Nigeria, although communities of Hausa-speakers are found all over West Africa.  The Hausa word for salt is gishiri.  In the traditional Hausa view of how the body functions during pregnancy, it is thought important for there to be an appropriate balance between sweet and sour, bitter and salty substances.  When labor becomes obstructed, the cause is often attributed to an imbalance in the woman’s body resulting from “too much salt” that is said to produce a membrane over the vagina that inhibits the baby from coming out.  This is treated by cutting the vagina with a razor, a knife, or another sharp object.  When this is done, the urethra or bladder is often injured, resulting in a fistula.  The rectum may be cut as well.  The same procedure may also be done for a variety of other perceived “women’s problems,” with similarly disastrous results.

Coital Injury:    One of the outcomes of early marriage is coital injury.  In some parts of Africa, girls may be given in marriage as early as the age of seven.   When a pre-pubertal girl has sex with a grown man, terrible injuries can result, including penetration through the vagina into the rectum.   Fortunately, these injuries tend to be easier to repair than those caused by childbirth injury.  Who can imagine the psychological injury?

Rape:    Another terrible cause of VVF is rape.  We have seen several cases where a woman was raped by soldiers, then had an assault weapon inserted into her vagina and fired.   How these women survive is unimaginable.   The new Center in Sierra Leone is seeing many women with VVF resulting from serial rape that occurred during that country's Civil War.  We hope to develop effective counseling programs for women with such severe emotional trauma. 

Ritual Cleansing:   In some parts of the world, certain rituals are performed following childbirth to “cleanse” the mother and to “restore” her vagina for intercourse.  In some areas this process includes packing the vagina with  salts.  The produces a severe chemical vaginitis which causes shrinking and stricture formation.  In some causes the materials used are so caustic that the tissues are destroyed and a fistula results. 

STDs and HIV:   At VVF centers serving more urban populations, a particularly horrible form of VVF is often seen.  Many country women who move into large cities find themselves forced into   prostitution to earn a living.  HIV infection almost inevitably follows.  As clinical AIDS begins to appear, the immune system is no longer effective in keeping infections in check. Women living as prostitutes are exposed to a wide variety of sexually transmitted diseases on a daily basis.   Tissue-destructive diseases such as lymphogranuloma venereum can be particularly virulent, eating into the genital tissues and causing fistulas which generally cannot be repaired.

Malignancy:   One major consequence of poor economic status is lack of access to basic medical care, such as screening for cervical cancer, the world’s largest cancer killer of women.  Although pre-cancerous changes are easily diagnosed and treated, most women in the Third World have no access at all to any form of screening for cervical cancer.   As cervical cancer grows, it may spread into the vagina and bladder, producing a fistula.  Fistulas of this kind are not generally treatable.   

Just as with childbirth injuries, these other causes of VVF are intertwined with poverty and  culture.  Only substantial changes in the world socio-economic order will bring these tragedies to an end.