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In developing countries, the predominant cause of VVF is prolonged obstructed labor (97%). VVFs are associated with marked pressure necrosis, edema, tissue sloughing, and cicatrization. The frequency of VVF is largely underreported in developing countries.
The magnitude of the fistula problem worldwide is unknown but believed to be immense. In Nigeria alone, Harrison (1985) reported a vesicovaginal fistula rate of 350 cases per 100,000 deliveries at a university teaching hospital. The Nigerian Federal Minister for Women Affairs and Youth Development, Hajiya Aish M.S. Ismail, has estimated that the number of unrepaired VVFs in Nigeria is between 800,000 and 1,000,000 (2001). In 1991, the World Health Organization identified the following geographic areas where obstetric fistula prevalence is high: virtually all of Africa and south Asia, the less-developed parts of Oceana, Latin America, the Middle East, remote regions of Central Asia, and isolated areas of the former Soviet Union and Soviet-dominated eastern Europe.[13, 14]
In contrast to developing countries, countries that practice modern obstetrics have a low rate of UGFs and VVF remains the most common type. Less frequently, UGFs may occur (1) between the bladder and cervix or uterus; (2) between the ureter and vagina, uterus, or cervix; and (3) between the urethra and vagina. Of note, a ureteric injury is identified in association with 10-15% of VVFs.
The majority of UGFs in developed countries are a consequence of gynecological surgery. Consequently, the incidence may change as surgical management changes. The incidence of VVF in the United States is debated. Although most authors quote an incidence rate of VVF after total abdominal hysterectomy (TAH) of 0.5-2%, others suggest only a 0.05% incidence rate of injury to either the bladder or ureter. So if injuries to the bladder and ureters occur in roughly 1% of major gynecologic procedures, and approximately 75% are associated with hysterectomy, and if there are about 500,000 hysterectomies performed each year then about 5,000 women will experience an injury.
Lee, in a series of 35,000 hysterectomies, found more than 80% of genitourinary fistulas arose from gynecological surgery for benign disease. Uncomplicated TAH accounted for more than 70% of these surgeries. The indications for these TAH surgeries excluded the more complex diagnoses, such as pelvic inflammatory disease (PID), endometriosis, and carcinoma; instead, they were performed primarily for diagnoses such as abnormal bleeding, fibroids, and prolapse. In approximately 10% of cases of VVF, obstetrical trauma was the associated etiology. Radiotherapy and surgery for malignant gynecologic disease each accounted for 5% of cases.
Notably, a rise in incidence of UGFs paralleled the switch in policy toward the preference of performing a total hysterectomy over a supracervical hysterectomy.
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