Surgery to create anuses inspiring fistula-free generation
Kelina is nine, and has used diapers all her life. She was born with a congenital abnormality that left her without an anus. [Names of minors in this report have been changed to protect their identity.] The nine-year-old is among dozens of women who appeared for a pool repair of fistula at the Vesico-Vaginal Fistula […]
Kelina is nine, and has used diapers all her life. She was born with a congenital abnormality that left her without an anus. [Names of minors in this report have been changed to protect their identity.]
The nine-year-old is among dozens of women who appeared for a pool repair of fistula at the Vesico-Vaginal Fistula Centre of Ogoja General Hospital early November in Cross River State.
Without a normal anal opening, Kelina has had to pass both urine and faeces through her vagina. It is a rare condition called congenital fistula: an unopened anus or vagina.
“Imagine what she and her parents have been going through,” says Dr Sa’ad Idris, lead surgeon on the fistula repair team. “All the time, her [vagina] is packed with faeces.
"The nurses in the clinic have been having a really very difficult time with her, cleaning her up and packing her with diapers because she cannot control stool.”
Now the team worked hours to create Kelina an anus.
Two previous surgeries at a federal hospital in Abuja were unsuccessful, and her parents—a catechist father and a farmer mother from Amana in Obanliku area of Cross River—quickly got tired of all the drugs and injections.
“There felt there was nowhere else they go could,” said Peter Njagu, who administers the VVF unit.
The Idris team worked hours, tunnelling through to create an anal canal. Then they diverted her bowel movement through the canal.
Kelina is the third girl since August surgeons have had to create an anus for at the centre.
The second is Linda. She lay almost lifeless as the team worked on her. It took hours to get the diversion right.
Besides both girls, more than 500 women have undergone surgical repair for fistula at the centre alone.
Fistulas are abnormal holes formed in the vagina during prolonged and obstructed labour at childbirth.
The basics are simple: the head of a foetus presses against portions of the birth canal during childbirth. In prolonged labour the pressure is sustained.
Some women have been known to labour for up to 72 hours.
The pressure ruptures the vaginal wall and can also rupture nearby tissues—the bladder or the rectum—causing contents of either of both to leak into the vagina.
Women with rectovaginal fistula leak faeces through the vagina; those with vesicovaginal fistulas leak urine uncontrollably due to a ruptured bladder.
The stench is grounds for much stigma and discrimination. Some are even totally abandoned by family.
Ekaette Bassey was abandoned, dumped at the VVF clinic in Ogoja by an unidentified man two months ago, believed to have been a pastor.
Four in her family of six are already dead. Her only living sister and relative couldn’t tolerate living with her and left her behind.
“I stay with my sister in Akankpa but later on she abandoned me, I couldn’t see her or anybody. I kept begging people on the streets to help me because I was very sick and I needed money to feed,” she recalled.
The race is on for a fistula-free generation, but a backlog and new emerging cases of the condition are overwhelming efforts to stem the source.
“I cannot say that we are on track,” said Iyeme Efem, country manager for Engender Health, which implements a US-funded project Fistula Care Plus to prevent, treat and rehabilitate women and girls living with fistula.
“We have a backlog of over 200,000 women living with fistula and we have new cases occurring every year of 12,000.”
Engender Health routinely gets volunteer surgeons to offer their skills, gets surgical centres across states to offer space and personnel. It is the “pooled effort” in which Kelina, Linda and Ekaette underwent repair.
The pool is able to do around 2,000 repairs a year. Adhoc repairs at teaching hospitals and pet projects run by governors’ wives also add to the trickle of repairs, sometimes doubling it a year to 4,000.
“It is not up to the number of new occurrences every year let alone attacking the backlog,” said Efem.
“It is like telling me that Nigeria is on track when the tap is still running and the bucket of water is overflowing and what we are using is a teaspoon to try to empty the bucket of water.”
Health minister Isaac Adewole this year announced free fistula care services at tertiary hospitals nationwide in efforts to expand access.
Projections show tertiary hospitals stepping in might help mop up the backlog: 49 teaching hospitals each doing 15 repairs a month total 735, in addition to the current 4,000 combined.
But not all teaching hospitals and not all gynaecologists take on fistula repair. And some gynaecologists do cause fistula in attempts to perform Caesarean sections.
It has prompted plans to liaise with the Society of Obstetricians and Gynecologists of Nigeria to put up modules to teach surgeons fistula repair right at university.
“A lot of fistulas are formed by us the medical personnel probably because of a lack of expertise or something else. If you look at it, the commonest site where you would have seen this fistula is the junction between the bladder and the urethra,” said Idris, a former health commissioner for Zamfara state, taking a teaching moment as he operated on a patient.
“The main thing is to restore her continence, for her to be closed and dried and then her sexuality. After then she will become a complete woman again.”
With more than 500 repairs at the centre, it is testimony awareness is growing about the condition and where to get help.
Cross Rivers has said it is willing to provide “additional support” to help combat fistula in the state, according to health commissioner Inyang Asibong.
Linda Ayade, wife of the state governor, donated food and financial support to put the repaired clients through their stay at the centre.
But the centre’s coordinator Njagu said the centre still faced challenges with personnel, mobility to transport clients.
Another major problem is liaising with family members, which makes reintegration difficult.
Many of the women are mostly divorced, rejected by their spouse and community or chucked out of home on account that their condition is the result of a curse or witchcraft. The cycle increases the stigma and trauma.
"Reintegration is essential but there is no mapped out plans for it and the way forward requires all partners to unity in rehabilitation and sensitization of the these patients,
“Repairing VVF is not only about closing the hole but an holistic situation where they get their womanhood back.” said Njagu.
A day after her surgery, Kelina is wide awake and without a diaper. Her mother cannot believe it. She still wonders whether her daughter’s new anus really works. But she is waiting and watching to be sure.
“I don’t know yet. Maybe, in a week or two, if she doesn’t need diapers, it would be good,” she said.