Pelvic Floor Dysfunction and Social and Mental Health Sequelae Following Childbirth Injuries in Women in Eastern and Central Africa

Abstract

Female pelvic organ dysfunction occurring in eastern and central Africa results in significant morbidity and adverse social and mental health sequelae.Lack of adequate resources available for health care compounds the suffering faced by these women. Obstetric fistula (OF), chronic 4th degree obstetric tears and severe pelvic organ prolapse(POP) are all common gynaecological morbidities seen in Uganda, D.R. Congo and Ethiopia. Despite successful closure of OF, bladder dysfunction and incontinece may persist due to detrusor overactivity, stress urinary incontinence and voiding dysfunction. Chronic 4th degree obstetric tears require effective surgical repair. Women suffering with severe POP need to be given surgical and non‐surgical options of treatment. Non‐surgical options include the availability and use of support pessaries. This research has focused on evaluation of post‐OF bladder dysfunction assessment and treatment options. In particular, urodynamic bladder function studies were utilized and a bulking agent used as an option for post-‐OF repair continence surgery. A surgical repair technique for chronic 4th degree obstetric tears has been described with post‐operative follow‐up of women giving encouraging results. Support pessaries have been introduced and evaluated for women experiencing severe POP. In order to be able to improve treatment and management options available for women affected with such pelvic floor dysfunction, additional information and understanding regarding risk factors and anatomical defects are needed. The relevance of height and age as risk factors for OF have been evaluated here. Pelvic floor anatomy as measured with 4D pelvic floor ultrasound includes levator hiatal dimensions and identification of levator muscle trauma. Assessment of nulliparous Ugandan women has documented differences in levator hiatal dimensions compared to non‐Ugandan women, and Ugandan women with OF,chronic 4th degree obstetric tears and severe POP have also been scanned and levator hiatal areas and incidence of levator muscle trauma compared. Significantly, the levator hiatal area in women with OF is smaller than in women with chronic 4th degree obstetric tears and severe POP. Possible reasons for these findings are discussed. The incidence of levator muscle 3 defects in women with pelvic floor dysfunction is compared with all 3 groups experiencing a similar high rate of complete levator muscle trauma. The social and mental health of women with pelvic floor dysfunction including risk of domestic violence has been assessed. High levels of loss of social cohesion and mental health dysfunction have been identified in women with OF, chronic 4th degree obstetric tears and severe POP. The social and mental health of women with pelvic floor dysfunction including risk of domestic violence has been assessed. High levels of loss of social cohesion and mental health dysfunction have been identified in women with OF, chronic 4th degree obstetric tears and severe POP. Through identifying and highlighting the health sequelae faced by women with pelvic floor dysfunction including OF, chronic 4th degree obstetric tears and severe POP, effective treatment and management options can be evaluated and promoted. Further research is required to consolidate the peri­operative outcomes of the surgical techniques described here with functional long­term outcomes necessary to guide future recommendations. Understanding risk factors associated with the development of pelvic floor dysfunction may guide strategies for prevention. Social and mental health dysfunction needs to be identified and addressed within this group of women with the availability of adequate support networks and treatment. In addition, there must be community­wide awareness of the prevalence of domestic violence with effective solutions promoted.