When urine leaks non-stop

By Dr Brigid Monda

Imagine leaking urine continuously all day, every day whether you are lying down, sitting up or standing but you cannot do a thing about it.

Imagine walking around wet with urine and smelling of it continually? This is the life of women suffering from vesico-vaginal fistulae or VVF — an abnormal communication or hole between the urinary bladder and the vagina that allows the continuous, uncontrolled escape of urine from the bladder into the vagina.

It is a common and widespread problem in developing countries like ours, the commonest cause being prolonged, obstructed labour in a pregnant woman.

The organs you use for passing urine are found in the pelvis, a large bony bowl with a sheet of muscles forming its base. If you stand with your hands akimbo, they (your hands) will lie on the rim of this bowl and the bottom of the bowl will lie between your legs.

The urinary bladder lies inside this bowl storing urine and contracting to empty out the urine through the urethra as you urinate. There are three sets of muscles that help you control urination: the bladder, that expands to store urine or contracts to expel it; the small sphincter muscles that open or close the urethra to let out or keep in the urine; and the muscles of the pelvic floor at the bottom of the pelvic bowl that hold up the bladder and urethra.

Good bladder control takes teamwork from all these muscles, the nerves that communicate with the brain through the spinal cord and the brain itself. As the bladder fills, it stretches to accommodate the urine and its nerves respond to this stretching sensation by sending signals to the brain that then triggers your urge to urinate. When you empty your bladder, the bladder muscles contract, forcing urine out through the urethra. For a woman with VVF, this system fails because urine drains continuously from the bladder through the VVF and out through the vagina.

During normal labour, the bladder is pushed upwards in the abdomen so that the upper vaginal wall, the base of the bladder and urethra are compressed between the baby’s head and the bony pelvis. If this occurs briefly, no tissue gets damaged but if there is prolonged obstruction, the blood supply to these compressed tissues is cut off and the tissues die, sloughing off three to 10 days after delivery, thereby creating a hole between the bladder and the vagina. The woman then begins to leak urine through the vagina.

There are thousands of cases of VVF in developing countries like Kenya but the exact figures are unknown because many women suffer in silence and are ostracised by their communities. Many are divorced or separated from their spouses, majority uneducated and living in poverty.

Most are young and were pregnant for the first time because their communities encourage marriage and pregnancy at an early age before their bodies achieve full growth and maturity especially of the pelvic bones.

This is compounded by poor nutrition and infections, which stunt their growth further, leaving them with pelvises that are too narrow to allow a fully-grown baby through.

Few of these women or girls are attended to by qualified health care workers or have access to medical facilities during childbirth so they labour for days and end up delivering a dead baby. Often they are left with complications like foot drop due to damaged nerves of the lower limbs, VVF, urinary tract infections and severe excoriations or irritation of the genital skin due to continuous exposure to the ammonia in the leaking urine. These areas lack skilled health care providers so many women rely on traditional healers.

After all, giving birth is regarded as a normal process that does not require medical attention. Even when these women desired to deliver at home, there is lack of transport making it nearly impossible to access a medical facility.

Female Genital Mutilation (female circumcision) also contributes to a high fistula rate because of the scar tissue formed that contributes to difficult labour.

VVFs can be treated and cured in majority of cases. Kenyatta National Hospital in conjunction with AMREF are offering free treatment for all women suffering from VVF between June 15 and June 28, and this will continue throughout the year.