Monday, January 31, 2011

#21 Pee

I had a blog called poop, so I figured I needed one called “pee” too.  Plus, that’s all I smelled yesterday.  

Lyol’s finally getting the hang of things I think.  I don’t know what kind of treats Nana Bland is giving him during the day, but this morning he woke up at 6:15 and said, “Pee.”

“Okay, Let’s go to the Toilet!”

“Toy” (Lyol’s name for toilet)

We run to the toilet and Lyol ACTUALLY pees on his little plastic toilet that Wendy loaned us.  Amazing!  His cloth diaper is DRY from last night!  (Trust me, it’s more motivating when you’re in cloth diapers).


She came with her Dad on Sunday this week.  Tall, shy, Arabic girl in her early 20’s.  I’m sure she’s been embarrassed for some time now.  She would barely look you in the eye, letting her orange and white scarf hang over her head and face, mostly looking at the floor.  

I tried starting with a history.  Though it was unnecessary because the room smelled like old urine the moment she came into the office.  

She didn’t speak any French, any Arabic (neither did I), or any other local language from around here.  Apparently she only spoke another language similar to Arabic.  So with the help of a nurse, my French was translated into Arabic, and her father translated everything to her.  And back again.  Needless to say, the history was not helpful.  Her only child was living and 2 years old, and she had only had this problem for 3 months.  No history of trauma either.  So I threw away the history.  

I started with a vaginal exam after the men left the room.  Okay, there’s the diagnosis.  Vesico-vaginal fistula (A tract from the bladder to the vagina).  She had a 2 cm hole behind where the urethra should be.  A GAPING hole allowing the stench of urine to escape all over her beautiful arabic clothing.  

VVF’s are a huge problem in Africa.  They have huge hospitals in other parts of Africa, one specifically well known in Ethiopia, with many specialized surgeons.  I don’t know of one in Tchad yet, but I’m sure many women have this problem here.  

Many women also die in childbirth here in the villages.  When there is a problem, it is often several days of labor before they seek help.  If the baby’s head is stuck in the vagina, it can cause the tissue between the vagina and the bladder to die.  Several days after, this tissue falls off and eventually causes a hole (or fistula) to remain between the bladder and the vagina.  It’s often old and scarred down tissue too, so not always easy to repair.  We RARELY have this problem in first world countries due to excellent prenatal and obstetric care.  Here, you can become an outcast with the awful odor of urine.  

We weren’t able to do her surgery until yesterday.  I promised that she would be the first surgery of the day, but I had an emergent bleeding 6 month molar pregnancy to do first.  This week has been extremely busy for some reason (trauma ortho cases and amazing other cases that will have to wait for another blog).  Really you never know what’s going to come in the door.

My dad and I scrub in to start the case (very glad he’s here).  The huge gaping hole in her bladder is staring at us.  There is ACTUALLY no urethra (the hole that you pee out of).  It had been scarred off, or closed up on it’s own.  We are both sure this problem happened during childbirth.  Okay....this is way out of my league!  I’ve only seen ONE fistula before in the states and it was more like a pinhole near the cervix.  Luckily my dad has done many fistulas before when he used to live in nigeria MANY EONS ago (before I was born).  Of course, it was much more difficult in the days before opposable thumbs, what with the pterodactyles swooping by (that was Olen’s sentence of course).  

Dad said he’s made urethras before, so we find an area that looks like it may have some healthy tissue and maybe some muscle for the urethra.  I poke a small curved clamped through this area and into the bladder.  Okay, never done that before!  Just made a makeshift urethra.  We thread our suture that we’re going to use later through the same hole as a guide for the foley.  In goes the foley.  The foley needs to stay in for a while I think, maybe 10 days?  I don’t know, I guess I’ll have to read on that, and if any urogynecologist has any suggestions, please feel free to e-mail me.  I certainly don’t want her new urethra closing off too early.  

Next we move on to the “easier” part.  After cutting off some of the scar tissue, the healthy bladder mucosa and vaginal tissue bleeds.  Yes!  Bleeding tissue means healthy tissue.  We were able to close the mucosa, then an extra layer on top of the bladder mucosa, and then finally closed off the vaginal epithelium.  

I asked Samedi (the janitor, turned nurse, but in reality surgeon here) how long he would leave the foley.  He said 7 days.....and he’s made several urethras before due to fistulas in his many years here.  This was nothing new to him!  He says they were able to pee afterwards too, so we will see.  Please pray for the recovery of this young woman.  


Two weeks ago a young woman came in with the same smell.  She had delivered a dead baby at home 12 days before and now was leaking urine continuously.  An extensive exam revealed necrosing vaginal and bladder tissue hanging into her vagina.  There was not only the stench of urine, but also the smell of rotting dead tissue.  My dad and I debrided (scraped away) what we could, and then cleaned it with diluted bleach water.  Her fistula repair (about 3cm hole) will be difficult I think because it is deep in the vagina and harder to get to.  At least she has an urethra (the normal hole you pee with).    I put a foley cather in her for one night to see if it would help collect some of the urine.  It didn’t help, so I took it out the next morning.  She will come back in 2 months for her fistula repair.  

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