Leech Infestation in the Vulvar Region: Causes of Vaginal Bleeding in a Six years old Child

Leeches are hermaphroditic rare blood-sucking human endoparasitesof phylum Annelida and class Hirudinea. Leech infestation is a zoonotic disease acquired by drinking contaminated water, swimming in ponds and streams.¹ Epidemiology of leech bites in literature is limited and the majority of existing data are case reports from the tropics or subtropics.^2–4

Leech bites can occur on various orifices of the body including internal body cavities and orifices, such as the uterus, rectum, urinary bladder, vulva, nasal cavity, peritoneal cavity, nasopharynx, oropharynx, oesophagus, trachea, bronchi and the vagina.⁵

Different chemicals for leech removal have been utilized and include anesthetics drugs like lidocaine and topical anesthetic spray. Salt, saline, vinegar, alcohol, and heat are also viable options. Of these, saltwater has been shown to be effective in causing the leech to relax and release. Vaginal bleeding resulting from leech bite is rare, but when it occurs, it may be of severe morbidity.^2–4

In the present case report that happened at Kabaya district hospital, a six year old child with vaginal bleeding that turned out to be caused by vaginal leech infestation is presented.

Kabaya district hospital is a rural hospital with 144-bed capacity and serves 188,902 inhabitants and is geographically difficult to access due to the lack of reliable roads and bridges, especially in the rainy season.

Validation of an obstetric fistula screening questionnaire: a case-control study with clinical examination

Background

Obstetric fistula (OF) is a significant cause of maternal morbidity in lower resource settings where women experience obstructed labor without timely access to skilled obstetric care. The true prevalence of OF is unknown; however, it is estimated to affect 2 to 3.5 million women globally. The Demographic and Health Surveys’ (DHS) Fistula Module includes the OF symptom questions most frequently used for prevalence estimates, but these questions have not been validated. The aim of this study is to validate a symptom-based screening questionnaire for OF, including a question in the DHS’ Fistula Module.

Methods

With an international panel of fistula surgeons, we developed and face-validated a screening questionnaire that assessed for symptoms of lower urinary tract fistula (LUTF) and lower gastrointestinal tract fistula (LGTF), as well as urinary and fecal incontinence (UI, FI). We evaluated the discriminative ability of the questionnaire using a case–control study design in a 1:2:2 ratio: cases were parous women with fistula confirmed on examination, controls included parous women without fistula on examination, with and without UI symptoms. All women underwent screening for fistula symptoms and a physical examination, with examiners blinded to screening results.

Results

Of the 367 Rwandan women who completed the questionnaires and underwent clinical examination, 59 women had LUTFs and 34 had LGTFs, 274 women were classified as controls with and without symptoms of UI. All LUTF screening questions performed well, including the DHS fistula question. The combination of two LUTF screening questions had the highest sensitivity (100%; 95% CI 94%, 100%), specificity (96%; 95% CI 93%, 98%), and area under the curve (AUC) (0.98). The combination of a LGTF screening question and FI question demonstrated the highest sensitivity (97%; 95% CI 85%, 100%), specificity (98%; 95% CI 95%, 99%) and AUC (0.98).

Conclusions

Our OF screening questionnaire, including the DHS fistula question, demonstrated high sensitivities, specificities, and AUC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01317-2.

Obstetric fistula (OF) is a birth injury which may occur in women living in lower resource settings who experience obstructed labor (not progressing normally) without access to skilled obstetric care. This injury causes a woman to constantly leak urine and/or feces from her birth canal. As OF affects poor women who live far from healthcare it is difficult to fully understand how many women worldwide have an OF. Furthermore, although some Demographic and Health Surveys (DHS) include OF symptom questions, the accuracy of these questions in identifying women with OF has not been studied.

To more accurately determine which women may have an OF, we developed an OF screening questionnaire after consulting OF experts worldwide, which included a DHS OF question. We asked women from Rwanda this questionnaire and then examined these women to see if they have OF. Through this process we identified 59 women with a LUTF, 34 with a LGTF, and 274 without an OF. The best performing questions were able to identify women with LUTF 100% of the time and women with LGTF 97% of the time. We also showed that one DHS question detects women with LUTF and LGTF 100% and 85% of the time, respectively. Public health officials can now use the questions we studied to more accurately estimate how many women worldwide have OF, and best direct resources and skilled health care workers to the areas with the greatest need.

The changing perception and knowledge of obstetric fistula: a qualitative study

INTRODUCTION AND HYPOTHESIS

To describe the knowledge and perceptions of obstetric fistula (OF) among affected and unaffected women.

METHODS

Twenty-five semi-structured interviews were conducted with women who had received OF repair. Three focus groups were conducted: one group of women with urinary incontinence but no OF, one group of women with OF, and one group of women without genitourinary complaints. Interviews and focus groups were conducted using the grounded theory approach. This study took place in two urban hospitals in Rwanda from April to November 2015. Transcripts were coded using MAXDA11 and analyzed using the axial technique and the constant comparative method.

RESULTS

Nearly all participants correctly described OF and its symptoms, and 93% of interviewed women attributed OF to complications in vaginal delivery or cesarean section. Several participants described renouncing stigmatizing beliefs after learning about OF from the radio, health workers, or word of mouth. Still, it was found that women with OF were more knowledgeable about OF etiology than women without genitourinary conditions.

CONCLUSIONS

Compared to prior studies, women's knowledge about OF appears to be more medically based, with media and health workers playing a role in reducing stigmatizing beliefs. These findings support continued investment in OF awareness campaigns, which seem to be increasing knowledge about OF and reducing stigma.