Committee 20

The Obstetric Vesicovaginal Fistula in theDeveloping World

Chairman

L. L. WALL (USA)

Members

S.D. ARROWSMITH (USA),

N. D. BRIGGS (NIGERIA),

A. BROWNING (ETHIOPIA),

A. LASSEY (GHANA)

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CHAPTER 22

1. UROLOGIC INJURY

2. GYNECOLOGIC INJURY

3. THE RECTO-VAGINAL FISTULA

4. ORTHOPEDIC TRAUMA

5. NEUROLOGIC INJURY

6. DERMATOLOGIC INJURY

7. SOCIAL CONSEQUENCES OF PROLONGED

OBSTRUCTED LABOR

1. THE FISTULA COMPLICATED BY URETHRAL

DAMAGE

2. URINARY DIVERSION FOR THE IRREPA-RABLE FISTULA

XI. CONCLUSIONS ANDRECOMMENDATIONS

X. DEALING WITH THE BACKLOGOF SURGICAL CASES

IX. PREVENTION OF OBSTETRICFISTULAS

VIII. COMPLICATED CASES ANDTECHNICAL SURGICAL

QUESTIONS

VII. SURGICAL TECHNIQUE FORFISTULA CLOSURE

VI. EARLY CARE OF THE FISTULAPATIENT

V. THE CLASSIFICATION OFOBSTETRIC FISTULAS

IV. THE “OBSTRUCTED LABOR INJURY COMPLEX”

III. EPIDEMIOLOGY OF THE OBSTETRIC FISTULA

II. THE RELATIONSHIP OFOBSTETRIC FISTULAS TO MATERNAL MORTALITY

I. LEVELS OF EVIDENCE CONCERNING OBSTETRIC

FISTULAS

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CONTENTS

“In vast areas of the world, in South East Asia, inBurma, in India, in parts of Central America, SouthAmerica and Africa 50 million women will bringforth their children this year in sorrow, as in ancientBiblical times, and exposed to grave dangers. Inconsequence, today as ever in the past, uncountedhundreds of thousands of young mothers annuallysuffer childbirth injuries; injuries which reducethem to the ultimate state of human wretchedness.

Consider these young women. Belonging generallyto the age group 15-23 years, and thus at the verybeginning of their reproductive lives, they are moreto be pitied even than the blind, for the blind cansometimes work and marry. Their desolation des-cends below that of the lepers, who though scarred,crippled and shunned, may still marry and find use-ful work to do. The blind, the crippled and the lepers,with lesions obvious to the eye and therefore appea-ling to the heart, are all remembered and cared for bygreat charitable bodies, national and international.

Constantly in pain, incontinent of urine or faeces,bearing a heavy burden of sadness in discoveringtheir child stillborn, ashamed of a rank personaloffensiveness, abandoned therefore by their hus-bands, outcasts of society, unemployable except inthe fields, they live, they exist, without friends andwithout hope.

Because their injuries are pudendal, affecting thoseparts of the body which must be hidden from viewand which a woman may not in modesty easily speak,they endure their injuries in silent shame. No chari-table organization becomes aware of them. Theirmisery is utter, lonely, and complete.”

—- RHJ Hamlin and E. Catherine Nicholson,(Hamlin and Nicholson 1966)

People in the developing and the industrialized worldsshare a common humanity and with this comes a com-mon susceptibility to the pathophysiology that maylead to urinary incontinence; however, the obstetricfistula is the one continence issue that is both unique

to and particularly prevalent in developing countries.Although the obstetric fistula was once common inWestern Europe and the United States, it is virtuallyunknown in these regions today. The prevalence ofobstetric fistulas has also fallen precipitously in themore industrialized nations of Asia and Latin Ameri-ca; but fistulas remain both prevalent and problematicin Africa and in the less developed regions of Asia andOceania. This disparity between the rich and poornations of the world requires special attention, parti-cularly because obstetric fistulas can be completelyand reliably prevented by the provision of proper heal-th care. It is this lack of appropriate health care—-spe-cifically the lack of appropriate health care for pre-gnant women in impoverished Third World coun-tries—-that is responsible for the widespread preva-lence of this devastating cause of incontinence in cer-tain areas of the world today. The obstetric fistula hasvanished from industrialized nations because thosecountries created efficient and effective systems ofmaternity care that provide effective access to emergen-cy obstetric services for women who develop complica-tions during labor. The fistula problem in Third Worldcountries will not be solved until those nations alsodevelop effective systems of maternal health care.Unfortunately, “Safe Motherhood” has largely becomean “orphan” initiative (Rosenfield and Maine1985);(Graham 1998; Weil and Fernandez 1999). Invirtually no other area in which health statistics arecommonly collected is the disparity between the indus-trialized and the developing worlds as great as in thearea of maternal health (AbouZahr and Royston 1991).This remains one of the most glaring, and one of themost neglected, issues of international social injustice inthe world today. It is no surprise that Graham has calledthis the “scandal of the century” (Graham 1998).

This chapter provides an overview of the pathophysio-logy that leads to obstetric fistula formation and dis-cusses the relationship of obstetric fistulas to the broa-der issue of maternal mortality with which it is inex-tricably linked. This chapter also summarizes the mostimportant current issues in the treatment of obstetricfistulas and suggests directions for much-needed futu-re research in this area.

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The Obstetric Vesicovaginal Fistula in theDeveloping World

L. L. WALL,

S.D. ARROWSMITH, N. D. BRIGGS, A. BROWNING, ANYETEI LASSEY

Scientific data on the problem of obstetric fistulas,their prevalence and the ways in which they shouldbe treated, are limited by unusual historical circum-stances. Prior to the middle of the 19th Century, anobstetric vesicovaginal fistula was generally regar-ded as an incurable and hopeless condition. It wasonly after the work of the American surgeon J.Marion Sims and his colleague and successor Tho-mas Addis Emmett (Sims 1852);(Emmet 1868);(Harris 1950); (Wall 2002); (Zacharin 1988) that sur-gical cure of this condition could be undertaken withreasonable confidence. As obstetrics began to deve-lop into a more scientific medical specialty in the

first half of the 20th Century, maternal mortalityunderwent a precipitous decline throughout Europe,the United States, and other developed nations (Lou-don 1992a; Loudon 1992b). This meant that the obs-tetric fistula vanished from the clinical and socialexperience of the Western world just as Westernmedicine was starting to become more rigorouslyscientific. As a result of these historical circum-stances, the Western medical literature on obstetricfistulas is old and relatively uncritical by currentscientific criteria. This literature consists mainly ofanecdotes, case series (some quite large), and perso-nal experiences reported by dedicated surgeons whohave labored in remote corners of the world whilefacing enormous clinical challenges with scanty orabsent resources at their disposal (Evidence Levels 4and 5). The committee charged with producing thisreport was able to locate only a handful of articles,all quite recent, that rise to a higher level of eviden-ce. For example, there appears to be only one pros-pective, randomized clinical trial in the current medi-cal literature on vesico-vaginal fistulas in the develo-ping world (Tomlinson and Thornton 1998), andonly one comparative study of surgical techniques inthe repair of obstetric fistulas (Rangnekar, Imdad etal. 2000). This finding underlines how the problemof obstetric fistulas in developing countries has beenneglected by the bioscientific medical community ofthe industrialized world. The paucity of well-desi-gned studies makes it impossible to produce asophisticated meta-analysis of hard scientific data onthe obstetric fistula problem at this time. While ack-nowledging this difficulty, the members of the com-mittee feel that it is possible to arrive at a consensusregarding most major aspects of the fistula problem.

This report presents a general summary of the cur-rent state of our knowledge regarding obstetric fistu-las in the developing world and the challenges pre-sented by this condition. The committee regards thisreport as a point of departure for further work—-anda clarion call for further action on this problem—-acknowledging that many important issues remainunclear and urgently require more intensive scienti-fic study.

The commonly accepted definition of a maternaldeath is “the death of a woman while pregnant orwithin 42 days of termination of pregnancy, irres-pective of the duration and the site of the pregnancy,from any cause related to or aggravated by the pre-gnancy or its management but not from accidental orincidental causes” (AbouZahr and Royston 1991).The most common measure of maternal mortalityused for international comparative purposes is thematernal mortality ratio: the number of maternaldeaths per 100,000 live births. The available statis-tics show huge discrepancies between the developedand the developing worlds (WHO, UNICEF et al.2000). The overall world maternal mortality ratio isestimated at 400 maternal deaths per 100,000 livebirths. In developed regions of the world the ratio is20 deaths per 100,000 live births, contrasted with440 deaths per 100,000 live births in less developedregions. The worst statistics come from sub-SaharanAfrica, where nearly 1% of all pregnant women canexpect to die in any given pregnancy. There are manyproblems associated with the collection of maternalmortality statistics and the estimation of maternalmortality ratios, especially in developing countries,and these statistics are generally acknowledged to beunderestimates to some (usually to a substantial)degree.

For an individual woman, the most important statis-tic is not the maternal mortality ratio, but rather theestimation of her risk of pregnancy-related deathacross her reproductive lifespan. A woman’s lifetimerisk of maternal death is a function of her risk ofdying in any particular pregnancy multiplied by thenumber of times she is likely to become pregnant.These risks are therefore highest in areas of high fer-tility where access to emergency obstetric care ispoor. In the affluent, industrialized developed

II. THE RELATIONSHIP OFOBSTETRIC FISTULAS TO MATERNAL MORTALITY

I. LEVELS OF EVIDENCE CONCERNING OBSTETRIC

FISTULAS

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regions of the world, a woman’s lifetime risk ofdying from an obstetric complication is small (1 in2,800); but in impoverished Third World regions, herrisk of death is substantial (1 in 61). In sub-SaharanAfrica, the risk is even higher (1 in 16). Worldwide,the vast majority of maternal deaths are clustered ina handful of nations with large populations and mar-ginal obstetric care. Only 13 countries account for70% of all maternal deaths [India, Nigeria, Pakistan,Democratic Republic of the Congo, Ethiopia, Tanza-nia, Afghanistan, Bangladesh, Angola, China,Kenya, Indonesia and Uganda]. When ranked accor-ding to obstetric risk (maternal mortality ratio), vir-tually all of the most dangerous countries for pre-gnant women are found in sub-Saharan Africa. Inrank order, the countries with the highest maternalmortality ratios (greater than 1,000 deaths per100,000 life births) are Sierra Leone, Afghanistan,Malawi, Angola, Niger, Tanzania, Rwanda, Mali,Somalia, Zimbabwe, Chad, Central African Repu-blic, Guinea Bissau, Kenya, Mozambique, BurkinaFaso, Burundi and Mauritania (WHO, UNICEF et al.2000). The maternal mortality estimates for 2000 aresummarized in Table 1).

The majority of maternal deaths are due to five prin-cipal causes: hemorrhage, sepsis, hypertensive disor-ders of pregnancy, unsafe abortion, and obstructedlabor (AbouZahr and Royston 1991). The vast majo-rity of fistulas are due to obstructed labor. Not sur-

prisingly, obstetric fistulas are most prevalent inareas where maternal mortality is high and whereobstructed labor is a major contributor to maternaldeaths. These are areas where access to emergencyobstetric care is poor and as a result of the lack ofeffective infrastructure, accurate epidemiologicalinformation is also poor in these regions—-a conti-nuing point of difficulty in the evaluation of mater-nal mortality in general and in the evaluation of obs-tetric fistulas in particular.

Obstetric fistula formation is linked directly tomaternal mortality. Maternal mortality is embeddedin a complex network of social issues that have to dowith the social status of women, the distribution andavailability of healthcare resources, perceptionsabout the nature and importance of maternal healthproblems, and the social, economic and politicalinfrastructures of developing countries, but the com-mon thread linking all of these factors together ispoverty (Graham, Fitzmaurice et al. 2004). If onelooks at the country rankings in the Human Deve-lopment Index produced by the United NationsDevelopment Programme, one finds that the coun-tries with the worst maternal mortality problems areall heaped together at the bottom of the index: in fact,the 25 poorest countries in the world are all in sub-Saharan Africa. All of these countries have very highmaternal mortality ratios and a high prevalence ofvesicovaginal fistulas. Poor women die more fre-

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Table 1. Maternal Mortality Estimates for 2000 (WHO, UNICEF, and UNFPA 2000)

Maternal Mortality Ratio Number of Maternal Deaths Lifetime Risk of (Maternal deaths per Maternal Death, 1 in:100,000 live births)

World total 400 529,000 74Developed Regions* 20 2,5000 2,800

Europe 24 1,700 2,400

Developing Regions 440 527,000 61Africa 870 235,000 16

Northern Africa** 130 4,600 210Sub-Saharan Africa 920 247,000 16

Asia 390 323,000 65Eastern Asia 55 11,000 840South-central Asia 520 207,000 46South-eastern Asia 210 25,000 140Western Asia 190 9,800 120

Latin America & the Caribbean 190 22,000 160

Oceania 240 530 83

*Includes Europe, Canada, the United States of America, Japan, Australia and New Zealand which are excluded from the regional totals.

**Excludes Sudan, which is included in sub-Saharan Africa

quently, poor women get fistulas, and the poorer thewoman the greater her likelihood of dying or suffe-ring a catastrophic obstetric complication. Poorwomen do not have adequate, prompt access toemergency obstetric care. Indeed, it is commonlysaid that obstetric fistulas result from the combina-tion of “obstructed labor and obstructed transporta-tion.” Thaddeus and Maine (Thaddeus and Maine1994) have articulated the concept of three “stages ofdelay” that result in maternal mortality: delay indeciding to seek care, delay in arriving at a healthcare facility, and delay in receiving adequate careonce a woman arrives at such a facility. All of thesefactors are present in the development of obstetricfistulas. Laboring women are often neglected in thehope that “everything will come out all right” ontheir own. Other women refuse to seek care for fearthey will be perceived as “weak” or “cowardly,” orbecause they are afraid of the strange social environ-ments found in hospitals. Frequently the seriousnessof the situation is not appreciated or help is notsought for fear of the family incurring high financialcosts. Even if help is sought, poor roads and inade-quate public transportation often result in long delaysin reaching a health care facility, and even if thelaboring woman makes it to a hospital, the servicesavailable there may still be inadequate to meet herneeds in the face of a developing obstetric catas-trophe.

The three “stages of delay” keep women on what issometimes termed the “road to maternal death.” Insimilar fashion it seems that there is also a “road toobstetric fistula” that begins when young girls growup in nutritionally marginal circumstances, are mar-ried around the age of menarche, become pregnantwhile still adolescents, and labor at home eitheralone or under the care of untrained birth attendantsfor prolonged periods of time and without adequateaccess to emergency obstetrical care. In addition,many such women become victims of harmful tradi-tional medical practices that further complicate theirsituation. The obstetric fistula pathway is summari-zed in Figure 1.

In industrialized countries most vesico-vaginal fistu-las (VVF) are the result of radiation therapy or sur-gery (Latzko 1942); (Everett and Mattingly 1956);(Counsellor and Haigler 1956); (Radman 1961);

(Moir 1966); (Massee, Welch et al. 1964); (Weed1967); (Taylor and Droegemueller 1967); (Goodwinand Scardino 1980); (Enzelsberger and Gitsch 1991)(Langkilde, Pless et al. 1999). In the developingworld, on the other hand, most fistulas occur fromthe neglect of obstetric complications. As such, theyoccur under very different circumstances.

To date there has never been a comprehensive world-wide survey designed to determine precisely whereobstetric fistulas occur. Questions regarding the inci-dence and prevalence of obstetric fistulas have neverbeen included on the standardized demographic andhealth surveys (DHS) that are carried out to evaluatepopulation characteristics and overall health status indeveloping countries. Virtually no population-basedsurveys have been carried out in countries wherethere appears to be a high incidence and high preva-lence of obstetric fistulas. Furthermore, the urinaryand/or fecal incontinence that accompanies a fistulamakes these women social outcasts, pushing them tothe margins of society where they are ignored andfurther obscuring the true extent of the problem.There is a very real need for ongoing scientificresearch in this area. Until such work is forthcoming,we are left with only indirect means of describing theepidemic. In a short survey of available informationon obstetric fistulas published by the World HealthOrganization in 1991 that encompassed a literaturereview and correspondence with over 250 indivi-duals, institutions and organizations in developingcountries, a map was created showing the distribu-tion of countries where obstetric fistulas had beenreported (Figure 2). The committee members, frompersonal experience and contact with other workersin the field, know that this map should include vir-tually all of Africa and south Asia, the less developedparts of Oceania, Latin America, and the MiddleEast; and, we suspect, the more remote regions ofCentral Asia and selected isolated areas of the formerSoviet Union and Soviet-dominated eastern Europe.A recent survey of 9 African countries carried out byEngenderHealth for the United Nations PopulationFund, has provided additional anecdotal evidence ofhow widespread the fistula problem is in sub-Saha-ran Africa (UNFPA 2003).

The true magnitude of the fistula problem worldwi-de is unknown, but it is clearly enormous. The situa-tion in Nigeria may be cited as an example. Arrows-mith (1994), writing from the plateau region of cen-tral Nigeria, noted that “the local popular press esti-mates that the region may harbor up to 150,000 vic-tims of vesicovaginal fistula.” Harrison, also writing

III. EPIDEMIOLOGY OF THE OBSTETRIC FISTULA

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Figure 1. The Obstetric Fistula Pathway: Origins and Consequences (©Worldwide Fistula Fund, used by permission).

from northern Nigeria, reported a vesico-vaginal fis-tula rate of 350 cases per 100,000 deliveries at a uni-versity teaching hospital (Harrison 1985). Karshima,who has carried out village-based survey work onobstetric fistulas in the middle belt of Nigeria, sus-pects that there may be as many as 400,000 unrepai-red fistulas in Nigeria (J. Karshima, personal com-munication, 2001), and the Nigerian Federal Minis-ter for Women Affairs and Youth Development,Hajiya Aisha M.S. Ismail, has estimated the numberof unrepaired vesico-vaginal fistulas in Nigeria atbetween 800,000 and 1,000,000 (personal communi-cation, 2001).

The data on maternal morbidity (non-fatal obstetriccomplications) in developing countries are poor, butit obvious that the number of serious morbid epi-sodes or “near misses” greatly exceeds the number ofmaternal deaths in the developing nations (Prual,Huguet et al. 1998). In parts of the world where awoman’s lifetime risk of maternal death is high, awoman’s lifetime risk of suffering serious maternalmorbidity (including obstetric fistula) may be extra-ordinarily high. In one of the few studies that haslooked at the issue of maternal morbidity, Fortneyand Smith calculated the ratios of serious morbiditiesto maternal mortalities in Indonesia, Bangladesh,

India and Egypt. For each maternal death, they cal-culated that there were 149, 259, 300 and 591 seriousmorbidities in these respective countries, and 112,114, 24, and 67 life-threatening morbidities respecti-vely (Fortney and Smith 1996). In the face of suchsobering statistics, Danso and colleagues suggestedthat in regions of the world where obstructed labor isa major contributor to maternal mortality, the obste-tric fistula rate may approach the maternal mortalityrate (Danso, Martey et al. 1996). Other authors havereached similar conclusions (Hilton and Ward 1998;Hilton 2003).

In the absence of good population-based epidemiolo-gical studies, most information on fistulas has comefrom large series of patients seen at teaching hospi-tals or at dedicated fistula centers. Just as there arereasons to be wary of hospital-based statistics in sur-veys of maternal mortality (AbouZahr and Royston1991), there are reasons to be cautious about consi-dering hospital-based surveys of fistula patients to berepresentative of the over-all population of womenwith fistulas from obstructed labor. Answers to thefollowing questions appear to be crucial in delinea-ting the true extent of the fistula problem worldwide:

• Where do fistula patients come from?

• What is their social background?

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Figure 2. Countries from which obstetric vesico-vaginal fistulas have been reported (WHO 1991). The prevalence is actuallysubstantially greater than this map indicates.

• What is their educational level?

• What is the age at marriage of women who deve-lop fistulas?

• What is the distribution of fistulas by age and pari-ty at the time of their occurrence?

• In which pregnancy do obstetric fistulas occur?

• What proportion of women who develop fistulashad access to obstetric care, and if such care wasavailable, why was it not used in a timely fashion?

• Where do women who develop fistulas deliverand who attends those deliveries?

• How long are these women in labor before theyrecognize that labor is obstructed and seek help,and how long is the delay before effective help isobtained?

• What is their marital/social status at the time oflabor?

• What is the physical condition of these womenwhen they go into labor?

• How long do women who develop fistulas waitbefore they undergo an attempt at surgical repair,and at what age do they present for repair?

• What is the social status of fistula victims afterthey develop this problem?

• Does this status change after fistula closure?

• What role do harmful traditional beliefs and prac-tices play in the genesis of prolonged obstructedlabor and fistula formation?

Although detailed answers to these questions awaitdetailed population-based research, preliminaryimpressions can be obtained from surveys taken offistula patients in hospital settings in several coun-tries. The overall impression is that fistula patientscome from poor rural areas where infrastructuredevelopment is rudimentary and access to healthcare—particularly access to basic midwifery andemergency obstetric services—is lacking. Fistulapatients tend to be young women, many of whommarried very early, of short stature, poorly educated,married to farmers or petty traders who themselveshave little or no formal education. They typicallyhave had little or no access to prenatal care, and evenif they have had access to antenatal screening, theyhave often nonetheless delivered at home attendedby family members or traditional midwives. If theyhave sought help from trained midwives or medicaldoctors, this often occurs late in labor after seriouscomplications have already set in.

Several papers from Africa support this picture of thefistula patient. Kelly and Kwast (Kelly and Kwast1993) reviewed a 10% sample of fistula patients seenat the Addis Ababa Fistula hospital between 1983and 1988, by reviewing the records of every tenthpatient. The mean age of these women was 22.4years (range 9 – 45 years); 42% were less than 20years of age, and 65% were less than 25 years of age.Of the women surveyed, 52.3% had been deserted bytheir husbands and 21.5% had to live by begging forfood. Nearly 30% had delivered alone, and the meanduration of labor was 3.9 days (range 1-6 days).

In one review of 150 fistulas from Ghana (Danso,Martey et al. 1996), 91.5% were the result of obs-tructed labor and 8.5% were the result of complica-tions of difficult gynecological surgery (22). Nearly53% of the obstetric fistula patients were under theage of 25 and nearly 43% of patients were primigra-vid. Interestingly, nearly 25% of the patients had aparity of 5 or more, indicating that labor can becomeobstructed even in women who have previously deli-vered vaginally. This probably represents the tenden-cy for birth weights to increase with successive pre-gnancies, as well as the effects of aging on changesin pelvic anatomy.

Information from several studies in northern Nigeriais similar. Tahzib (Tahzib 1983) reviewed records of1,443 patients with vesico-vaginal fistulas seen inthe clinics at Ahmadu Bello University in Zaria bet-ween 1969 and 1980. Delivery occurred at home in64.4 % of these women. Among women who deve-loped fistulas, 54.8% were under the age of 20 andonly 22.7% were older than 25 years. The majorityof women developed a fistula in their first pregnan-cy (52%), and 21.5 % of fistula patients were parity4 or greater. Wall and colleagues (Wall, Karshima etal. 2004) analyzed 899 obstetric fistula patients fromJos, Plateau State, Nigeria and found that womenwith fistulas tended to have been married early (oftenbefore menarche), to be short (nearly 80% less than150 cm tall), small (mean weight less than 44 kg), tobe impoverished, poorly educated, and to come fromrural agricultural families. Fistulas occurred mostcommonly in first pregnancies, but over 20% of fis-tulas occurred in women of parity 4 or greater). Twocase control studies from northern Nigeria have alsofound fistula patients to be shorter, to be of lowersocioeconomic status, and to have less educationthan control patients without fistulas (Ampofo, Otuet al. 1990; Onolemhemhen and Ekwempu 1999).

Virtually every paper on vesico-vaginal fistulas fromdeveloping countries demonstrates that the most

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common cause of fistula formation by far is prolon-ged obstructed labor (Krishnan 1949; Lavery 1955;Mahfouz 1957; Naidu 1962; Aziz 1965; Yenen andBabuna 1965; Coetzee and Lithgow 1966; Bird1967; Mustafa and Rushwan 1971; Lawson 1972;Tahzib 1983; Tahzib 1985; Waaldijk 1989; Iloaba-chie 1992; Kelly 1992; Arrowsmith 1994; Amr 1998;Goh 1998; Hilton and Ward 1998; Gharoro andAbedi 1999; Wall, Karshima et al. 2004) accountingfor between 76% and 97% of fistulas in most largeseries. Vangeenderhuysen, Prual and Ould el Joudrecently proposed an evaluation of the incidence ofobstetric fistulas based on a population-study ofsevere obstetric morbidity among 19,342 women fol-lowed prospectively through pregnancy in six westAfrican cities: Abidjan, Bamako, Niamey, Nouak-chott, Ouagadougou, Saint-Louis, and a rural area inKaolack Region, Senegal (Vangeenderhuysen, Prualet al. 2001). Only two cases of vesico-vaginal fistulaoccurred in this population, for an incidence of 10.3per 100,000 deliveries. These two fistulas occurredin a rural area and no fistulas were reported fromurban areas, giving a rural incidence rate of 123.9fistulas per 100,000 deliveries. Based on an estimateof 33,748,000 deliveries per year in sub-SaharanAfrica, these authors estimated that sub-SaharanAfrica produced 33,451 new obstetric fistulas peryear.

Another rough way of evaluating the extent of thefistula problem is to look at the proportion of laborsthat become obstructed and to try to extrapolate theincidence of potential fistulas from this data. Esti-mates for the prevalence of obstructed labor rangefrom 0.5% - 4.7% in Nigeria (Lister 1960; Ozumbaand Uchegbu 1991) to 1.7% - 2.0% for India (Sarkarand Paul 1990; Kamalajayaram 1993). The WHOprospective multicenter trial of the use of parto-graphs in conjunction with a standardized labormanagement protocol found a baseline incidence ofprolonged labor in 6.4% of labors at the start of thestudy, which fell to 3.4% after the partograph proto-col was introduced (Kwast 1994). If one assumedthat labor would become obstructed in approximate-ly 2.0% of cases in Third World countries, using anestimate of 33,748,000 births per year in Africawould result in as many as 674,060 cases of obstruc-ted labor each year. If 10% of African women withobstructed labor subsequently developed a fistula,there would be roughly 67,000 new fistulas eachyear in Africa alone.

In Harrison’s seminal study of African obstetricsbased on an analysis of 22,774 consecutive delive-

ries at Ahmadu Bello University Teaching Hospitalin Zaria, Nigeria (Harrison 1985), there were 79women delivered at the hospital who had or develo-ped a vesicovaginal fistula, giving a ratio of 1 fistulafor every 288 deliveries, a fistula incidence rate of0.35%, (350 fistulas per 100,000 births). This is anastonishing figure; however, there were also 203cases of uterine rupture. This means that a catastro-phic outcome due to obstructed labor occurred in 282deliveries, or 1.2% (1,200 such outcomes per100,000 births). Harrison’s poignant comment that“Labour is a horrifying experience for a substantialproportion of women in Northern Nigeria, as it is inmany other places in the Third World” is not unders-tated (Harrison 1985).

Other important causes of fistulas include injuriessustained during complicated gynecologic surgeryperformed under very difficult circumstances or fis-tulas resulting from complications of Cesarean deli-very (often involving women who arrive at hospitalalready at death’s door or in need of immediateemergency surgery which ends up being performedby physicians without extensive operative experien-ce under circumstances in which they have inade-quate equipment and support). Vesico-uterine fistu-las, for example, are frequently the result of compli-cations encountered during Cesarean section, ratherthan direct consequences of prolonged obstructedlabor, although this latter presentation is by no meansuncommon (Yip and Leung 1998; Jozwik and Joz-wik 2000; Billmeyer, Nygaard et al. 2001; Porcario,Zicari et al. 2002). Fistulas arising as the result ofsurgical complications are likely to increase in fre-quency as access to rudimentary bioscientific medi-cine and surgery becomes more common in ThirdWorld countries but before smoothly functioningsystems of supervision, supply, and quality controlare in place (Sundari 1992). They represent an ThirdWorld version of what Moser called “diseases ofmedical progress:” iatrogenic complications of newinnovative therapies (Moser 1956). For example, inthe study of 164 fistulas reported by Danso and col-leagues (Danso, Martey et al. 1996) from Kumasi,Ghana, 150 cases (91.5%) were due to obstetric com-plications. Of these 150 fistulas, 121 were due toprolonged obstructed labor and 24 were due to com-plications of cesarean section. A further 12 caseswere due to complications of abdominal hysterecto-my. Out of 164 fistulas, therefore, 36 (22%) were dueto complications of surgery, a phenomenon that doesnot exist in situations where access to hospital-basedmedical care does not exist. A further and more dra-

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matic example of this phenomenon can be found in arecent large survey of 230 vesicovaginal fistulasfrom Ramabothi Hospital in Thailand which wererepaired between 1969 and 1997 (Kochakarn, Rata-na-Olarn et al. 2000). Only 10 cases in this serieswere due to prolonged labor or childbirth trauma.The remaining 220 cases were due to complicationsof abdominal hysterectomy (164 cases), vaginal hys-terectomy (23 cases), radical hysterectomy (8 cases),radiation therapy for cervical cancer (9 cases) or cer-vical cancer frankly invading the bladder (7 cases),suprapubic lithotomy (2 cases) and pelvic fracture (2cases). Nearly three-quarters of these cases werereferred from other hospitals and represent compli-cations that have become more prevalent as moresophisticated medical care has reached larger pro-portions of the population of Thailand.

Fistulas may also be caused by accidents such aspenetrating injuries to the vagina and bladder invol-ving cattle horns or impalement by falling on a stick,infection (particularly lymphogranuloma venereum,but also diphtheria, measles, schistosomiasis, tuber-culosis, infected centipede bites, etc.), foreign bodies(Arikan et. al. 2000; Fourie and Ramphal 2001),bladder calculi (Piercy, Gregory et al. 1987; Rai andRamesh 1998), mishaps during masturbation(Ramaiah and Kumar 1998), and cervical cancer. Intheir series of 309 urinary fistulas treated in Pieter-maritzburg, Natal, South Africa between 1954 and1963, Coetzee and Lithgow (Coetzee and Lithgow1966) reported 248 as resulting from obstructedlabor (80%), 9 (3%) from complications of pelvicsurgery, and 52 (17%) from advanced carcinoma ofthe cervix. Particularly troubling are fistulas causedby sexual abuse, rape, or from attempts forcibly toenlarge the vaginal introitus of child brides so thatsexual relations can commence (Tahzib 1985; Shar-ma, Madhusudnan et al. 1987; Muleta and Williams1999; Roy, Vaijyanath et al. 2002).

In some parts of the world, harmful traditional prac-tices are also responsible for fistula formation. Forexample, in northern Nigeria, a harmful traditionalpractice called gishiri-cutting is responsible for fistu-la formation in 2 – 13% of cases (Tahzib 1983; Tah-zib 1985; Wall 1988; Ampofo, Otu et al. 1990; Wall,Karshima et al. 2004). Gishiri is the Hausa word for“salt.” It is often used to refer to the encrustations ofsalt that occur on the outsides of porous water-jars astheir contents evaporate. Gishiri is an important eth-nomedical condition in Hausa traditional medicine.The belief is that an imbalance of salty or sweetfoodstuffs can cause a “film” to grow over the

woman’s vagina, causing a variety of gynecologicalcomplaints, the most important of these being diffi-cult labor (Wall 1988). When this diagnosis is made,surgical treatment is often undertaken. A midwife orbarber is summoned. A sharp object such as a knife,razor blade, or piece of broken glass is inserted intothe vagina, and a series of random cuts is made toalleviate the postulated obstruction and “open theway” for the baby to come out. Serious infection,life-threatening hemorrhage, and fistulas frequentlyresult from this practice. The gishiri fistula typicallypresents as a direct longitudinal slit in the bladderneck and urethra, occasionally presenting as a simi-lar posterior injury affecting the rectum.

Another traditional practice that has been reported toproduce fistulas is the insertion of caustic substancesinto the vagina, either as part of a traditional herbalremedy for a gynecologic condition (Lawson 1968)or as part of traditional puerperal practices to “help”the vagina return to its nulliparous state. The latterpractice is a part of the traditional folk medicine ofseveral Arab countries (Kingston 1957; Frith 1960;El-Guindi 1962). The practice was summarized byBetty Underhill in her 1964 report of 65 such casesseen at the Bahrain Government Hospital between1957 and 1963 thus (Underhill 1964):

The immediate effect of the pessary on the hyperae-mic vagina is the production of severe inflammationwhich goes on to ulceration. Healing of the ulcersleads to a very severe fibrosis and the vaginabecomes partly or completely occluded by a substan-ce with an almost cartilaginous texture. The walls ofthe upper third of the vagina are held apart by thecervix and the lower third is constantly pulled upon

“For hundreds of years it has been the custom ofArab women to pack the vagina with salt for thefirst week after delivery. This is popularly suppo-sed to restore the vagina to its nulliparous state andto add to the husband’s sexual pleasure. Since thepractice has survived for so long it must be presu-med that this desirable effect is sometimes achie-ved. It is certainly true, however, that in a greatmany cases the end results are devastating and it isthese unhappy women who are driven to hospitalfor relief. … The substance used is crude rock saltsold in the bazaar. A piece of salt roughly the sizeand shape of an egg is pushed into the vagina dailyfor 2 to 15 days after the delivery. An additionalincentive to the use of salt is its supposed antisep-tic property, and some women are said to employ itbetween pregnancies as a contraceptive.

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by the levator ani muscle. The lax middle third iscommonly the area affected by fibrosis and thepatient is left with a tiny lower vagina 2 to 5 cm long,then a block or cord of fibrous tissue with an upperchamber indented by the cervix.”

The fibrosis that results is extensive enough to pro-duce obstructed labor in many cases (Fahmy 1962).Fistulas may result from either obstructed labor(Fahmy 1962) or by direct chemical action. As Naimhas written, “The method of salt packing determinesthe site and types of the fistulae that may develop.Thus in Kuwait, where the whole vagina is packedwith rock salt, combined rectovaginal and vesicova-ginal fistulae develop due to rock salt being incontact with both the anterior and posterior vaginalwalls. In Saudi Arabia, where pieces of rock salt areinserted high in the vagina, rectovaginal fistulae onlywere met with (Naim 1965).” In some cases thevagina is completely occluded, leading to the forma-tion of a hematocolpos, dysmenorrhea, infertility andrelated gynecological conditions (Underhill 1964).

Much popular concern has focused recently on geni-tal cutting practices commonly referred to as “fema-le circumcision” or “female genital mutilation” (forexample, (Aziz 1980; Abdalla 1982; Boddy 1982;El-Dareer 1982; Toubia 1994; WHO 1998; Gruen-baum 2001). While these practices should rightly becondemned by the medical community as being mar-kedly injurious to the health of women and femalechildren, there is absolutely no evidence in the worldliterature to suggest that practices of this type are themajor cause of fistulas in developing countries.While obstetric fistulas are common in communitieswhere various forms of female genital mutilation arepracticed, the former are not usually caused directlyby the latter. Rather, these two phenomena bothreflect the low social status of women in these coun-tries, which in turn is reflected by a striking under-investment in women’s reproductive health care inthose countries, and a consequent lack of access toemergency obstetric care and poor general gynecolo-gic health.

Where female genital mutilation is practiced, itcontributes to the genesis of fistulas in two ways.First, as in the case of gishiri-cutting among theHausa, surgical attempts to modify the female geni-talia in any fashion can cause direct injury to thebladder or urethra. When such procedures are carriedout without anesthetic under unsterile conditions byunskilled practitioners who do not understand fema-

le pelvic anatomy, the risk of catastrophic complica-tions is great, and fistulas may be created by directtrauma to the urinary tract in such cases. Secondly,when large amounts of vulvar or vaginal tissue areremoved as occurs in cases of infibulation (“Pharao-nic circumcision”) where the vaginal introitus issewn almost completely closed or where excessivevulvar scarring has resulted from such practices, thevaginal outlet may become so narrow and constrictedby dense scar tissue that the fetus cannot be expelledat the end of the second stage of labor; indeed, ananterior episiotomy is usually required in order toeffect vaginal delivery in such women. If the outletcannot be opened sufficiently to allow passage of thefetus, the resulting obstructed labor may end in a fis-tula. However, for this cause to be of major impor-tance, labor would have to progress normallythrough the entire pelvis, become obstructed only atthe outlet. The available evidence suggests that obs-tructed labor occurring only at the outlet is a relati-vely rare occurrence.

Most of the evidence suggests that in most caseswhere fistulas occur, labor becomes obstructed at thelevel of the pelvic brim or the mid-pelvis, rather thanat the pelvic outlet. Further evidence for the primaryimportance of obstetric factors (rather than genitalcutting practices) in the creation of vesicovaginal fis-tulas can be seen in the fact that the Hausa, whoappear to have one of the highest prevalences of obs-tetric fistulas in the world, do not practice “femalecircumcision,” and those fistulas that do occur due togishiri-cutting constitute only a small portion of fis-tula cases. Comparative radiographic studies suggestthat the Nigerian pelvis is considerably smaller thanthat of European (Welsh) women, particularly at thepelvic inlet, least significantly at the pelvic outlet(Kolawole, Adam et al. 1978).

This suggests that there are anatomic differences thatpredispose African women to obstructed labor(Briggs 1983). Because sexual maturity is reachedbefore growth of the pelvic dimensions has beencompleted, pregnancies that occur in early adoles-cence are more likely to be complicated by obstruc-ted labor than those that occur in older women(Moerman 1982). Early marriage and accompanyingearly pregnancy are also linked to a relatively lowsocial status of women, tying these factors togetherin one more way. Many of these women also appearto suffer from chronic anemia and malnutrition,which further compromise their obstetric capabili-ties.

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Obstructed labor occurs when the presenting fetalpart cannot pass through the maternal bony pelvis.The presenting part then becomes wedged againstthe maternal pelvic bones, compressing the soft tis-sues in between (Figure 3). The uterine contractionsforce the presenting part deeper into the pelvis, com-pressing the maternal soft tissues more forcibly. Ifthis process is not relieved by surgical intervention,the blood supply to the entrapped soft tissuesbecomes compromised, ultimately resulting in tissuedeath and fistula formation.

The pathophysiology of obstructed labor was descri-bed clearly and succinctly by Mahfouz in 1930(Mahfouz 1930):

The slough that develops from this pressure necrosismost commonly results in a vesico-vaginal fistula(Figure 4). Once this has occurred, the unfortunatewoman suffers from constant, unremitting loss ofurine. She can attempt to stay this flow with the useof rags or cloth, but she can never get rid of it. J.Marion Sims, who first developed a consistently suc-

cessful method of fistula closure, expressed well thesituation of the patient with a fistula (Sims 1852):

The accident, per se, is never fatal; but it may wellbe imagined that a lady of keen sensibilities so afflic-ted, and excluded from all social enjoyment, wouldprefer death. A case of this kind came under myobservation a few years since, where the lady abso-lutely pined away and died, in consequence of herextreme mortification on ascertaining that she washopelessly incurable.”

The location and nature of the maternal injury thatresults from prolonged obstructed labor is a functionof the force and duration of the compression thatoccurs, as well as the level at which labor becomesobstructed (Figure 5). As Mahfouz remarked (Mah-fouz 1930): “The situation of the fistula depends to agreat extent on the state of the cervix, when impac-tion and compression occur, and also on the plane ofimpaction. If pressure and compression occur beforethe cervix is pulled up over the head, the vault of thevagina and the cervical tissues may be involved inthe slough. The resulting fistula will be vesico-cervi-co-vaginal, or uretero-vaginal, as the case may be.”The location of the fistula is often determined by theparticular configuration of the woman’s pelvis. Thus,John St. George noted (St. George 1969):

“Vesico-vaginal fistulae occurred more often inprimigravidae (often very young) than in multipa-rae. Deep transverse arrest of the fetal head wascommoner in primiparae with an android type ofpelvis, and therefore the site of the fistula was

“Its diagnosis is sufficiently easy. Incontinence ofurine, following a tedious labour after a lapse offrom one to fifteen days, will always prove its exis-tence. But to determine the exact size, shape, andrelative position of the artificial opening requiresome nicety of examination. The consequences ofthe involuntary discharge of urine are indeed pain-ful. The vagina may become inflamed, ulcerated,encrusted with urinary calculi, and even contrac-ted; while the vulva, nates, and thighs are more orless excoriated, being often covered with pustuleshaving a great resemblance to those produced bytartar emetic. These pustules sometimes degenera-te into sloughs, causing loss of substance, andrequiring a long time to heal. The clothes and bed-ding of the unfortunate patient are constantly satu-rated with the discharge, thus exhaling a disa-greeable effluvium, alike disgusting to herself andrepulsive to others.

“The process by which a fistula develops afterlabour is the following. When labour becomes dif-ficult, on account of disproportion between thepelvis and presenting part, or when the presenta-tion is abnormal, the uterine contractions increasein strength and endeavour to force the presentingpart through the brim. The membranes protrudeunduly in the vagina, and premature ruptureoccurs. In consequence of early rupture and dis-proportion the full force of the uterine contractionsis directly exerted upon the foetus and the presen-ting part is forced against the brim of the pelvis orgets tightly impacted therein. The vesico-vaginalseptum, and the cervix if the latter is not dilated,will be tightly compressed against the back of thesymphysis pubis. The uterus in such cases usuallypasses into a state of tonic contractions which pre-vents any remission in the pressure exerted on thesoft parts. As a result of the continued pressure thetissues undergo necrosis and slough away. Theduration of compression in such cases is usuallyvery long, but I have seen cases in which a fistuladeveloped after 3 hours of compression only. Atabout the fifth day of the puerperium the sloughbegins to separate and urine dribbles involuntarilyinto the vagina. …

IV. THE “OBSTRUCTED LABOR INJURY COMPLEX”

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Figure 3. Obstructed labor from absolute cephalo-pelvicdisproportion, from William Smellie’s Sett of AnatomicalTables with Explanations, and an Abridgement of the Prac-tice of Midwifery. London, 1754

Figure 4. Typical mid-vaginal vesico-vaginal fistula fromobstructed labor. A metal sound passed through the urethracan clearly be seen inside the bladder. (©Worldwide FistulaFund, used by permission).

Figure 5. Types of genito-urinary fistulas. The locationdepends on the point at which labor becomes obstructed. A.Utero-vesical fistula. B. Cervico-vesical fistula. C. Mid-vaginal vesico-vaginal fistula. D. Vesico-vaginal fistulainvolving the bladder neck. E. Urethro-vaginal fistula.From Elkins (1994).

Many women who develop an obstetric vesico-vagi-nal fistula have been delivered vaginally with the useof instruments or have had an abdominal delivery byCesarean section. As early as the 19th Century, obs-tetricians were often blamed for creating fistulasthrough the injudicious use of operative techniques.Although incompetent surgical delivery is undoub-tedly responsible for some fistulas, the vast majorityof patients undergoing operative delivery have beenin labor for a prolonged period of time and havealready suffered the ischemic insult that ultimatelyleads to fistula formation. The mode of delivery istherefore often unrelated to the development of thefistula that subsequently occurs (Emmet 1879). AsDas and Sengupta noted in their series from India(Das and Sengupta 1969):

The prevalence of women who have had prolongedlabors and then undergone operative delivery is inpart a function of increasing access to obstetric care,even if that access is not timely enough to preventthe development of a fistula. In his review of vesico-vaginal fistulas in Jordan, M.F. Amr (Amr 1998)summarized the relationship between women’s heal-th care and fistula formation with these words: “Theincidence of urinary fistula reflects the standard ofobstetric and gynaecological care and its availabilityto the population. Most fistulae are due to obstetriccauses such as prolonged and obstructed labour, dif-ficult instrumental delivery and other obstetric mani-pulations, and ruptured uterus.”

The vast majority of women in non-industrializedcountries who develop a vesico-vaginal fistula do so

as the result of prolonged obstructed labor fromcephalo-pelvic disproportion. The presenting fetalpart is wedged into the pelvis, trapping the woman’ssoft tissues between two bony plates which effecti-vely shut off the blood supply to the affected tissues.This results in extensive tissue necrosis which fre-quently destroys the vesico-vaginal septum andresults in fistula formation; however, it is importantto realize that obstructed labor produces a broad-spectrum “field injury” that may affect many parts ofthe pelvis. The damage that occurs is not limited tovesico-vaginal or recto-vaginal fistula formationalone. This fact is not generally appreciated by mostWestern doctors. Although the fistula that results isusually the dominant clinical injury, it is wrong tofocus solely on the “hole in the bladder” to the exclu-sion of the other consequences of obstructed labor.Women who have sustained an obstetric fistula areusually injured in multiple ways, all of which impacttheir lives and well-being, and all of which must beconsidered in their care. Arrowsmith, Hamlin andWall (Arrowsmith, Hamlin et al. 1996) have calledthis spectrum of injury the “obstructed labor injurycomplex” (Table 2). The understanding that onemust treat the “whole person” with a fistula—-andnot just her injured bladder or rectum—-is the singlemost important concept in fistula care. Doing thiseffectively requires some understanding of the multi-system consequences of prolonged obstructed labor.

1. UROLOGIC INJURY

Obstetric vesicovaginal fistulas are not caused bytearing or laceration of the bladder; rather they resultfrom ischemic injury. Normal tissue perfusion is dis-rupted by compression of the soft tissues by the fetalhead. This leads to ischemia, tissue death, subse-quent necrosis, and fistula formation, along withvarying degrees of injury to surrounding tissueswhich, although they have not died, nonetheless areoften not completely healthy either, having sufferinga non-fatal but debilitating ischemic vascular injuryas well. This process has an impact at various levelsthroughout the urinary tract.

a) Bladder

The most familiar injury from obstructed labor is thevesicovaginal fistula. The loss of bladder tissue frompelvic ischemia during obstructed labor affects boththe technique needed for, as well as the functionaloutcome of, fistula repair. Loss of bladder tissue isone of the main reasons why obstetric fistula repairis technically difficult. The surgeon must try to closelarge defects in the bladder often with only small

“Pressure necrosis is responsible to a great extentfor the fistula. Most of the instrumental labourgroup were also prolonged labour cases and wouldprobably have resulted in vesico-vaginal fistulaeven without instrumentation. Therefore, all caseswere not caused by instrumental delivery as suchbut were due to pressure necrosis that had alreadyexisted.”

more often at the bladder neck or was juxta-ure-thral. Primiparae were also permitted longerlabour by their folk because of their youth, andhence their fistulae were extensive. On the otherhand, labour in multigravidae was often obstructedat the inlet because of a secondary flat pelvis; inthese cases mid-vaginal or juxta-cervical fistulae,which were more amenable to surgery, were morecommon.”

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remnants of residual bladder tissue with which towork. Although there are as yet no basic histologicstudies of the tissue surrounding obstetric fistulas, itseems clear that these tissues have themselves sus-tained significant damage during obstructed labor.The fistula itself develops in an area which becomesnecrotic; but the tissues surrounding the fistula havealso suffered varying degrees of ischemia. Althoughnot dead, these tissues have been seriously damaged.In repairing obstetric fistulas, this unhealthy tissuesurrounding the fistula must be used to close thedefect—-a problem that has led many fistula sur-geons to the brink of despair (Figure 6).

In some cases pressure necrosis may destroy virtual-ly the entire bladder, so that if the defect can be clo-sed at all, the afflicted woman is left with a remarka-bly small (30 - 50 ml) bladder that remains virtuallyfunctionless. Because most of the innervation of thebladder runs through the base and trigone, ischemicinjury to these areas probably also produces an ele-ment of neuropathic bladder dysfunction. Basicscientific studies confirming this hypothesis have yetto be undertaken.

Clinical experience with fistula patients also sug-gests that bladder compliance may be altered by theextensive fibrotic changes that often take place. Todate there have been few urodynamic studies repor-ted on patients who have undergone successful fistu-la closure (Schleicher, Ojengbede et al. 1993; Carey,Goh et al. 2002). In the former study bladder com-pliance was not measured. In the latter study byCarey et. al., of 22 women with severe urinary incon-tinence after fistula closure, 9 had urodynamic stressincontinence with normal bladder compliance, 3 had

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Table 2. Spectrum of Injuries Seen in the “ObstructedLabor Injury Complex”

Urologic Injury

Vesico-vaginal fistula

Urethro-vaginal fistula

Uretero-vaginal fistula

Utero-vesical fistula

Complex combinations of fistulas

Urethral damage, including complete urethral loss

Stress urinary incontinence

Secondary hydroureteronephrosis

Chronic pyelonephritis

Renal failure

Gynecologic Injury

Amenorrhea

Vaginal stenosis

Cervical damage, including complete cervical destruction

Secondary pelvic inflammatory disease

Secondary infertility

Gastrointestinal Injury

Rectovaginal fistula

Acquired rectal atresia

Anal sphincter incompetence

Musculoskeletal Injury

Osteitis pubis

Neurological Injury

Foot-drop

Complex neuropathic bladder dysfunction

Dermatologic Injury

Chronic excoriation of skin from maceration in urine/feces

Fetal Injury

Approximately 95% fetal case mortality rate

Social Injury

Social isolation

Divorce

Worsening poverty

Malnutrition

Depression, sometimes suicide

Figure 6. Large mid-vaginal vesico-vaginal fistula withscarring. The ureters, which have been catheterized for bet-ter visualization, lie directly on the margins of the fistula.(©Worldwide Fistula Fund, used by permission).

urodynamic stress incontinence with poor bladdercompliance, 9 had mixed incontinence, and one hadvoiding difficulty with incomplete bladder emptyingand overflow. There is a great need for further inves-tigation of these issues; unfortunately, those hospi-tals most likely to see large numbers of patients withobstetric fistulas lack the resources for such urologicinvestigation. The potential use of bladder augmen-tation operations to restore the functional bladdercapacity of such patients remains largely uninvesti-gated. Although there are well-established surgicaltechniques for bladder augmentation that can be usedin the health care systems of industrialized countries,for the most part those developing countries in whichfistulas are most likely to be major problems are pre-cisely those countries in which the capacity is lac-king to perform such operations safely, competently,and successfully. At least for the present, complexbladder augmentation operations (cecocystoplasty,ileocystoplasty, gastrocystoplasty, etc.) do not appearto be feasible therapies for most women withcontracted bladders after obstetric fistula repair. Onepossible solution to this problem may lie in the useof “auto-augmentation” operations in which a por-tion of the detrusor muscle is removed, permittingthe underlying bladder mucosa to expand, in essencecreating a large bladder diverticulum (Kennelly,Gormley et al. 1994; Snow and Cartwright 1996;Leng, Blalock et al. 1999). At present the potential ofthese techniques in the treatment of fistula patientswith small fibrotic bladders remains completelyunexplored within the context of the developingworld.

A number of patients with vesicovaginal fistulasdevelop vesical calculi (Pang, Lok et al. 2002; Dale-la, Goel et al. 2003). Often these bladder stonesdevelop in association with a foreign body in thevagina. In some cases a foreign body may have beenthe original cause of the fistula (such as an objectused for masturbation or a container filled with tra-ditional herbal medicines, placed in the vagina for anostensibly therapeutic purpose). In other cases, thestone may form in association with an object thatwas placed into the vagina in an attempt to plug thefistula and prevent urine loss, which subsequentlybecame stuck, eventually became calcified, and ulti-mately increased the overall misery of the afflictedwoman. In other cases, no foreign body can befound. Frequently it is the increasing pain associatedwith stone formation that causes the suffering patientto present for care. In fistula cases complicated bythe presence of vesical calculi, the stone is often

located supratrigonally and the bladder may be ableto hold at least a small amount of urine in the vicini-ty of the calculus (which allows for its continuedgrowth) (Dalela, Goel et al. 2003). Removal of thestone (usually at a separate operation) is a pre-requi-site for successful fistula closure in such cases. Afterstone removal, the bladder should be allowed to healfor several months prior to attempted fistula closure.Frequent irrigation of the bladder after the stone hasbeen removed may improve healing of the injuredtissues prior to fistula closure, but there are insuffi-cient data to substantiate this proposal except inanecdeotal cases.

b) Urethra

The ischemic changes produced by obstructed laboroften have a devastating impact on urethral function.The great Egyptian fistula surgeon Naguib Mahfouzwas well aware of this problem. As he wrote in 1930(Mahfouz 1930):

The finest centers in the world report fistula closurerates in excess of 90%, yet many patients who havehad a successful fistula repair continue to have seve-re urinary incontinence. Although the bladder defecthas been closed successfully, many patients havedefective, injured urethras which are often foreshor-tened, fibrotic, functionless “drainpipes” denselybound in scar tissue. Such patients may remainalmost totally wet even when their fistulas have beenclosed. Perhaps as many as 30% of fistula patientshave some element of persistent stress incontinenceafter repair (Hassim and Lucas 1974; Hudson, Hen-

I have carefully examined 100 patients sufferingfrom what was termed vesico-vaginal fistuladuring the last 10 years. I found by careful exami-nation and measurement of the urethra that thesloughing which ultimately led to the formation ofthe fistulae had in more than half the cases invol-ved from one-third to half of the urethra. This isnot to be wondered at, since in most cases of obs-tructed delivery in which the bladder is pulled upabove the brim of the pelvis the urethra is pulledup with it. If the seat of obstruction happens to beat the brim of the pelvis, the neck of the bladderand a small portion of the upper third of the ure-thra seldom escapes compression. In cases inwhich the presenting part is impacted in the cavi-ty of the pelvis, or detained at the outlet, the enti-re urethral canal will be lying in the plane of com-pression. In some of these cases the urethrasloughs away completely.”

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rickse et al. 1975; Schleicher, Ojengbede et al. 1993;Browning 2004). One small study of 55 patients withobstetric fistulas who had undergone successful clo-sure of their fistulas found that 30 women (55%) hadpersistent urinary incontinence. Urodynamic testingdemonstrated genuine stress incontinence in 17women (31%), detrusor over-activity in 2 (4%) andmixed incontinence due to both conditions in 11(20%) (Murray, Goh et al. 2002). The developmentof successful techniques for dealing with persistenttransurethral incontinence after successful fistulaclosure remains an unmet challenge in fistula surge-ry (Hilton, Ward et al. 1998; Murray, Goh et al. 2002;Browning 2004).

Loss of the urethra traditionally has been the mostfeared form of obstetric fistula. Complete urethralloss occurs in about 5% of fistula patients, withabout 30% of fistula patients sustaining partial ure-thral injury. Mahfouz stated (Mahfouz 1930) that fis-tulas “in which the whole urethra has sloughed” are“the most troublesome of all.” The experience ofsubsequent surgeons seems to bear this out. In a 1980series based on 1,789 fistula patients, Sister AnnWard reported that only 26 cases were inoperable;but in all 26 urethral loss was present (Ward 1980).In urethral fistula repair, the surviving tissues mustbe reassembled not just as a tube, but as a supple,functional organ that serves both as a conduit forurine as well as a “gatekeeper” ensuring that the pas-sage of urine occurs only at socially appropriatetimes and places. There are no comparative surgicalstudies that evaluate differing techniques of urethralreconstruction in patients with obstetric fistulas.Work of this kind is badly needed.

c) Ureters

Ureterovaginal fistulas from direct injury to the dis-tal ureter during obstructed labor are uncommon,comprising only about 1% of fistula cases. Depen-ding on the amount of tissue that is lost at the blad-der base, the ureteral orifices can be found in bizarrelocations, ranging from the lateral vaginal walls allthe way up to the level of the vesicourethral junctionand the pubic arch (Figure 6). Aberrant ureteral loca-tions of this kind can easily be missed on clinicalexamination and are one cause of persistent inconti-nence after otherwise “successful” fistula closure.Standard urological tools such as ureteral stents areusually not available in hospitals in the developingworld, and most of the surgeons who work in suchhospitals are not trained in “urologic” techniquessuch as ureteral reimplantation (Waaldijk 1995).

d) Kidneys

The incidence of secondary injury to the upper uri-nary tract in fistula patients has received little study,but this phenomenon appears to be clinically impor-tant. Clinical experience suggests that renal failure isa common cause of death in women with obstetricfistulas. Upper tract damage could result from chro-nic ascending infection, obstruction from distal ure-teral scarring, or even from reflux in very youngpatients. Lagundoye et al (Lagundoye, Bell et al.1976) found that 49% of fistula patients had someabnormality of the kidneys when intravenous uro-grams were performed. Most of the pathology thatwas detected consisted of minor calyceal blunting,but 34% of patients had hydroureter, 9.7% had urete-ral deviation, four patients had bladder stones, and10 patients had a non-functioning kidney. In thedeveloping world, hospitals typically have neitherthe laboratory capability to detect azotemia, nor theradiographic facilities to diagnose hydroureterone-phrosis. It is clear, however, that secondary damageto the kidneys is common in patients with obstetricfistulas.

2. GYNECOLOGIC INJURY

a) Vagina

An impaction of the fetal head serious enough tocause ischemic injury to the bladder will also causeischemic injury to the vagina, which is likewise trap-ped between the two bony surfaces. These injuredareas heal with varying degrees of scarring. A smallsonographic study by Adetiloye and Dare (Adetiloyeand Dare 2000) detected fibrotic changes in 32% offistula patients and minor vaginal wall fibrosis inanother 36%. Vaginal injuries in fistula patients existalong a spectrum that includes only small focalbands of scar tissue on one end all the way to virtualobliteration of the vaginal cavity on the other.Roughly 30% of fistula patients require some formof vaginoplasty at the time of fistula repair.

The degree of vaginal injury has several importantimplications. In the first instance, severe vaginalinjury results in loss of substantial portions of thevagina. In many instances the scarring is such thatvaginal intercourse is simply not possible. There isvirtually no information available on the sexual func-tioning of fistula patients, yet this is obviously animportant concern in healthy marital relationshipsand undoubtedly contributes to the high rates ofseparation and divorce that appear common amongthese women. Surgical repair of fistulas in women

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with extensive vaginal scarring often requires the useof flaps and tissue grafts in order to close the fistula.Little work has been done to assess whether nor notsexual function normalizes in women who have hadsuch operations. The presence of scarring thatrequires the use of plastic surgical techniques of thiskind markedly reduces the effectiveness of surgicalrepair when fistula closure is attempted by surgeonswho lack experience in reconstructive gynecologicsurgery. Although several papers have describedvarious techniques for vaginoplasty that may berequired in fistula patients (Dick and Strover 1971;Hoskins, Park et al. 1984; Margolis, Elkins et al.1994), there is a pressing need to investigate the roleof vaginal plastic surgery at the time of fistula repairand to evaluate subsequent sexual functioning inpatients who require surgery of this kind.

Vaginal scarring impacts more than just sexual func-tioning. The presence of vaginal scarring appears tobe an important prognostic factor in determining thelikelihood both of successful fistula closure, and alsofor the development of debilitating urinary stressincontinence after otherwise successful fistula repair.In one unpublished series of 26 fistula patients withsevere vaginal scarring, 57.7 percent suffered fromstress incontinence after fistula repair and 23.5 per-cent had a persistent or recurrent fistula. This wouldcompare to an expected stress incontinence rate ofaround 26% and a failed fistula closure rate of about7% in the overall population of fistula patients(Arrowsmith, personal communication). As LawsonTait remarked in his book, Diseases of Women (Tait1879): “One case, which I utterly failed to improvein any way, had the whole vagina destroyed by slou-ghing, so that the rectum, ureters, and uterus openedinto a common cloaca about two inches deep, withwalls of cartilaginous hardness. In such cases thedamage is nearly always very extensive and very dif-ficult to remedy.” Kelly and Kwast have also repor-ted worsening surgical outcome in fistula patientswho have vaginal scarring than in those without suchfindings (Kelly and Kwast 1993).

b) Cervix, Uterus, and Future Reproductive Perfor-mance

From an obstetric point of view, timely terminationof obstructed labor requires operative intervention,most often by cesarean delivery. When timely accessto cesarean section is not available, prolonged obs-tructed labor results in a high rate of uterine rupture,usually with catastrophic consequences for bothmother and child. For example, Ekele and co-wor-kers reported one uterine rupture for every 79 deli-

veries in Sokoto, Nigeria, an impoverished rural areawith poor obstetric services (Ekele, Audu et al.2000). Cesarean delivery in such cases is often life-saving, but in some cases it may also be implicatedin the formation of a vesico-uterine fistula (Yip andLeung 1998; Billmeyer, Nygaard et al. 2001; Porca-rio, Zicari et al. 2002). Vesico-uterine fistulas canpresent in different ways, depending on their loca-tion, size, and the degree of patency of the endocer-vical canal. The least troublesome vesico-uterine fis-tulas do not result in incontinence, but are characte-rized by the absence of vaginal menstruation in thepresence of cyclic hematuria (“menouria” or “Yous-sef’s syndrome”), whereby the menstrual flow exitsexclusively through the urinary tract (Youssef 1957;Arrowsmith, Hamlin et al. 1996; Jozwik and Jozwik2000). Other vesico-uterine fistulas may be associa-ted with various combinations of altered menstrua-tion and either periodic or continuous incontinence.The finding most characteristic of a uterovesical fis-tulas is demonstrable loss of urine through the cervix(a finding that also occurs with vesicocervical fistu-las). It should be pointed out that both uterovesicaland vesicocervical fistulas can also result from pro-longed obstructed labor in the absence of operativeintervetion.

Many patients sustain severe cervical damage as wellas vaginal injury in the course of obstructed labor.When fistula patients are examined, a completelynormal cervix is rarely seen. The presence of cervi-cal injury would also help explain the apparentlyhigh prevalence of pelvic inflammatory diseaseencountered among these patients. In the worstcases, prolonged obstructed labor may result in com-plete cervical destruction, leaving the patient with noidentifiable cervical tissue at all. Unfortunately,detailed descriptions of the condition of the cervixhave not been included in the series of fistulas publi-shed to date. Since cervical competence is such animportant factor in future reproductive performance,this is yet another clinical area that demands furtherstudy.

A review of the menstrual histories of 998 patientswith obstetric fistulas in Ethiopia (Arrowsmith,Hamlin et al. 1996) showed 63.1 percent were ame-norrheic. Other studies have shown amenorrhea ratesfrom 25% to 44% (Aimakhu 1974; Bieler and Schna-bel 1976; Evoh and Akinla 1978). Many of thesepatients undoubtedly have hypothalamic or pituitarydysfunction (Bieler and Schnabel 1976). While thehigh incidence of amenorrhea in VVF patients iswidely recognized, only one unpublished study has

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been done to look specifically at uterine pathology inthe VVF population. Dosu Ojengbede of the Univer-sity of Ibadan (personal communication) performedhysteroscopy on fistula patients in Nigeria and foundthat intrauterine scarring and Asherman’s syndromeare common. The combination of widespread ame-norrhea, vaginal scarring, and cervical destructionleads to a tremendous problem of secondary inferti-lity among these patients. To date, there have been noserious scientific efforts to explore treatment of cer-vical and uterine damage in VVF patients.

Subsequent reproductive performance of womenwho have had an obstetric vesicovaginal fistula hasbeen analyzed in a few articles (Naidu and Krishna1963; Aimakhu 1974; Evoh and Akinla 1978;Emembolu 1992). Emembolu analyzed the subse-quent reproductive performance of 155 fistulapatients delivered at Ahmadu Bello University Tea-ching Hospital in Zaria, Nigeria, between January1986 and December, 1990 (Emembolu 1992). Thisseries included pregnancies in 75 women who beca-me pregnant after successful fistula closure and 80women who became pregnant while still afflictedwith an unrepaired fistula that had occurred in a pre-vious pregnancy. The data presented do not allowone to determine the subsequent fertility rates ofwomen who develop a fistula, but clearly indicatethat women can, and do, become pregnant after sus-taining an obstetric fistula. The proportion of bookedpregnancies receiving antenatal care was higher inthe repaired group (73%) than in the unrepairedgroup (51%), and reproductive performance was bet-ter (but still dismal) in those patients who had had afistula repair. Of the 69 patients whose fistulas hadbeen repaired, there was a recurrence in 8 (11.6%),and among those undergoing a trial of vaginal deli-very, the fistula recurrence rate was nearly 27%. Inwomen with pre-existing, unrepaired fistulas whobecame pregnant but who did not register for prena-tal care in the subsequent pregnancy, maternal mor-tality and morbidity in those pregnancies was high,reflecting continuation of the conditions that let tofistula formation in the first place (Emembolu 1992):

The commonest maternal morbidity, excludingrecurrence of VVF, was hemorrhage requiring bloodtransfusion in 35 patients (27.3%). Others includedruptured uterus in 3 unbooked patients whose fistu-lae had not been repaired, bladder injury at cesareansection in 1.6% and acute renal failure in 0.8%. Thematernal complications occurred more frequently inthe patients whose fistulae had not been repaired andwho were also unbooked.”

The largest series is that of Aimakhu, who analyzedsubsequent reproductive performance in 246 womenwho underwent successful fistula closure at Univer-sity College Hospital in Ibadan, Nigeria, between1957 and 1966 (Aimakhu 1974). Only 48 patientsbecame pregnant following fistula repair with a totalof 65 pregnancies. All but 6 of these were managedat University College Hospital. Five patients had

aborted prior to the 16th week of gestation, leavingonly 60 viable pregnancies. The plan was to performelective Cesarean section on all patients who becamepregnant after fistula surgery, but only 49 Cesareanoperations were carried out. The results of the vagi-nal deliveries were not encouraging. Aimakhu sum-marized the results in this fashion (Aimakhu 1974):

“Of the eight vaginal deliveries, six were our bookedpatients, and they were all admitted in the secondstage of labor; one patient had in fact delivered thefirst of her twins before arrival. There were no mater-

section, the uterus was found to have ruptured.The macerated female fetus weighting 2800 g wasdelivered and the patient had a repair of the uteruswith bilateral tubal ligation. She however died onthe sixth post-operative day of persistent anemiaand overwhelming infection due to Klebsiella spe-cies.

Mrs. M.A., a 28-year old unbooked para 1+0 (stil-lbirth) who had a residual vesico-vaginal fistulawas admitted in labor at 34 weeks gestation. Shehad been in labor at home for about 19 h prior toadmission in the second stage of labor. Vaginalexamination revealed marked vaginal stenosisadmitting only one finger. A diagnosis of advancedobstructed labor with fetal distress was made. Atcesarean section, a severely asphyxiated femalebaby weighing 2200 g with Apgar score of 1 and 2at 1 and 5 min was delivered. The baby died within30 min of delivery. The mother subsequently deve-loped post-partum eclampsia with septicemia fromStaphylococcus aureus and died on the fourthpost-operative day.

“Mrs. A.A., a 25-year-old unbooked para 1+0(neonatal death) whose VVF was as yet unrepai-red was admitted at 40 weeks gestation in thesecond stage of labor. She had been in labor athome for over 20 h before admission. Vaginalexamination revealed that the vagina was marked-ly stenosed and the patient in advanced obstructedlabor with an intrauterine fetal death. At cesarean

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nal deaths among these six patients and there was noreopening of the fistulae after delivery. Five of theseven babies survived. The seventh patient withvaginal delivery had an instrumental vaginal delive-ry elsewhere. The baby was stillborn and the fistularecurred. At the beginning of the repair of the newfistula in our unit, this patient died from cardiacarrest. The eighth patient with vaginal delivery sus-tained her first fistula in her first delivery in 1952.This was successfully repaired elsewhere 4 yearslater. In 1962 she was allowed a vaginal delivery inanother hospital. The baby was stillborn and the fis-tula recurred. Following another successful repair ofthe fistula she became pregnant again. She defaultedfrom a cesarean section offered her in our unit. Shedelivered at home another stillborn baby and the fis-tula was again reopened.”

Patients who underwent cesarean delivery fared bet-ter. There were 49 fetuses delivered and 47 survived.There was no recurrent fistula among women pre-viously repaired who became pregnant and had asubsequent cesarean section. There was one maternaldeath from pulmonary embolism in a woman whounderwent a emergency delivery at 32 weeks gesta-tion due to a prolapsed fetal umbilical cord.

3. THE RECTO-VAGINAL FISTULA

Rectovaginal fistulas appear to be significantly lesscommon than vesico-vaginal fistulas. In case seriesof patients presenting with vesico-vaginal fistulas,between 6% and 24%% have a combined recto-vagi-nal and vesico-vaginal fistula (Figure 7) (Emmet1868; Naidu 1962; Aziz 1965; Coetzee and Lithgow1966; Bird 1967; Mustafa and Rushwan 1971; Ash-worth 1973; Tahzib 1983; Tahzib 1985; Waaldijk1989; Arrowsmith 1994; Amr 1998; Hilton and Ward1998; Wall, Karshima et al. 2004). In most series,isolated recto-vaginal fistulas are less common thancombined fistulas. Indeed, most series do not evenmention isolated recto-vaginal fistulas as a clinicalphenomenon. In a series of patients from Turkeyreported by Yenen and Babuna (Yenen and Babuna1965), 7.1% had recto-vaginal fistulas and 6.5% had“combined” fistulas. From the report it is not clear ifthis latter figure was comprised solely of recto-vagi-nal and vesico-vaginal fistulas, or if it included othercombinations of urinary tract fistulas as well (vesico-cervico-vaginal, urethro-vaginal, etc.). Kelly andKwast (Kelly and Kwast 1993), reporting data fromthe Addis Ababa Fistula Hospital, noted a 15.2% pre-valence of combined fistulas, and a 6.8% prevalenceof isolated rectovaginal fistulas in that population.

Ethiopia appears to have one of the highest rates ofrecto-vaginal fistulas reported in the literature. Whe-ther this relates to specific obstetric characteristics ofthe Ethiopian population or whether this relates toother social factors—-such as the cases of rape andsexual abuse of young Ethiopian girls reported byMuleta and Williams (Muleta and Williams 1999)—is unclear.

Since the pubic symphysis poses an obstruction todelivery through the anterior pelvis, in normal birthmechanics the fetal head is normally forced poste-riorly towards the rectum, anus, and perineum at theend of the second stage of labor. In non-obstructedlabor, direct laceration of the perineum is not uncom-mon, occasionally resulting in a complete perinealtear with complete disruption of the anal sphincter. Ifthis is not repaired, a complete perineal tear withsphincter disruption can create a recto-vaginal fistu-la at the anal outlet (Radman, Al-Suleiman et al.2003). This mechanism of fistula formation seemsmore likely to account for low recto-vaginal fistulas,whereas recto-vaginal fistulas higher in the pelviswould seem more likely to be caused by direct tissuecompression from obstructed labor.

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Figure 7. Large combined vesicovaginal and rectovaginalfistula. (©Worldwide Fistula Fund, used by permission).

As Mahfouz noted in 1938 (Mahfouz 1938):

In Das and Sengupta’s series of 135 obstetric fistulasfrom India, there were 12 patients with recto-vaginalfistulas, 6 patients with complete perineal tears, 1patient with both a recto-vaginal fistula and a com-plete perineal laceration, and 1 patient with a recto-vaginal fistula as well as a fistula-in-ano, giving aposterior fistula rate of 20/135 or 14.8%.

Because recto-vaginal fistulas appear to be less com-mon than genito-urinary fistulas in the developingworld, less attention has been paid to describingtechniques for their repair in this setting. Mahfouzrecommended different approaches to recto-vaginalfistulas, depending on their location (Mahfouz1938).

These general principles still prevail. For example,Arrowsmith (Arrowsmith 1994) recommended oralcathartics and cleansing enemas (where the fistulaswere small enough to allow the patient to retain someenema fluid), followed by wide mobilization of thefistula, a two-layered rectal closure, with perinealreconstruction and the use of Martius bulbocaverno-sus fat flaps for large defects. These general prin-ciples have also been endorsed by Hudson (Hudson1970).

More problematic is the very high recto-vaginal fis-tula, where the fistula occurs in the upper vagina(Eden 1914; Mahfouz 1934; Lawson 1972; Bentley1973). Such cases are particularly troublesome if thevagina is very stenotic or the fistula is fixed andtethered in such a manner as to prevent its being dis-sected free and brought down low enough so that avaginal repair can be attempted. Extremely skilledfistula surgeons may still be able to repair such fistu-las transvaginally, but in many cases the route ofrepair for these injuries may need to be transabdomi-nal. Before attempting to repair a rectovaginal fistu-la using a transabdominal technique, the patientshould always have a thorough bowel preparationand undergo a temporary transverse colostomy. InHudson’s series of 88 high rectovaginal fistulas, suc-cessful closure was significantly more likely if acolostomy had been performed prior to attemptedfistula closure (Hudson 1970). Each abdominalrepair operation is likely to be different, due to thecomparative rarity of the high rectovaginal obstetricfistula and the variable severity and extent of theconcurrent pathology that is likely to accompany it,but in general the surgeon should attempt to separatethe vagina from the rectum, close the rectum in mul-tiple layers, interpose a pedicled graft of omentumbetween the rectum and the vagina and, where pos-sible, close the vagina separately (Bentley 1973).

Clinical experience suggests that “double fistulas”(combined vesico-vaginal and recto-vaginal fistulas)are more difficult to repair than solitary rectovaginal

In dealing with rectal fistulae situated at a distan-ce from the perineum the latter should not be cutthrough. These fistulae should be dealt with by aflap-splitting operation performed on the sameprinciples employed in operating on urinary fistu-lae. The separation of the rectal from the vaginalwall should be carried until a point well beyondthe upper and lower limits of the fistulae. In rectalfistulae this separation can be effected more easi-ly, and much more widely, than separation of thebladder in urinary fistulae.”

“The methods of treatment of faecal fistula differaccording to their site. If the fistula is situated atthe vaginal outlet, incorporated in or lying imme-diately above an incompletely healed perineal tear,the perineum should be cut through. In otherwords, the recto-vaginal fistula is converted into acomplete tear of the perineum and is dealt with assuch. The vaginal and rectal walls are next separa-ted from one another by a transverse incision. Thisseparation should be carried well above the upperedge of the fistula. The rent in the rectum is nowcarefully sutured with catgut. The sutures shouldnot pierce the mucous membrane of the gut. Thenext step is to unite the levator ani muscles in themiddle line so that a thick mass of tissue is inter-posed between the lines of sutures in the vaginaand rectum respectively. The cut ends of thesphincter should now be very carefully broughttogether and the perineum reconstructed in theusual manner.

“The process by which faecal fistula forms afterlabour differs greatly from that which leads to theformation of a urinary fistula. Sloughing, due topressure-necrosis produced by impaction of thepresenting part, which accounts for the overwhel-ming majority of urinary fistulae, is seldom thecause of faecal fistula. It accounted for 2 casesonly in my series of 75. The majority of the remai-ning cases were the result of a complete tear ofperineum which extended into the recto-vaginalseptum. The lacerated edges of the perineum uni-ted spontaneously in the lower part where the tis-sues were fleshy, but remained ununited at theupper end where tissues were thin. This results ina permanent communication between the vaginaand rectum at the upper end of the healed tear.”

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fistulas (Hudson 1970). In patients with double fistu-las, the amount of normal tissue available for use asvaginal flaps is often very limited, and the reductionin vaginal space that occurs after successful closureof a double fistula can be formidable. The presenceof a concurrent rectovaginal fistula also decreasesthe likelihood of successful closure of a vesicovagi-nal fistula.

Rectovaginal fistula repair presents special problemsfor the fistula surgeon, particularly in cases wherethe fistula is high or complex. Many gynecologicsurgeons may not be comfortable performing a colo-stomy, let alone more complex colon and rectal ope-rations such as a colo-anal pull-through procedure.Colostomy surgery requires access to more sophisti-cated anesthesia capability than vaginal fistularepair, and in many cultures a colostomy is no moreacceptable than a rectovaginal fistula, particularly asuseable colostomy appliances are often difficult orimpossible for most fistula patients to obtain. From aresearch perspective, the issue of anal sphincterfunction in obstetric fistula patients remains virtual-ly unaddressed, both with regard to the presence ofinjuries in women who only have a vesico-vaginalfistula, as well as in patients who have had success-ful recto-vaginal fistula repair. One recent study of55 patients with obstetric fistulas from Ethiopiafound 21 women (38%) had symptoms of alteredfecal control after repair, including 13 (24%) whohad problems with both urinary and anal control(Murray, Goh et al. 2002). Of these 21 patients, 3 hadundergone repair of a combined vesicovaginal andrectovaginal fistula, and 18 had undergone vesicova-ginal fistula repair alone.

4. ORTHOPEDIC TRAUMA

Ischemic injury from obstructed labor not onlyaffects pelvic organs, but also the pelvis itself. Thesechanges are most pronounced in the pubic symphy-sis. The normal radiography of the symphysis pubishas been described in detail by Vix and Ryu (Vix andRyu 1971). In obstructed labor, the pubic bones areoften directly involved as they form one side of thebony vise in which the vulnerable soft tissues aretrapped. In fistulas where large amounts of bladdertissue are lost, the periosteum of the pubic arch canoften be palpated directly through the fistula defect.It is these cases in which ischemic damage to thepubic bones is most likely to be demonstrable. In astudy of 312 Nigerian women with obstetric vesico-vaginal fistulas Cockshott (Cockshott 1973) detectedbony abnormalities in plain pelvic radiographs in 32

percent of these patients. The findings included boneresorption, marginal fractures and bone spurs, bonyobliteration of the symphysis, and wide (>1 cm)symphyseal separation. Most of these changesappear to be the result of avascular necrosis of thepubic symphysis. Their long-term significanceremains uncertain and further study is required.

5. NEUROLOGIC INJURY

Another tragic injury associated with obstetric fistu-la formation is foot-drop (Waaldijk and Elkins 1994).The relationship between difficult labor and neurolo-gical injury has been known for centuries, and thecondition was traditionally called “obstetric palsy”(Sinclair 1952). Women with this condition areunable to dorsiflex the foot and therefore walk witha serious limp, dragging their injured foot, and usinga stick for support (Figure 8). Sinclair’s paper onmaternal obstetric palsy in South Africa (Sinclair1952), made the comment that “There are no recordsof this lesion associated with vaginal fistulae, wherethere has been prolonged pressure by the foetal skullin the lower part of the pelvis.” This statement isclearly wrong. In Waaldijk and Elkins’ review of 947fistula patients, nearly 65% of those studied prospec-tively had evidence of peroneal injury either by his-tory or physical examination (Waaldijk and Elkins1994). The prevalence of clinical footdrop amongpatients seen at the Addis Ababa Fistula Hospital isabout 20% (Arrowsmith, Hamlin et al. 1996).Various theories have been proposed for the etiologyof this condition. In general clinical series of per-oneal nerve palsy, the most common etiologies

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Figure 8. Fistula patient with foot-drop, manifested by aninability to dorsiflex the foot. In particular note the traumato the toes, as well as the constant puddle of urine in whichshe walks. (©Worldwide Fistula Fund, used by permission).

appear to be direct trauma from ankle inversion,fractures of the hip, femur, fibula or tibia; knee inju-ries, alcoholic neuropathies, and a variety of miscel-laneous or idiopathic causes. In obstetric patients thelesion most likely develops from one of three causes:prolapse of an intravertebral disk, pressure from thefetal head on the lumbo-sacral nerve trunk in the pel-vis leading to direct compression of the peronealnerve, or direct trauma to the peroneal nerve fromprolonged squatting and pushing in the second stageof labor (Sinclair 1952; Reif 1988; Colachis, Pease etal. 1994). Of the three possible etiologies, the lastseems the most likely; however, to date no one hasperformed electromyographic studies of the lowerextremities in fistula patients with foot-drop to eva-luate the neurophysiological abnormalities that arepresent. Foot-drop has also been associated withtrauma sustained in difficult forceps deliveries, parti-cularly mid-pelvic rotations, but again, as othershave emphasized “The peripheral nerve lesion follo-wing instrumental delivery may have developed inany case and forceps were but incidental or at themost a precipitating factor in border-line cases” (Sin-clair 1952). The prognosis for recovery from thisinjury is unclear, as there are no proper prospectivestudies of women who have developed this condi-tion. Waaldijk and Elkins suggest that most patientsrecover some or all of their nerve function sponta-neously within two years of the injury (Waaldijk andElkins 1994); however 13% showed persistent signsof nerve trauma. In some cases the affected womenare almost completely crippled from bilateral lesionsand suffer tremendously from the additional burdenimposed by immobility on someone who already suf-fers from intractable urinary incontinence. Physio-therapy and the use of posterior splints improve thecondition of some patients. Others may require sur-gical intervention: the use of posterior tibialis tendontransfer is a well-established procedure for patientswith foot-drop from other causes (such as leprosy),and it may be that this method will be useful in trea-ting women with unresponsive obstetric palsy aswell (Hall 1977; Richard 1989).

6. DERMATOLOGIC INJURY

The condition of the skin, which is in constant, unre-mitting contact with a stream of urine or feces, is oneof the most bothersome problems for the fistulapatient (Figure 9). The problems thus encounteredhave been eloquently described since the early daysof fistula surgery. The great American gynecologistThomas Addis Emmett summarized the clinicalsituation in 1868 (Emmet 1868):

“Unless the greatest care has been given to clean-liness, the sufferer, in a few weeks after receivingthe injury, becomes a most loathsome object. Fromthe irritation of the urine, the external organs ofgeneration become excoriated and oedematous,with the same condition extending over the but-tocks and down the thighs. The labia are frequent-ly the seat of deep ulcerations and occasionally ofabscesses. The mucous membrane of the vagina isin part lost, and the abraded surface rapidlybecomes covered at every point with a sabulous oroffensive phosphate deposit from the urine. If theloss of tissue has been extensive, the inverted pos-terior wall of the bladder protrudes in a semi-stran-gulated condition, more or less incrusted with thesame deposit, and bleeding readily. This depositwill frequently accumulate to such an extent in thevagina that the sufferer becomes unable to walk oreven to stand upright, without the greatest agony.

The deposit must be carefully removed as far aspossible by means of a soft sponge, and the rawsurface brushed over with a weak solution of nitra-te of silver. If, at any point, it cannot be at firstremoved without causing too much bleeding, thedeposit itself must be treated in the same manner,or coated with the solid stick. Warm stiz-baths addgreatly to the comfort of the sufferer. The vaginamust be washed out several times a day with alarge quantity of tepid water. After bathing, it isbest for the patient to protect herself by freelyanointing the outlet of the vagina and the neighbo-ring parts with any simple ointment.

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Figure 9. Encrustation of the vulva with uric acid salts, asthe result of the constant trickle of urine from the fistula.(©Worldwide Fistula Fund, used by permission).

Further work remains to be done on determining theoptimal regimen of skin care for patients with fistu-las within the context of developing countries. Itseems clear that efforts of this kind will producemarked improvements in the reduction of patient suf-fering, even before fistula closure is undertaken.

7. SOCIAL CONSEQUENCES OF PROLONGED

OBSTRUCTED LABOR

Although physicians tend to think in terms of clin-ically definable injuries, much of the suffering thatfistula patients endure is a result of the social conse-quences of their condition. It is vitally important tounderstand the social context in which these injuriesoccur (Wall 1998; Wall 2002). Although there is nosuch thing as a monolithic “African culture”, inmany areas where fistulas are endemic there appearto be recurring patterns that allow for some generalobservations to be made regarding the position ofwomen. In countries where there are high fistularates, women generally have a lower social statusthan men. Often a woman’s role in family life centersaround a strong obligation to satisfy the sexual needsof her husband and to provide him with offspring(preferably male), and both men and women aredependent on their children for care when they beco-me old. In many African societies, women are oftencalled upon to perform heavy manual labor, tending

the fields, carrying water and firewood. Religion—be it Islam, Christianity, or a traditional African reli-gion—-also plays a more central role in day-to-daylife than is common in Western countries. Each ofthese areas of human life is affected in a profoundlynegative way by the injuries sustained in obstructedlabor.

a) Marriage and Family Life

In societies where obstetric fistulas are still preva-lent, a woman’s role in life is defined almost exclu-sively in terms of marriage, childbearing, and thefamily life that results (Wall 1988; Wall 1998).Because most women in these societies appear toaccept this role at present, the inability to have chil-dren or to satisfy her husband’s sexual needs maydiminish her own sense of self worth. Vaginal inju-ries often make intercourse impossible, and theconstant stream of urine makes it otherwise unplea-sant. As members of agrarian societies, women areoften expected to contribute long hours of hard laborworking on the family farm. Foot drop and associa-ted pelvic injuries may make the satisfactory perfor-mance of these tasks impossible. The woman, for-merly a productive laborer, then becomes an econo-mic burden as an invalid. The combination of all ofthese factors often leads to a gradual disintegrationof the marriage over time, which then ends withcomplete rupture of the relationship. The existingdata suggest that large numbers of fistula patientsbecome divorced or separated from their husbands,particularly when it becomes evident that theircondition is chronic, rather than transient. Unpubli-shed data from Ethiopia suggest that almost 50 per-cent of VVF victims are divorced or separated (S.D.Arrowsmith, personal communication). Murphy’sresearch documented similar findings in northernNigeria (Murphy 1981). In analyzing 899 fistulapatients from Jos in north central Nigeria, Wall andcolleagues (Wall, Karshima et al. 2004) found thatonly 26.4% of these women were still married:22.1% were separated from and 48.9% had beendivorced by their husbands.

Infertility is a devastating problem to couples in anyculture, but it is difficult to underestimate the impor-tance of fertility in African societies. Large familiesare a source of pride and a symbol of affluence.Since the social, economic, and political lives ofthese societies are still dominated in many respectsby ties of kinship, not having offspring is a disasteron many fronts. Furthermore, large families may bethe only source of reliable (or affordable) farm labor,a critical economic factor in societies based on pea-

She must be instructed to wash her napkins tho-roughly when saturated with urine, and not simplyto dry them for after-use. Time, and increasedcomfort of the patient, are gained by judiciousattention to such details.

About every fifth day, the excoriated surfaces yetunhealed should be protected with the solution ofnitrate of silver; and it is frequently necessary topursue the same general course for many weeks,before the parts can be brought into a perfectlyhealthy condition. This point is not reached untilnot only the vaginal wall, but also the hypertro-phied and indurated edges of the fistula, haveattained a natural color and density. This is thesecret of success; but the necessity is rarely appre-ciated; without it, the most skillfully performedoperation is almost certain to fail.

When the proper condition has been broughtabout, the surgeon may then be able to decideupon some definite plan of procedure for the clo-sing of the fistula.

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sant agriculture. Because governmental social welfa-re programs are unreliable or non-existent in mostAfrican countries, children are the only hope one hasfor security in old age. The fetal mortality in indivi-dual cases of obstructed labor is staggering, withfetal loss typically running in excess of 90%. Theoverall reproductive histories of women with an obs-tetric fistula is similarly dismal: In the large series of899 fistula patients from Jos, Nigeria, Wall and col-leagues (Wall, Karshima et al. 2004) found that outof a total of 2,729 infants born to these fistulapatients, only 819 living children survived, a long-term survival rate of only 30%. Since obstructedlabor is most commonly a complication of awoman’s first labor, and since she is typically infer-tile thereafter, the majority of fistula victims (about70%) have no living children. Not only is this adisaster for the affected woman, but from her hus-band’s perspective, it puts his whole future in jeo-pardy as well. Faced with this prospect, many menfind it easier to rid themselves of their damagedwives and seek other, fertile, spouses.

Although obstructed labor is most common as acomplication of a first pregnancy, it can occur in anypregnancy if the baby is too large, if labor starts witha fetal malposition or malpresentation, or if othercomplications arise. Not all obstetric fistulas occur inteenaged girls having their first baby: in a review of121 obstetric fistulas from Kumasi, Ghana, Dansoand colleagues found that 43% of their patients hadhad three or more pregnancies, and that 25% had hadfive or more (Danso, Martey et al. 1996). Wall andco-workers (Wall, Karshima et al. 2004) found that45.8% of fistulas occurred in first pregnancies, butthat 20% of fistulas occurred in women of high pari-ty (> 4 pregnancies). Similarly, at the Addis AbabaFistula Hospital, nearly 25% of fistula patients havehad three or more pregnancies, and 11 percent havehad six or more children (Kelly and Kwast 1993).What happens to the living children when theirmother’s life is ruined in this fashion? Importantindirect health consequences of fistula formationsuch as this have been largely unexplored.

b) Religious and Social Implications

In some parts of the world, such as northern Nigeria,married women live under a system of “wife seclu-sion” in which their social contacts are severely res-tricted to her immediate family and female neighbors(Wall 1988; Wall 1998). The offensive odor thataccompanies total urinary and/or fecal incontinenceusually curtails even this limited opportunity forsocial interaction. In order to deal with the never-

ending problem of foul smells and omnipresent urineand fecal loss, the families of these patients oftenremove them from the main family dwelling into aperipheral hut, sometimes even forcing them to liveout doors. Not uncommonly, they are often forcedout of the family compound altogether over time(Hamlin and Little 2001; Wall 2002).

Because of the nature of her injury, a fistula patientsimply cannot maintain normal hygiene, no matterhow hard she tries. This fact has an enormous impacton all aspects of her life, including her participationin religious or spiritual life. Fistula women are gene-rally regarded as both physically and rituallyunclean. Many African religious groups, especiallyMuslims, require personal cleanliness as a prerequi-site for worship. This often excludes them from par-ticipation in religious activities (often a centralconcern of African social life), this further dimi-nishes their sense of self-worth and social connec-tedness.

The tragedy faced by these women was describedvery eloquently by Kelsey Harrison, who had exten-sive experience with their plight as a result of hislong tenure as Professor of Obstetrics and Gynaeco-logy at Ahmadu Bello University in Zaria, Nigeria(Harrison 1983):

“Whether in hospital or outside, their own societygoes to great lengths to ostracize these girls, anaction disparaged by outsiders but considered rea-sonable by most local people including certain(male) health workers. Their point of view isstraightforward enough. The safe delivery of ahealthy baby is always an occasion for great rejoi-cing and at the naming ceremony held on the eigh-th day after birth, the whole family and local com-munity celebrate. In the case of the girl with anobstetric fistula, the baby is usually stillborn andthis together with the fact that her odour is offen-sive means that such celebrations cannot takeplace. Soon, her incontinence becomes confusedwith venereal disease, and the affected familyfeels a deep sense of shame. The consequences aredevastating: the girl is initially kept hidden; sub-sequently, she finds it difficult to maintain decentstandards of hygiene because water for washing isgenerally scarce; divorce becomes inevitable anddestitution follows, the girl being forced to beg forher livelihood. So traumatic is this experience thateven when cured, some girls never regain theirself esteem.”

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In considering the overall impact of the fistula pro-blem, one should consider the life-time burden ofsuffering that this condition presents. The vast majo-rity of these women are young and develop their fis-tula in their first pregnancy. In a series of over 9,000fistula victims in Ethiopia the average patient agewas 19 yrs (Arrowsmith, Hamlin et al. 1996). Mostof the injuries associated with prolonged obstructedlabor cause permanent disability without causingearly death. The members of the committee haveseen patients seeking surgery over 40 years aftertheir initial injury: the wasted years of human liferepresented by such cases is mind-numbing.

Professor Abbo Hassan Abbo, Professor of Obste-trics and Gynaecology at the University of Khartoumin the Sudan, himself an international authority onfistulas, tells a powerfully poignant story of a groupof Somali women with fistulas who, in despair, chai-ned themselves together and jumped off the dock inMogadishu in a mass suicide because their sufferinghad become unendurable. (A.H. Abbo, personalcommunication).

It is easy to overlook the enormous social conse-quences that a fistula produces for the afflictedwoman unless one sees her in her own social setting.The proper care of fistula victims requires a holisticapproach that pays as much attention to healing thepsycho-social wounds inflicted on these women as itdoes to curing their physical injuries (Wall 2002).Programs for women with obstetric fistulas mustencompass education, literacy training, the develop-ment of social networks, and the provision of skillswith which to earn an adequate livelihood, if thesocial problems that these women face are to beovercome (Bangser, Gumodoka et al. 1999). Somewomen are so injured that they can never return totheir home villages, and many have such seriousmedical problems that they linger around fistula cen-ters and become permanent residents. At the AddisAbaba Fistula Hospital, many of these women beco-me nursing aides, taking care of other fistulapatients. In a unique social experiment, that institu-tion is developing a permanent residential farm forthe most severely injured of these women, in essen-ce forming a new women’s community based on sha-red experiences and the “sisterhood of suffering” thathas resulted (Hamlin and Little 2001).

At the present time, there is no generally accepted,standardized system for describing, classifying, orstaging obstetric fistulas. The situation remainsmuch the same as it was in 1951, when Bayard Car-ter and colleagues lamented (Carter, Palumbo et al.1952), “It is difficult to interpret and to comparemany of the reported series of fistulas. There is a realneed for standard methods to describe the fistulas,the actual operations, and results.” McConnachie(McConnachie 1958) eloquently summed up the pro-blems surrounding discussions of fistula repair in thefollowing words:

In describing their experience with fistula repair,many surgeons have put forth various systems orrationales for grouping cases together. The earliestsuch system was that of Sims (1852) who classifiedfistulas according to their location in the vagina: 1)urethro-vaginal fistulas, where the defect was confi-ned to the urethra; 2) fistulas situated “at the bladderneck or root of the urethra, destroying the trigone;”3) fistulas involving the body and floor of the blad-der; and 4) utero-vesical fistulas where the openingof the fistula communicated with the uterine cavityor cervical canal. Succeeding authors have added to,modified, and re-grouped the categories of fistulas ina variety of ways (Emmet 1868; Mahfouz 1930;Thomas 1945; Krishnan 1949; McConnachie 1958;Moir 1967; Lawson 1968; Hamlin and Nicholson1969; Waaldijk 1994; Waaldijk 1995; Hilton and

“It is common to find that each author has eitherused his own form of classification based solely onthe anatomical structures involved, or the size ofthe fistula, or even one of convenience. But no twowriters seem to have reached any common groundsfor agreement other than that a urinary fistula ispresent. This lack of agreement has preventedcomparison between individual workers’ materialor results, based on a common scientific classifica-tion. Such classification needs to be full yetsimple, workable in its details so that it will not becumbersome, to be based on the three principalanatomical structures involved in urinary leakage[bladder, urethra, ureters], and to take into accountthe clinical aspects of site, size, accessibility andcondition of the tissues involved in attemptedrepair.”

V. THE CLASSIFICATION OFOBSTETRIC FISTULAS

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Ward 1998). Mahfouz (Mahfouz 1930) listed themain points to be considered in the evaluation of afistula as follows:

• The situation, size, form and variety of the fistula

• The scarring of the vagina and its effect on themobility of the fistula

• The attachment of the fistula to the pelvic walls

• The condition of the urethral sphincter and per-meability of the internal orifice of the urethra(occasionally the urethra is completely occludedby fibrosis)

• The location of the ureteral orifices, and their rela-tion to the edges of the fistula

• The presence of complications such as recto-vagi-nal fistula, inflammatory lesions of the pelvis,vagina, vulva or peritoneum

• The presence of more than one fistula

There is an urgent need to develop a standardized,generally-accepted system for describing and classi-fying fistulas, to aid communication between fistulacenters and to facilitate research in this field. Thecommittee has not taken upon itself the task of deve-loping such as system, but recommends that theStandardization Committee of the InternationalContinence Society make this a priority in the future.The committee feels that the following factorsshould be taken into account in the development of astandardized ICS Classification System:

• The system should provide a simple yet precisemethod of describing fistula location and size.Although the size of the fistula may be quiteimpressive in cases of prolonged obstructed labor,the actual size of the opening is probably lessimportant in the overall prognosis than are otherfactors. As John St. George noted in 1969 (St.George 1969), “This [size] is not very importantas long as other factors are favourable. It has beenfound that an opening of 1 cm or less with unheal-thy tissues, fixed to bone within a stenosed vagi-na, is worse than an opening of 5 cm or more withlax vaginal walls, no fixity and a wide vaginalintroitus. Also, a small bladder neck fistula isfound to be more difficult and less successful atrepair than a large mid-vaginal fistula.”

• The system should make some attempt to assessthe impact of the fistula on function; i.e. how doesthe fistula impact the bladder neck, urethra, ure-ters, or (in the case of rectovaginal fistulas) theanus and its sphincter mechanism?

• The presence, location, and degree of vaginalscarring should be quantified, as this appears to bedirectly related to the probability of successful fis-tula closure. Many authors have commented onthe grim prognosis for fistulas complicated byvaginal scarring. Das and Sengupta noted (Dasand Sengupta 1969): “Massive scarring is fre-quently present and is definitely a great handicapfor a successful vaginal operation. Annularconstriction ring around the vagina, distal to thefistula, with fixity to the pubic bones with cartila-genous margins are very unfavourable signs. But,fortunately it is noted that once the neighbouringbands of adhesions are released, the bladder canbe brought down easily and anatomic appositionmade.”

• Any classification system for fistulas should bebased on criteria that correlate with the prognosisfor successful surgical repair. This will requirelooking at the whole patient, rather than simplylooking at just the fistula. In a comparative studyof failed fistula repairs carried out in Addis Ababa,Kelly and Kwast (Kelly and Kwast 1993) found astatistically significant association (p < 0.001)with failed fistula repair and a ruptured uterus,with a previous history of failed surgical repair(especially repairs carried out at other, non-spe-cialist, institutions), with the presence of limbcontractures, with the need for special preoperati-ve feeding in order to become fit enough for sur-gery, and with the presence of a “complicated” fis-tula requiring more extensive, more complicated,surgical intervention. These authors believed thatthese factors reflected a more extensive injuryfrom prolonged obstructed labor. McConnachie(McConnachie 1958) suggested that failures infistula surgery were due to previous failed repairswith increased scar tissue formation, differencesin the grade and type of fistulas reported invarious series, to inexperienced operators takingon cases beyond their surgical capabilities, and“residual urinary sepsis and alkalinity.” Furthercomparative studies are needed to ascertain ifthese factors are reliably associated with surgicalfailure, and to determine if other, as yet unascer-tained, factors are also related to a poorer surgicalprognosis.

• There should be a standardized definition of “suc-cess” in fistula surgery. In his series of 303 fistu-las, McConnachie (McConnachie 1958) refusedto regard the patient as “cured” even though thefistula was “closed” unless “she also has comple-te urinary continence and control.” This principle

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reduced his overall success (“closed and dry”) ratefrom 79.5% to 65.1%. Perhaps as many as onethird of women who undergo successful fistulaclosure still have significant incontinence due tothe presence of sphincteric damage and/or otherpersistent alterations in bladder or anorectal func-tion. To classify as a “success” a woman who hasa closed fistula but continuous, debilitating stressincontinence from a non-functioning urethra isboth dishonest and clinically unhelpful.

• In describing surgical success rates, the time atwhich this assessment is made must be clearlyspecified. Long-term outcome data on womenwho have undergone fistula repair surgery arealmost entirely lacking in the literature. Given thedifficult circumstances from which most fistulapatients come, and the difficulties of travel andcommunication in rural Africa, this is not surpri-sing. As a result of these problems, most “suc-cesses” are reported as such only at the time ofdischarge from hospital, with almost no furtherfollow-up. This may well be misleading as toactual outcome. Coetzee and Lithgow (Coetzeeand Lithgow 1966) defined “cure” of a patientwith a vesicovaginal fistula as follows:

• “For a 100% cure the following conditions mustbe fully satisfied: 1) The patient should have com-plete continence by day and by night, and toachieve this it has been found that the bladdershould hold a minimum of 170 ml. 2) No stressincontinence should be present. 3) The vaginashould allow normal coitus without dyspareunia.4) Traumatic amenorrhea should not result. 5) Thepatient should be able to bear children.”

• General agreement should be reached concerningwhat constitutes an “irreparable fistula”—that is,which women should be offered urinary and/orcolonic diversion as their first surgical procedure,rather than undergo an attempt at fistula closure?The committee recommends that the term “irrepa-rable fistula” be used in preference to the phrase“hopeless fistula,” which is sometimes encounte-red in these discussions.

• Any system for the classification or staging ofobstetric fistulas must emphasize low-technology

clinical assessment, since such a system will haveto be used in areas of the world with extremelylimited resources. Fistulas afflict the world’s poo-rest women, not the affluent elites of industriali-zed economies.

• In view of the multi-system pathology producedby obstructed labor, any classification systemshould note the presence of associated conditionsrelated to the primary pathophysiological processin obstructed labor, such as the presence of neuro-logic injury, damage to the pubic symphysis, theconcurrent presence of a recto-vaginal fistula, thepresence of chronic skin ulcers, nutritional state,etc.

• Because most of the suffering endured by fistulavictims is the result of social isolation and aban-donment and the subsequent loss of self-esteemand economic deprivation that results from thissocial isolation, the evaluation of women withobstetric fistulas should include information onthese social “co-morbidities.” The fistula problemin the developing world is inextricably intertwi-ned with its social milieu, and this must be open-ly acknowledged.

Although many patients with vesico-vaginal fistulasappear for care many years after they have sustainedtheir injury, others arrive at a medical facility in obs-tructed labor, or shortly after the fistula appears. Thetraditional teaching has been that an attempt at repairshould be deferred for three months until the extentof the injury has fully manifested itself and anyinfection/inflammation in the injured tissues hasresolved. However, it also appears to be true thatsome fistulas might be prevented by prompt treat-ment of women who arrive at a health-care facilityimmediately after obstructed labor, that some fistulasmight close spontaneously if the bladder is drainedfor a prolonged period of time, and that a subset offistulas might even be amenable to early closure.John St. George (St. George 1969) believed thatprompt medical treatment of patients after obstructedlabor could prevent post-partum sepsis and promotethe healing of injured tissues, thus preventing somefistulas altogether, or at least minimize the extent ofinjury that developed. He advocated vigorous localcare of the injured tissues and prompt antibiotictreatment as soon as such patients were seen. He des-cribed one particularly noteworthy case:

VI. EARLY CARE OF THE FISTULAPATIENT

Achieving standards this high in patients whohave undergone extensive pelvic trauma fromobstructed labor will not be easy, but honesty isthe first prerequisite if progress is to be made withtrue scientific integrity.

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Further research on the effectiveness of immediatelocal care after fistula formation should be encoura-ged. Waaldijk (Waaldijk 1994) found that 50 - 60%of smaller fistulas (< 2 cm) would heal spontaneous-ly, if prompt prolonged bladder drainage was startedwithin three months of the initial injury. If the fistu-la did not close with simple catheter management, heperformed an early surgical closure. Using this regi-men, he reported a successful closure rate in 92% ofcases, with continence in 94% of those in whom thefistula was closed successfully. These results areencouraging, but await replication at other centers.

In general, specific issues of surgical technique areamong the least important issues in obstetric fistula

repair today. In practiced hands, skilled fistula sur-geons routinely achieve fistula closure rates of 80%or better. Multiple papers reporting large case seriessupport this contention (Mahfouz 1929; Mahfouz1930; Mahfouz 1934; Mahfouz 1938; Krishnan1949; Abbott 1950; Lavery 1955; Mahfouz 1957;Naidu 1962; Aziz 1965; Yenen and Babuna 1965;Coetzee and Lithgow 1966; Hamlin and Nicholson1966; Moir 1966; Bird 1967; Moir 1967; Hamlin andNicholson 1969; Mustafa and Rushwan 1971; Law-son 1972; Ashworth 1973; Waaldijk 1989; Iloaba-chie 1992; Kelly 1992; Arrowsmith 1994; Amr 1998;Goh 1998; Hilton and Ward 1998; Gharoro andAbedi 1999; Wall, Karshima et al. 2004). There is afairly general consensus concerning the basic prin-ciples of fistula repair, which can be summarized asfollows:

• The best chance for successful fistula closure is atthe first operation. In their large series of 2,484fistula patients, Hilton and Ward (Hilton and Ward1998) reported successful fistula closure in 82.8%of patients at the first attempt. Successful closurewas achieved in only 65% of those patients whorequired two or more operations.

• The fistula should be widely mobilized from thesurrounding tissues at the time of repair, so thatfistula closure can be achieved without tension onthe site of repair.

• The repair must be “water-tight” at the time ofclosure. If it is not, failure is virtually certain. Thesimplest way to test this is to instill a solution ofcolored water into the bladder at the time of fistu-la closure and make certain that no leakage can bedemonstrated. If leakage occurs, the operationmust be revised until leakage can no longer bedemonstrated. As J. Marion Sims wrote in his ori-ginal paper on fistula repair (Sims 1852), “if asingle drop of urine finds its way through the fis-tulous orifice, it is sure to be followed by more,and thus a failure to some extent is almost inevi-table.”

• The traditional teaching has been that the fistulashould be closed in multiple layers, avoiding over-lapping suture lines, whenever this can be achie-ved; however, in some cases there is simply notenough tissue present to achieve a multi-layeredclosure, and recently some surgeons have begunexperimenting with single-layer closure tech-niques. At present, no data are available to assessthe effectiveness of single-layer closure tech-niques in an objective fashion.

VII. SURGICAL TECHNIQUE FORFISTULA CLOSURE

“The patient, who was aged 18, was brought to thehospital three days after delivery, following labourwhich lasted seven days. She was incontinent ofurine and faeces. She was very pale (haemoglobinconcentration 3.7 g per 100 ml), dehydrated, toxicand unable to walk. Vaginal examination revealeda gaping opening with offensive purulent lochiaand discharge. The lateral walls of the vagina hadsloughed, revealing both pubic rami and the rightischial tuberosity. The perineum was torn, leavingan indefinite anal sphincter. A large vesico-vaginalfistula and a small recto-vaginal fistula, both withinfected edges, were seen. Apart from blood trans-fusions, parenteral antibiotics and high protein dietwere given: the vagina was douched twice dailywith warm Dettol solution; this was followed eachtime by insertion of layers of sofra tulle gauze.After three weeks, the local treatment was givenonly once daily for another three weeks. When thepatient was examined under anesthesia ten weeksafter admission, and before discharge from hospi-tal, the vaginal walls had healed over and returnedto normal; the perineum had healed, leaving onlya wide vaginal introitus; the recto-vaginal fistulahad healed and the vesico-vaginal fistula wasreduced to 1 cm diameter with mobile surroundingedges. She returned for repair three months later,and this was successfully carried out. Preventionof sepsis was the chief factor in such a transfor-mation as occurred in this case, as in many others,and repair would otherwise have failed.”

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• After fistula repair, the bladder should be emptiedby prolonged continuous catheter drainage inorder to prevent distention of the bladder andincreased tension on the suture lines. The traditio-nal duration of bladder drainage is 14 days, but nocomparative trials have been carried out to see ifshorter duration of bladder drainage (for example,7 or 10 days) is associated with increased risk offailed repair. Research on the optimal duration ofbladder drainage is important, and has obviousconsequences for fistula centers with large clinicalvolumes. If, for example, the duration of post-ope-rative catheterization could be decreased from 14days to 10 days without a significant increase infailure rates, the center could increase the numberof fistula patients undergoing surgical repair byalmost 30%.

• Especially in the case of fistulas due to prolongedobstructed labor where the injury is the result ofprolonged ischemia and tissue necrosis, success-ful closure is enhanced by the use of tissue grafts(bulbocavernosus graft, gracilis muscle graft, etc.)which bring a new blood supply to the site ofrepair. There is one retrospective paper in the lite-rature that evaluated the repair of comparable fis-tulas with and without the use of Martius bulbo-cavernosus flaps and demonstrated substantiallyhigher rates of successful closure when such agraft was employed (Rangnekar, Imdad et al.2000).

Each fistula is unique, and an ability to improvise inthe face of unexpected findings or complications is avirtue that every fistula surgeon must strive to deve-lop. It is clearly not possible to illustrate here everydifferent type of fistula and all of the various tech-niques that may be employed to close them. Howe-ver, a generally accepted technique—-based largelyon the work of Drs. Reginald and Catherine Hamlinat the Addis Ababa Fistula Hospital in Ethiopiawhere nearly 25,000 obstetric fistulas have now beenrepaired— can be described and illustrated as fol-lows (Figures 10 - 29). The first prerequisite for suc-cessful fistula repair is meticulous attention to detail.As Abbot aptly (if somewhat quaintly) noted (Abbott1950), “There must be no attempt to operate on thesecases with one eye on the clock and the other on thetea wagon. In fact, the operator upon vesico-vaginalfistulae should combine the traits of daintiness, gent-leness, neatness and dexterity of the pekinese, withthe tenacity and perseverance of the English bull-dog.”

The position for fistula surgery depends upon the

nature and location of the fistula to be repaired. Forthe vast majority of straightforward fistulas (espe-cially for mid-vaginal fistulas) a high lithotomy posi-tion with the buttocks pulled well over the edge ofthe operating table, provides excellent exposure(Figure 10). Surgery in this position is easy to per-form under spinal anesthesia, which is the cheapestand easiest form of anesthesia for “low technology”settings in developing countries. To operate in theknee-chest position is relatively uncomfortable forpatients and can compromise pulmonary function.Performing operations in the knee-chest positiongenerally requires intubation of the patient, the useof general anesthesia, and continuous ventilation.Trans-abdominal surgery with the patient in the supi-ne position is rarely needed, except for certain com-plex fistulas. An abdominal approach increases boththe cost of surgery and the likelihood of complica-tions, such as wound infections. When doing fistulasurgery in the developing world, failure to use atrans-vaginal approach requires special justification,such as cases in which additional intra-abdominalpathology must be addressed.

The first requirement for successful fistula repair isadequate exposure of the operative field. Figure 11depicts a typically narrow, scarred vagina of the typethat often develops after obstructed labor. The vesi-covaginal fistula is obscured by scar tissue and aconstriction ring, and is not clearly visible. Whenthis scar tissue is released by performing vaginalrelaxing incisions, the fistula can be seen and repai-red. The fistula depicted here is a straightforwardmid-vaginal vesico-vaginal fistula.

It is generally preferable to identify and catheterizethe ureters in most operations so that they are readi-ly identifiable throughout the course of the opera-tion. This can usually be done by passing cathetersthrough the fistula into the ureters under direct vision(Figure 12). The purpose of ureteral catheterizationis to ensure that the ureters are not inadvertently liga-ted during the fistula repair, with subsequent renaldamage or death. (This was the cause of death inSims’ only operative fatality; unfortunately, it occur-red in a very public demonstration of his techniquefor fistula closure in London at the Samaritan Hospi-tal; see page 518 (McKay 1922). Once the uretershave been catheterized, the ureteral catheters can bebrought out of the bladder through the urethra, kee-ping them away from the operative field. Althoughsome fistula surgeons prefer to leave ureteral cathe-ters in place for up to 14 days after surgery, currentWestern urological practice would suggest that such

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Figure 12. Ureters are identified and cannulated, if pos-sible. The use of intravenous diuretics and/or vital dyes canbe used to improve ureteric localization, if needed.(©Worldwide Fistula Fund, used by permission).

Figure 11. Placement of labial staysutures helps increase lateral exposu-re. Incisions through bands of scar tis-sue are often necessary to allow inser-tion of retractors. Left side of the illus-tration shows the vagina prior torelaxing incisions. Right side showsenhanced exposure after relaxing inci-sions. (©Worldwide Fistula Fund,used by permission).

Figure 10. Exaggerated lithotomy position for fistula repair.The patient is positioned at 35 - 45 degrees, head down posi-tion, with the use of shoulder supports and the buttocks pul-led over the edge of the table. (©Worldwide Fistula Fund,used by permission).

catheters can be removed immediately at the end ofthe case, or within a day or two after surgery at most.

Once the fistula is exposed and the ureters are iden-tified, it is important to mobilize the fistula fully sothat it may be closed without tension. Figure 13demonstrates the first move in mobilizing a mid-vaginal fistula. The posterior border of the fistula isincised and the incision is carried out laterally ontothe vaginal sidewalls. The incision extends onlythrough the vaginal epithelium, not into the bladderitself. Wide vaginal dissection will allow completemobilization of the fistula.

Following the initial vaginal incision, the posteriorvaginal flap is developed, always keeping the courseof the ureters in mind (Figure 14).

Continued mobilization of the fistula is achieved byextending the incision circumferentially around thefistula, then anteriorly towards the urethra (Figure15). As before, the incision extends only through thevaginal epithelium, not into the bladder. When thisportion of the operation has been completed, thebladder should be freed completely from the vagina.

The anterior vaginal flaps then are developed widelyto mobilize the fistula more completely (Figure 16).Due to the presence of scarring and tethering of thefistula, it is generally useful to carry the anterior dis-section upwards behind the pubic symphysis, ope-ning the retropubic Space of Retzius and detachingthe bladder from its supports in this area. This allowsfull mobilization of the fistula (Figure 17). The ante-rior vaginal flaps can be sutured out of the operativefield using “stay sutures.”

Additional tension may be taken off the fistula at thispoint by performing a partial bladder suspension bypassing sutures from the bladder up behind the pubicsymphysis and anchoring the sutures in the symphy-seal periosteum (Figure 18). Persistent stress incon-tinence is relatively common in patients after other-wise successful fistula closure. It has been arguedthat suture placement of this type reduces the preva-lence of this problem post-operatively (Hassim andLucas 1974; Hudson, Henrickse et al. 1975); howe-ver, no controlled studies have yet been carried outthat document this assertion.

Once the fistula has been mobilized as fully as pos-sible, fistula closure can begin. There are many dif-ferent techniques by which this task may be accom-plished. One proven technique is to close the firstlayer of the bladder with a continuous, running,interlocking stitch of an absorbable suture (Figure

19). The initial suture bite should be placed beyondthe lateral margin of the fistula and the last sutureshould be placed in a similar position on the opposi-te side of the fistula. Although Sims initially “paredback” the edges of the fistula in his closure tech-nique, there seems to be no need to do this in the vastmajority of obstetric fistulas: a better philosophy isto preserve as much bladder tissue as possible, parti-cularly when attempting to close extensive fistulas.

After initial fistula closure has been completed, theprimary suture line should be reinforced by a secondlayer of closure if at all possible. Ideally this shouldbe done in such a fashion that the second row ofsutures imbricates the initial closure, rolling morebladder tissue over the first line of closure in order toprotect it (Figure 20). When the second layer hasbeen closed, the integrity of the repair should bechecked by instilling 150 - 250 ml of water coloredwith indigo carmine, methylene blue, or another sui-table dye. If there is no leakage of colored water, thefistula repair can be assumed to be “water tight,” andthe operation can proceed. If leakage is observed, therepair should be revised until no more leakage isobserved.

Extensive experience with fistula repairs has ledmany surgeons to believe that successful fistula clo-sure is markedly enhanced by the use of a bulboca-vernosus fat pad (Martius) graft (Shaw 1949; Mar-tius 1956; Hamlin and Nicholson 1966; Hamlin andNicholson 1969; Baines, Orford et al. 1976; Zacha-rin 1980; Given and Acosta 1989; Elkins, Delanceyet al. 1990; Fitzpatrick and Elkins 1993; Punekar,Buch et al. 1999; Rangnekar, Imdad et al. 2000).There is one small comparative surgical study thatdocuments this finding (Rangnekar, Imdad et al.2000).

Development of the fat pad graft should begin with avertical midline skin incision on the left or rightlabium majus, extending from the base of the monspubis to about the level of the middle of the vaginalintroitus (Figure 21). Sharp dissection with a surgi-cal scissors is used to expose a central “cord” oflabial fat, and this dissection is carried down to thedeep fascial layer (Figure 22). Even in thin, malnou-rished women, dissection of this fat is always pos-sible. Once this “cord” of fat has been identified anddissected, it is cross-clamped superiorly with a singleclamp and transected (Figure 23). The superiorstump is suture-ligated to achieve hemostasis.

Next, the superior aspect of the graft is grasped gent-ly with an Allis forcep and the cord of fat is further

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Figure 13. Once the ureters have been catheterized throughthe fistula, the catheters may be brought out through theurethra to move them out of the operative field. Dissectionof the fistula begins at its posterior margin by making anincision that runs from one vaginal sidewall to the other.Accentuation of tissue planes in some cases may be aided bylocal infiltration of saline or local anesthetic. (©WorldwideFistula Fund, used by permission).

Figure 14. Complete mobilization of the fistula is continuedby raising posterior vaginal flaps. The mobilization is car-ried out to each vaginal sidewall as well as to the cervix (ifone is still present). Special care must be taken at the 4 and7 o’clock positions to avoid possible injury to the ureters.(©Worldwide Fistula Fund, used by permission).

Figure 15. The mobilizing incision is extended circumfe-rentially around the fistula. When this is completed, ananterior midline incision is made in the vagina and exten-ded up towards the external urethral meatus. (©WorldwideFistula Fund, used by permission).

Figure 16. The anterior vaginal flaps should be mobilizedall the way from the edge of the fistula to the pubic arch.(©Worldwide Fistula Fund, used by permission).

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Figure 17. Once the anterior flaps have been fully develo-ped, the endopelvic fascia is perforated and the space ofRetzius is entered, to complete the full mobilization of thefistula. This portion of the operation is often technicallychallenging. The apices of the anterior vaginal flaps can beretracted out of the operative field with stay sutures toimprove visualization of the fistula. At this point, the blad-der base and vagina should be completely separated fromone another. It is generally not necessary (or advisable) totrim or “pare back” the edges of the fistula. This onlyincreases the size of the defect and decreases the amount ofremaining bladder tissue. (©Worldwide Fistula Fund, usedby permission).

Figure 19. Fistula closure. The bladder defect is closed intwo layers using absorbable suture. If any tension isencountered during bladder closure, the initial dissectionhas been inadequate and should be revised. The first closu-re can be made with either interrupted sutures or a conti-nuous running, interlocking, suture. (©Worldwide FistulaFund, used by permission).

Figure 18. Closure of the fistula begins by placing ancho-ring sutures lateral to the bladder defect and superiorlythrough the periosteum of the pubic arch. The sutures aredesigned to decreases tension across the line of bladder clo-sure. (©Worldwide Fistula Fund, used by permission).

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Figure 20. Fistula closure. A second set of sutures is placed,imbricating the second suture line over the first. When thishas been completed, “water tight” closure of the fistulashould be confirmed by gentling filling the bladder with asolution of colored water or sterile infant feeding formula tocheck of leakage. If any leakage is noted, the repair shouldbe taken down and reclosed until no leakage can bedemonstrated. (©Worldwide Fistula Fund, used by permis-sion).

Figure 21. Martius bulbocavernosus fat flap. A vertical skinincision is made in the labium majus from the base of themons to the level of the middle of the vaginal introitus.(©Worldwide Fistula Fund, used by permission).

Figure 22. Martius flap. Lateral and medial dissection ofthe bulbocavernosus fat is made down to the deep fasciallayer, exposing a “cord” of labial fat. (©Worldwide FistulaFund, used by permission).

Figure 23. Martius flap. Once the “cord” of fat has beenidentified and dissected, it is cross-clamped superiorly anddivided. The superior stump is suture-ligated to insurehemostasis. (©Worldwide Fistula Fund, used by permis-sion).

mobilized down to its base. It is important to protectthe base of the pedicle to insure that its blood supplyremains intact (Figure 24). At this point, surgicalscissors are used to dissect a tunnel that extends fromthe base of the fat pad’s pedicle into the vagina, tra-veling between the vaginal epithelium and the pubicarch (Figure 25). The tunnel should be large enoughto allow passage of the surgeon’s finger from thelabial defect down to the bladder base (Figure 26).

Prior to passing the graft through the tunnel, fouranchoring stitches of absorbable suture should be pla-ced into the muscularis of the bladder at the 2,4, 8, and10 o’clock positions. This allows the Martius graft tobe anchored into place securely against the repairedfistula, protecting it and bringing in a new blood sup-ply to nourish the surgical site (Figure 27). The graftis then passed through the tunnel to the bladder baseand is anchored into position using the previously pla-ced anchoring stitches. The fistula site should be com-pletely covered at this point (Figure 28).

Finally, the stay sutures which had been holding theanterior vaginal flaps out of the surgical field arereleased and the vaginal defect is closed as an “inver-ted T” (Figure 29). The ureteric catheters can now beremoved and a vaginal pack placed, if desired.

1. THE FISTULA COMPLICATED BY URETHRAL

DAMAGE

Virtually all authors with extensive experience in themanagement of obstetric fistulas comment on thegreat difficulty in achieving post-operative continen-ce in patients who have had extensive damage to theurethra, even if the fistula defect itself can be closedsuccessfully. J. Chassar Moir, the great British gyne-cologist, (Moir 1965) referred to the worst of thesecases as “circumferential” fistulas, which “involve adestruction of the bladder neck not only on the vagi-nal side but, in many instances, on the pubic side aswell. The result is a circumferential sloughing withsubsequent discontinuity of the urethra and bladder;the intervening tissue is merely the epithelium thathas grown over, and become adherent to, the perios-teum of the back of the pubic bone.” Fistulas invol-ving this level of destruction are daunting, and arerarely seen in developed countries. According toMoir, the three great problems involved in dealing

with this type of fistula are: 1) extremely difficultexposure; 2) technical difficulty in dissecting the tis-sue remnants from the pubic bone; and 3) difficultyin joining the bladder neck to the urethral remnant orstump, if, indeed, any portion of the urethra is stillintact. The basic principles of technique needed todeal with this type of injury are complete mobiliza-tion of the bladder so that it can be drawn down lowenough to create a tension-free anastomosis with theurethral remnant. Freeing the urethral remnants fromtheir adherence to the pubic bone may require asuprapubic incision with dissection from above inorder to accomplish this. In such cases Moir tookcare to reinforce the bladder neck with buttressingsutures, and generally brought in a Martius’ graft forbetter support and a renewed blood supply.

If only the posterior portion of the urethra had beensloughed and the anterior portion of the urethra wasintact, Moir (Moir 1964) advocated a different tech-nique for urethral reconstruction. In this technique, athin catheter was stitched into position to serve as asplint for the new urethra. The margins of the ure-thral bed were freed from the vagina and were mobi-lized to allow them to be pulled together over theunderlying catheter without tension. The vaginalincision was extended above the bladder neck andthen reinforced with “inrolling stitches.” The repairwas usually buttressed with a Martius bulbocaverno-sus fat graft, after which the vagina was closed overthe repair with vertical mattress sutures to achieve a“broad apposition” of the vaginal wall. The bladderwas then drained for 10 days and the vaginal sutureswere removed after 21 days. Although he reportedgood success with this technique, with 23 of 34women (67%) having “perfect or near perfectcontrol” six months after surgery, 8 of 34 (24%) hadpersistent stress incontinence, and 9% had no impro-vement, reconfirming the view that persistent stressincontinence remains a significant problem for manywomen after successful fistula closure. Similar tech-niques with similar results have been reported byother authors (Noble 1901; Symmonds 1969; Sym-monds and Hill 1978).

Various authors have described neourethral recons-truction using bladder flaps (Barnes and Wilson1949; Flocks and Culp 1953; Su 1969; Quartey1972; Tanagho and Smith 1972). All of these opera-tions are based upon transabdominal techniques;however, a transvaginal approach to neourethralreconstruction using an anterior bladder flap tech-nique was described by Elkins, Ghosh and co-wor-kers (Elkins, Ghosh et al. 1992) In this technique, aneo-urethra is created by mobilizing a flap from the

VIII. COMPLICATED CASES ANDTECHNICAL SURGICAL

QUESTIONS

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Figure 24. Martius flap. The superior aspect of the graft isgently grasped with an Allis forcep and the labial fat is fur-ther mobilized down to its base, which is left intact to main-tain its blood supply. (©Worldwide Fistula Fund, used bypermission).

Figure 25. Martius flap. A tunnel is dissected from the baseof the labial fat graft into the vagina, running between thevaginal epithelium and the pubic arch. (©Worldwide Fistu-la Fund, used by permission).

Figure 26. Martius flap. The final caliber of the tunnelshould be large enough to allow passage of the surgeon’sfinger from the labial defect down to the bladder base.(©Worldwide Fistula Fund, used by permission).

Figure 27. Martius flap. Prior to passing the graft throughthe tunnel, four anchoring stitches of absorbable materialare placed into the muscularis of the bladder at the 2, 4, 8,and 10 o’clock positions. (©Worldwide Fistula Fund, usedby permission).

anterior bladder, which is then rolled into a tube. Inthis technique, the anterior and lateral edges of thefistula are freed up and the space of Retzius is ente-red transvaginally beneath the pubic bone. The ante-rior bladder is then pulled down into the vagina andmobilized. A 3 cm incision is made into the bladderand the anterior bladder wall is then rolled around a16 Fr. Foley catheter to create a tube. After this istacked down, a similar incision is made on the otherside to complete mobilization of the tube. The ante-rior surface of the neourethra is then sutured in twolayers and the posterior edge of the fistula is closedtransversely, also in two layers. The neourethra isreattached to the posterior edge of the pubic sym-physis, and a Martius graft is placed, before reap-proximating the vaginal epithelium. This techniqueresulted in successful closure of the fistula in 18 of20 cases, 4 of whom had severe stress incontinencepost-operatively.

Based on their extensive experience with fistulas inAddis Ababa, Ethiopia, in 1969 Hamlin and Nichol-son introduced the concept of the “difficult urinaryfistula” to describe the complicated aspects of theproblem touched on by Moir. According to them(Hamlin and Nicholson 1969), the “difficult fistula”

“…is a complex of several grave injuries occur-ring together—-namely, a) total destruction of theurethra (all walls), the remaining tissue beingmerely fibrous connective tissue and squamousepithelium which has grown over and becomeadherent to the periosteum on the back of thepubic bones; b) an extensive sloughing of thebladder neck and trigone sometimes so large as tocause one or both ureteric orifices to open direct-ly into the vagina; and c) fibrosis to an incredibledegree which 1) narrows the vagina to the diame-ter of one fingerbreadth, and 2) binds the remainsof the bladder high up to the descending pubicrami and to the pubic symphysis. In a word, nopart of the patient’s lower urinary tract has esca-ped some degree of damage. This is the fistulawhich daunts the hearts of most observers who seeit for the first time. … The gynaecologist boldenough to attempt the classical flap-splitting ope-ration for a case like this soon discovers that he isoperating in an area as confined and almost asinaccessible as the inside of the toe of a leathershoe. He will find himself freeing the bladder ofscar and the lateral fixation of its torn edges bytouch only. … Within the vagina nothing exists …except, almost quite literally, skin and bone.”

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Figure 28. Martius flap. The graft is then brought throughthe tunnel and anchored securely into place against therepaired fistula. The site of fistula repair should be comple-tely covered at this point. (©Worldwide Fistula Fund, usedby permission).

Figure 29. Vaginal closure. The stay sutures holding thevaginal flaps are released and the vaginal defect is closed asan “inverted T” using absorbable sutures. (©WorldwideFistula Fund, used by permission).

In such cases, Hamlin and Nicholson recommendedconstructing a new urethra by creating a new “inner”urethra using the skin and fibrous connective tissuecovering the pubic bones and the inferior border ofthe pubic symphysis. In this technique, two lateralvertical incisions about 2 cm part are made in theskin, and left and right skin flaps were then createdand reflected medially until their edges could be joi-ned together without tension in the midline under-neath the urinary catheter that had been placed in thebladder. When joined, these fragile skin flaps are rol-led into a tube. At this point the neourethra is a fra-gile, untenable creation. As the authors noted, “Sucha fragile neourethra, standing unsupported, wouldalmost certainly necrose, and even if it survivedwould not restore any worthwhile degree of func-tion.” The neourethra was then reinforced using agracilis muscle flap taken from the thigh, preservingits neurovascular pedicle. The gracilis tendon is pul-led through a tunnel in the thigh that crosses theischiopubic ramus at the level of the urethra and isguided into the vagina, under the pubic symphysis,and is sutured to the anterior lip of the cervix, thelateral vaginal fascia, and the fibrous connective tis-sue covering the periosteum of the ischiopubic ramiand the pubic symphysis. Once this has been accom-plished, additional grafting is necessary using a Mar-tius flap which is then covered with skin flaps.

Using this technique, the authors reported no deathsand only one “complete failure” in 50 operations,this case being due to failure of the blood supply tothe gracilis muscle flap. In some cases small urethro-vaginal fistulas remained, which were repaired at asubsequent operation. Surprisingly, only 8 women(16%) developed “severe” stress incontinence afterthis reconstruction, four of whom regained “satisfac-tory” continence over time, and four of whom requi-red an operation for stress incontinence. In the latterfour patients, only two of these operations were com-pletely successful. Six patients (12%) developed aurethral stricture, three of which were successfullytreated by passage of a sound and three of whichrequired surgical correction. The remaining 35patients (70%) were discharged home within sixweeks of surgery cured or with mild residual stressincontinence which did not appear to be clinicallybothersome for them (Hamlin and Nicholson 1969).

Recently Browning (Browning 2004) described atechnique for urethral buttressing that could be car-ried out at the time of initial fistula repair, particular-ly in patients with urethrovaginal or bladder neck fis-tulas who are at high risk for persistent post-operati-

ve stress incontinence. The operation involves mobi-lization of a small strip of the ischiocavernosusmuscles (or their fibrotic remnants) along each sideof the urethra, then suturing them together in themidline under no tension to create a fibromuscularsling under the repaired/reconstructed urethra. AMartius fat graft was then created and sewn over thesling and site of the repair to improve vascularizationand healing of the repair. In this small series of 32complicated patients on whom this procedure wasperformed in 2002-2003, 22 of 32 were continent,the failures occurring in patients with small bladdersand/or severe vaginal scarring.

There is little information on subsequent treatment ofstress incontinence following successful fistula clo-sure. A standard Burch-type retropubic bladder necksuspension operation, combined with urethrolysisand tissue plication, may work in a few patients(Waaldijk 1994), but in general the results of thisapproach have been very disappointing. Carey andco-workers reported a small series of patients whohad undergone previous fistula closure and who laterunderwent re-operation for stress incontinence. Afterurodynamic testing, 9 women with severe genuinestress incontinence underwent a retropubic urethro-lysis and a pubovaginal sling procedure combinedwith placement of an omental J-flap. Four weeksafter surgery, 78% were continent; however, this fellto 67% at 14 month follow-up (Carey, Goh et al.2002).

The unstated assumption in all these surgical experi-ments has been that post-repair stress incontinence infistula patients is a variant form of intrinsic sphincterdeficiency and should, by extension, be treated simi-larly. Simply stated, however, we have almost noscientific understanding of why stress incontinenceoccurs after successful fistula closure because wehave virtually no scientific data on this problem. Is itdue to massive urethral damage? Is it due to necrosisof the puborectalis muscle complex and damage tothe fascial “hinge” that connects the periurethral tis-sues to the muscle along the urethra and at the blad-der neck? Is it due to disruption of the neural controlmechanisms that modulate sphincter function? Is itdue to unusual changes in transmission of intraabdo-minal pressure to the urethra and bladder neck whichare peculiar to patients who have undergone prolon-ged obstructed labor? Until we have a better scienti-fic understanding of the urethral pathology that deve-lops due to obstructed labor, we will not understandhow to deal with the stress incontinence that results.The attempts so far to solve the problem of persistent

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stress incontinence in post-repair fistula patientshave been uncontrolled empirical surgical experi-ments with rather poor outcomes. We can, andshould, do better than this.

2. URINARY DIVERSION FOR THE IRREPA-RABLE FISTULA

Although there is a general consensus in the literatu-re that some fistulas simply cannot be repaired withrestoration of full continence, there is no generalagreement as to which fistulas should be treated ini-tially by primary urinary diversion rather than anattempt at fistula closure. Similarly, there are noaccepted criteria in failed cases to dictate when fur-ther attempts at closure should be abandoned and thepatient should be offered some form of urinarydiversion as a treatment. The dilemma has been sum-marized by Hodges (Hodges 1999):

Because urinary diversion tends to be a “high tech-nology” approach to fistula management, its use incountries that do not have a well-developed nursinginfrastructure to support the ongoing care of suchpatients suggests that this technique should be usedwith extreme caution. For example, transplantationof the ureters into an ileal conduit requires the use ofan external collecting device. The use of suchappliances may well be unacceptable in the local cul-ture and patients are likely to experience significantdifficulty in obtaining suitable external appliancesand may have trouble performing good stoma care.The result of such a policy could well be simply totranspose the fistula from the vagina to the abdomen!Likewise, if continent urinary diversions are perfor-med with the creation of a catheterizable stoma, theproblem of clean intermittent self-catheterizationremains. This can be compounded by loss of thecatheter or the development of stomal stenosis, with

urinary retention, reservoir breakdown, sepsis, anddeath. Hodges (Hodges 1999) has reported a seriesof seven patients with intractable fistulas who weretreated in Uganda by continent urinary diversionusing a Mitrofanoff procedure in which the appendixis mobilized as the catheterizable stoma. There wasone death 6 days after surgery, apparently from coin-cidental complications rather than as a direct resultof the operative technique. The other six patientswere reported as doing well up to 14 months aftersurgery. Because of the possibility of the complica-tions already alluded to, “patients are encouraged toremain near a hospital which can deal with any like-ly complications; five of the six patients have takenthis advice. All patients carry spare catheters and aletter clearly explaining the nature of the procedureand the emergency treatment if there is a complica-tion.” Whether these arrangements would be suitablefor employment in different environments in othercountries remains unknown.

The “traditional” operation for dealing with the irre-parable fistula has usually been uretero-sigmoidosto-my in which the ureters are transplanted into the sig-moid colon, which then functions as a reservoir forboth urine and feces. The long-term consequences ofthis operation, such as anastomotic leakage with per-itonitis, ureteral stenosis and hydronephrosis, acuteand chronic pylonephritis, electrolyte imbalances,diarrhea, long-term renal failure, and the develop-ment of adenocarcinoma of the colon at the site ofureteral implantation, are well-known. These com-plications should give compassionate surgeons pausebefore recommending operations of this kind.

Several small series of fistula patients who haveundergone ureterosigmoidostomy have been repor-ted in the literature (Foda 1959; Humphries 1961;Attah and Ozumba 1993), including one patient whobecame pregnant and delivered a live infant follo-wing an emergency Cesarean section for a bleedingplacenta previa (Lassey, Peterson et al. 2002). Theseseries are somewhat difficult to evaluate, as the num-bers of patients reported are small and follow-up isoften unsatisfactory. For example, Das and Sengupta(Das and Sengupta 1969) resorted to urinary diver-sion and ureteral transplantation in 20 of 135 fistulapatients that they reported in one series from India.Of these patients, two died of uremia after the surge-

ry—one of the 9th and one on the 21st post-operati-ve day after a stormy post-operative course. They didnot know the follow-up of the other patients. Casefatality rates as high as 38.5% have been reportedfollowing these procedures in developing countries

Many centres which perform VVF repairs have asmall group of “problem” patients who have failedto gain continence despite often repeated attemptsby different surgeons. Urinary diversion, with allits disadvantages, is seen as an admission of defeatby the VVF surgeon and so this decision is reachedreluctantly. This reluctance is compounded by theconcern of performing such a major procedure inoften basic conditions. However, in the best inter-ests of the patient, eventually the experienced VVFsurgeon must admit when all attempts to gaincontinence have failed and consider urinary diver-sion.”

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(Thompson 1945); although such grim statistics tendto come from the older surgical literature, the condi-tions of surgical practice and the facilities availablefor patient care may not have changed appreciably inthose countries in which fistulas are still prevalent.

In recent years it has been discovered that many ofthe disadvantages of “classical” ureterosigmoidosto-my could be overcome by modifications of tech-nique, the so-called “Mainz II” pouch (Fisch, Wam-mack et al. 1993; Gerharz, Kohl et al. 1998). In thismodification the anterior colon is opened 12 cm dis-tal and proximal to the rectosigmoid junction, and aside-to-side anastomosis is made. This detubulariza-tion of the bowel reduces the force of coloniccontractions and creates a “low pressure” system thatdoes not appear to predispose such patients to thedevelopment of hydronephrosis. The bowel is atta-ched to the sacral promontory for stabilization, andthe ureters are mobilized bilaterally and transplantedinto the colon through a 4-5 cm submucosal tunnelon each side. Aside from the continuing need tomonitor such patients for the development of hyper-chloremic metabolic acidosis and the possibility ofthe growth of malignant polyps at the uretero-colonicimplantation site, patients undergoing the Mainz IIprocedure have done quite well, and almost all havehad socially acceptable urinary continence andimproved body image compared to patients under-going urinary diversion using an ileal-conduit.

Good long-term follow-up studies of patients whohave undergone urinary diversion of this type forirreparable fistulas in developing countries are vir-tually non-existent. If ureterosigmoidostomy iscontemplated for a fistula patient, it is essential thatshe has normal anal sphincter control pre-operative-ly. This can be assessed by giving a large volumeenema as a continence test to see how long she canretain it. It is also essential that patients be givenenough time and counseling to understand the pos-sible consequences of this type of surgery for theirlives and future health. Treatment of intestinal para-sites and a thorough bowel-prep prior to surgery areobvious essential components of this type of therapy.The optimal use of such techniques in fistula patientsremains to be determined; however, it is clear that“salvage therapy” of this type will continue to have aplace in the treatment of some patients with obstetricfistulas for many decades to come.

The ultimate strategy for dealing with obstetric fistu-las should be to prevent them entirely. Indeed, this isprecisely how the Western world solved the problemwithin its borders. Because obstetric fistulas are tiedclosely to overall maternal mortality, the best way toreduce fistula formation is to provide essential obste-tric services at the community level with promptaccess to emergency obstetric services at the firstreferral level. The success of this strategy has beenamply demonstrated by Loudon (Loudon 1992; Lou-don 1992), by Maine (Maine 1991) and the essentialelements of such obstetric care have been elaboratedin some detail by the World Health Organization(WHO 1986). Figure 30 shows the historical trendsin maternal mortality in the United States, Englandand Wales, and the Netherlands since 1920 (Loudon1992). At the beginning of the 20th Century, mater-nal mortality in Western Europe and North Americawas similar to that which currently exists in the deve-loping world. The introduction of antibiotics, bloodtransfusion, safe Cesarean section, better transpora-tion and improved access to care, along with the pro-fessionalization of obstetric care and midwifery ser-vices, led to a dramatic and continued decrease inmaternal mortality in all these countries (Loudon

IX. PREVENTION OF OBSTETRICFISTULAS

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Figure 30. Historical trends in maternal mortality in theUnited States, England and Wales, and the Netherlands,1920 - 1960. (Loudon 1992a).

1992; Loudon 1992; Loudon 2000). During the sameperiod the obstetric fistula virtually vanished fromthe experience of the industrialized world. Elimina-tion of obstetric fistulas from the developing worldwill require that their health care systems undergo asimilar transformation.

The committee believes that the fundamental com-ponents of such a program include the following:

• Promotion of breastfeeding and the elimination ofchildhood infections which hamper growth, suchas gastroenteritis, respiratory infections, alongwith immunization against the six “killerdiseases” of childhood: measles, diphtheria, teta-nus, polio, pertussis, tuberculosis.

• Adequate childhood nutrition to allow youngwomen to achieve full pelvic growth before child-bearing begins

• Delay in childbearing until full pelvic growthcompleted. There is substantial evidence to sug-gest that education is the best way to shelter girlsfrom premature childbearing.

• Provision of family life education, educationabout women’s health and sex education to ado-lescents.

• Elimination of traditional customs that promoteearly marriage. While respect for the principle ofindividual autonomy would argue for the elimina-tion of early betrothal and arranged marriages,even in cases where such practices continue thereshould be a mutually-understood and agreed-upon delay in the consummation of such mar-riages until the young woman has reached fullpelvic maturity. There is no advantage to anycommunity in having early adolescent pregnan-cies.

• Supervision of the labor of every pregnant womanby a trained birth attendant. For developing coun-tries this requires a commitment to developingculturally-acceptable community midwifery pro-grams and an expansion of midwifery trainingservices everywhere.

• Monitoring of every labor with the use of parto-grams to detect cephalo-pelvic disproportionearly and to prevent the development of obstruc-ted labor. There is overwhelming evidence thatsimple technology can accomplish this goal(Kwast 1994).

• Prompt, universal access to emergency obstetriccare at the first referral level. This should be afundamental goal of every health care system in

the world. This will require removal of culturaland institutional, as well as physical, barriers(Maine 1991; Thaddeus and Maine 1994; Net-work 1995).

• Universal basic education for women. There issubstantial evidence that the education of womenplays a major role in promoting maternal health,reducing maternal mortality, and eliminating obs-tetric fistulas (Harrison 1985; Harrison 1997).These goals appear to be achieved largely throughbetter access to and utilization of life-saving heal-th care services; however, it must be emphasizedthat for education to be effective in achievingthese goals, effective health care services mustfirst exist. Maternal mortality, and with it obste-tric fistula formation, is largely a problem of theworld’s poor: the affluent countries of the worldbear substantial responsibility for allowing thissituation to continue when relatively low cost,low technology interventions exist that could pre-vent it (Rosenfield and Maine 1985; Weil andFernandez 1999).

• Finally, education of men concerning the impor-tance of women’s reproductive health for theirown families in particular and for the communityat large. Because men control a disproportionateshare of social resources everywhere, but espe-cially in developing countries, they must unders-tand that “women’s health” is not “just a women’sissue,” but is one in which they too must becomeintimately involved.

The WHO Technical Working Group on the preven-tion and treatment of obstetric fistulas which met inGeneva from April 17-21, 1989 naively suggestedthat a plan could be put forth by which the backlogof existing fistula cases could be cleared up withinfive years (WHO 1989). Greater experience nowsuggests that solving the problem of cases awaitingsurgery will require a generation or more. Not only isthe backlog of unrepaired cases huge, but the absen-ce of adequate maternal health care and emergencyobstetrical services means that large numbers of newcases are continually occurring in those parts of theworld where the fistula problem is greatest, thusadding continually to the burden of injury, which isnot diminishing.

X. DEALING WITH THE BACKLOGOF SURGICAL CASES

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The special nature of the injuries produced by obs-tructed labor, the stigmatizing and socially isolatingnature of the injury, and the long periods of rehabili-tation needed before operation and the length of nur-sing care required after surgery, strongly argue infavor of the creation of specialized fistula centers inareas of the world where fistulas are highly preva-lent. Ideally, each country or region in which thisproblem exists should have its own dedicated center,and centers in neighboring countries should beencouraged to collaborate in sharing information andestablishing common protocols for research and trai-ning. There is an urgent need to create an internatio-nal network of fistula centers in the developingworld that can collaborate with one another in advan-cing the care of patients who have sustained an obs-tetric fistula.

Why are specialized fistula units needed? The firstargument is the efficiencies obtained from “econo-mies of scale.” A “focused factory” that does nothingexcept repair fistulas and take care of the related pro-blems stemming from obstructed labor will developspecial expertise in managing those problems. Sucha center can deal with more cases more efficientlythan a smaller service attached to a general hospital.Such a center also allows for the concentration of asufficient volume of cases for meaningful trainingprograms to be established through which additionalfistula surgeons and fistula nurses can be developedfor other centers in developing countries.

Second, the large volume of existing cases in deve-loping countries justifies this approach in terms ofthe sheer numbers of patients involved. The AddisAbaba Fistula Hospital in Ethiopia, for example, hasrepaired approximately 25,000 cases to date, and stillthere is no shortage of women needing services.

Third, fistula units in general hospitals must compe-te for scarce resources with the needs of the generalmedical and surgical population. Since fistula repairsare rarely emergencies, it is difficult to book andkeep scheduled operating theater time in the face ofongoing emergencies such a road traffic accidents,incarcerated hernia, intestinal perforations fromtyphoid or parasites, women in obstructed labor whoneed a surgical delivery, and so on. In settings wherethe health care system is already overwhelmed andwhere resources are scarce, scheduled fistula repairsare continually getting “bumped” from the operatingschedule by more acute emergencies. While this isperfectly understandable, it augurs poorly for thedevelopment of an efficient fistula service in such asetting. Furthermore, because fistula patients tradi-

tionally have required two weeks of post-operativecare for catheter drainage, they are more “bed inten-sive” than other surgical cases. In Lavery’s (Lavery1955) series of 160 obstetric fistula cases from SouthAfrica, the average duration of stay in hospital was57.3 days, with a range of 11 to 264 days. In an envi-ronment with constant pressure to turn over hospitalbeds more quickly, fistula patients are likely to recei-ve short shrift.

Fourth, fistula patients tend to integrate poorly intogeneral hospital wards. By the time most suchpatients arrive for surgical treatment, they have beencast out and stigmatized by the society in which theylive. They are psychologically and spiritually vulne-rable, and they are socially offensive due to the odorthat surrounds them. Many of these women are fur-ther stigmatized by unwarranted beliefs about whythey developed a fistula in the first place: it is assu-med by many to be a punishment for some offenseagainst God (such as a pregnancy originating in anadulterous relationship) or as the result of a hideousvenereal disease, which some consider contagious.Fear of the unknown breeds hostility towards thesepatients in the community at large.

Fifth, for reasons cited above, these patients do bet-ter in a communal environment. It is a great psycho-logical relief to fistula patients to realize that they arenot alone, to meet fellow sufferers with whom theycan share experiences. A “sisterhood of suffering”develops in a dedicated fistula center that is immen-sely beneficial in restoring psychological health andhope to these women. At the Addis Ababa FistulaHospital, most of the nursing care is provided by for-mer fistula patients, who provide a level of empathe-tic nursing unequaled anywhere in the world.

It seems unlikely that large, dedicated fistula centerssimilar to that which exists in Addis Ababa will bedeveloped in every country where there is great needwithin the foreseeable future. What then can bedone? For the reasons enumerated above, it is impor-tant that facilities be created that are dedicated exclu-sively to the care of women with obstetric fistulas.Such facilities need not be identical everywhere;their capabilities could be stratified into thosecapable of dealing with “simple” cases, and thosedealing with more complicated “high risk” fistulas(Elkins, Mahama et al. 1994).

Hamlin and Nicholson’s concept of the “difficult”fistula has already been alluded to (Hamlin andNicholson 1969). It is unrealistic to expect (andundesirable to encourage) a neophyte fistula surgeon

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to tackle cases of this complexity in a small, lowvolume fistula unit. However, the majority of obste-tric fistulas seen in developing countries are not thiscomplicated, and the size of the fistula has little bea-ring on the degree of urinary incontinence and resul-ting disability that the affected woman experiences:The same amount of urine runs out of an unscarred,freely mobile, 1 cm mid-vaginal fistula as runs out ofa 5 cm fistula in which the bladder neck and proxi-mal urethra have been destroyed, the vagina steno-sed, and the fistula scarred against the pubic sym-physis in dense bands of fibrosis. A relatively uns-killed fistula surgeon could easily fix the former, res-toring continence and hope to the afflicted patient,whereas he or she would likely get into serious diffi-culties in an attempt to operate on the latter.

Elkins and Wall (Elkins and Wall 1996) havedemonstrated that trained obstetrician-gynecologistsand general surgeons can quickly become proficientwith the basic principles of fistula surgery if they aregiven appropriate training and supervision throughan intensive “short course” in fistula repair: it doesnot take years of additional training to create capablefistula surgeons. Although such trainees may not befully able to tackle difficult or “high risk” cases, theycan certainly close the less complicated fistulas(Hamlin and Nicholson 1969; Elkins, Mahama et al.1994). What is required in order to achieve this levelof skill is an adequate volume of surgical cases thatcan be done under supervision while the basic tech-niques are mastered. Thus, it does seem feasible tocreate a “tiered” system of fistula centers withincountries where that need exists. The key to makingsuch programs work is trained, committed personnelwho have adequate local resources. Small programscan be started with a few dedicated beds in a generalhospital. If additional resources are provided, suchprograms can expand to occupy a dedicated ward atthe same facility. Ultimately, the program can beco-me transformed into an entirely separate facilitydedicated exclusively to the care and rehabilitationof fistula patients.

The following recommendations can be made for thecreation of specialized fistula centers in developingcountries:

• For the reasons outlined above, the creation ofdedicated fistula centers should be encouraged.

• Fistula centers should be located close to an all-weather road and good public transportation tofacilitate access by patients. Wherever possible,such centers should be located in the geographicregion in which fistulas are most prevalent, rather

than in capital cities which have few fistulas andwhich therefore require patients to travel long dis-tances to obtain care.

• Fistula centers should be located reasonably closeto a general hospital so that emergency cases canbe referred elsewhere, thus protecting the overallmission of the fistula program.

• Each fistula center should have a dedicated ope-rating theater, ideally one in which two or moreoperations can be carried out simultaneously tomaximize the turnover of cases.

• An in-patient ward of adequate size should beprovided to deal with the expected number ofcases. A ward of 40 or 50 beds should allow 500to 1,000 operative cases to be treated each year.

• A “step-down unit” or hostel should be located atthe fistula center to allow for pre-operative nutri-tional and educational support for fistula victims,and to allow better post-operative monitoring ofnon-acute patients.

• Care for fistula patients should be provided freeof charge as a matter of principle. Fistula victimsoverwhelmingly tend to be young, poor, uneduca-ted women, often deserted by husband and fami-ly, and from rural areas. There are many tragicstories of women who have suffered with fistulasfor decades because they were unable to scrapetogether bus fare to a hospital or the cost of surgi-cal supplies. Many studies of health care in deve-loping countries have demonstrated that the insti-tution of “user fees” dramatically reduces the uti-lization of services, often with worsening healthoutcomes (Ekwempu, Maine et al. 1990; Network1995). The total cost of supplies and services forfistula repair is generally quite modest ($250 -$400). Although this still represents a largeexpenditure in developing countries, set againstthe value obtained from giving a woman back herlife, it represents excellent cost-effective treat-ment. In order to bear these expenses, most fistu-la centers will probably require some degree ofexternal funding through international medicalaid; efforts in this direction should be encouraged.As the famous British surgeon Lawson Tait wrotein 1889 (Tait 1889), “I have already said that ope-rations for vaginal fistulae are rarely paid for,except in gratitude, because the patients are near-ly always poor. I must have operated on two orthree hundred cases, and I have not yet beenremunerated to an extent which would pay for theinstruments I have bought for the purpose.”

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• Fistula centers will require an on-site kitchen andlaundry facilities. In African general hospitals,many of these services are typically provided bythe family and relatives of the patient. The natureof the injury sustained by fistula victims meansthat many have been abandoned and lack thisfundamental resource for coping with their condi-tion. Fistula centers should therefore be preparedto provide the essentials of nutrition and laundry.Due to the vagaries of water and electric power indeveloping countries, fistula centers should havetheir own diesel generators and self-containedwater supply, wherever feasible.

• Facilities and surgical care should be providedwithin a framework of “low technology” medici-ne. Almost all surgical procedures can be provi-ded under simple spinal or ether anesthesia usingstandard surgical instruments, simple suture, andtransurethral catheter drainage. Clinical laborato-ry requirements should be kept to a minimum.Cinder block construction, open wards, sheetmetal roofing and simple architecture can be usedto keep construction and operating costs to aminimum.

• Adequate housing for doctors and nursing staffshould be provided, within the appropriate expec-tations of the local culture. If current and formerpatients are trained to work as nursing assistants,they can be housed acceptably in dormitory-stylehousing.

disenfranchisement. Fistulas are primarily a condi-tion that afflicts society’s “have nots,” and theprevalence of obstetric fistulas closely tracksworld maternal mortality statistics, especially inthose areas where obstructed labor is a principalcontributing cause of maternal death. The conti-nued prevalence of obstetric fistulas representsa tragic waste of some of the most precious ofthe world’s human resources: its young women.

• In theory, obstetric fistulas are completely pre-ventable by the provision of adequate, timelyobstetric care. The presence of obstetric fistulasin any country, therefore, is an indictment of thequality and effectiveness of its health care deli-very system. When obstetric fistulas do occur,they should be curable (“closeable”) in over90% of cases using appropriate low-technologymedical and surgical services.

• The fistula problem has been shamefullyneglected by the governments of those coun-tries in which they occur, by local health ser-vices, by non-governmental organizations, byinternational health organizations such asWHO, and by the foreign aid and internationaldevelopment agencies of the world’s wealthycountries. The fistula problem has been almostuniformly neglected by the world’s “SafeMotherhood” initiative, which itself has beenlargely ineffective in reducing maternal death indeveloping countries. The fistula problem hasbeen, and still is, an “orphan.” This situation isintolerable, and must be changed. There arefaint signs that the world is finally recognizingthis situation, but the response to date has beenwoefully inadequate (Donnay and Weil 2004).

• There is a great need for village-based commu-nity studies of the incidence and prevalence ofobstructed labor and fistula formation. It isclear that most fistulas arise from the combina-tion of “obstructed labor and obstructed trans-portation,” but much more work is needed tounderstand the social context in which obstetricemergencies arise and how they are dealt within developing countries. Nonetheless, theurgent needs of pregnant women should not besacrificed on the altar of epidemiologicalresearch; rather, more attention should be paidto improving emergency treatment for obstetriccomplications at existing referral facilities, toupgrading peripheral facilities to provide

• The precise extent of the fistula problem indeveloping countries is unknown. The avai-lable evidence suggests that at a minimum,hundreds of thousands (if not several millions)of women are afflicted with this conditionworldwide, most especially in sub-SaharanAfrica. The enormous burden of suffering cau-sed by fistulas is borne principally by youngwomen living under conditions where theiropportunities for education, economic prospe-rity, self-determination, and “the pursuit ofhappiness,” are limited by poverty, illiteracy,restricted social roles, the absence of adequatereproductive health services, and political

XI. CONCLUSIONS ANDRECOMMENDATIONS

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essential life-saving obstetric care, to educatingthe community about the danger signs of obstetriccomplications, and to working with communityleaders to improve access to emergency obstetriccare in areas where maternal mortality and obste-tric fistula rates are high.

• There is no standard classification system for obs-tetric fistulas. The committee recommends thatthe ICS take this task upon itself and that a sub-committee of the committee on the standardiza-tion of terminology by appointed to begin dealingwith this task.

• Although the solution to the fistula problem willultimately come from the provision of essentialobstetric services for all the world’s women, thecurrent needs of those women who have alreadydeveloped an obstetric fistula cannot be ignored.The committee recommends that specialized fis-tula centers should be created in all countrieswhere obstetric fistulas are prevalent. Womenwith fistulas should have access to prompt, highquality surgical reconstruction which should beprovided free of charge. Such facilities shouldserve as centers of compassionate excellence andshould provide high quality patient care, medicaland nursing education, and clinical research aspart of their mandate for existence. It is unlikelythat essential obstetric services will be availableto all of the world’s women within the foreseeablefuture; therefore, development of a sustainableclinical infrastructure to deal with the effects ofmaternal morbidity is likely to be an essentialneed in reproductive medicine for the rest of the21st Century.

• Although current surgical techniques consistentlyresult in fistula closure rates of 80% - 95% ofcases, there has been almost no scientifically rigo-rous research carried out on most of the persistenttechnical surgical questions raised by fistulas.Urgent work is needed in this area. Among theissues that should be addressed are:

1 The problem of persistent stress incontinenceafter successful fistula closure;

2 The management of dramatically reduced bladdercapacity in patients with large fistulas who haveundergone successful closure;

3 The best technique for rectovaginal fistula repair;

4 The role of urinary diversion for the “incurable”fistula, usually involving some form of uretero-sigmoidostomy;

5 The role of vaginoplasty in patients with vaginalatresia from obstructed labor;

6 The best method of caring for patients who pre-sent with a “fresh” fistula a few days or weeksafter delivery, including the role of early repair inselected obstetric fistulas;

7 Future reproductive function in patients who havesustained an obstetric fistula;

8 The proper role and choice of flaps and grafts infistula surgery;

9 The optimum duration of post-operative bladderdrainage after fistula repair;

10 The role of nutritional support in improving theoutcomes of patients with obstetric fistulas; and

11 The role of physical therapy and reconstructiveorthopedic surgery in the management of womenwith obstetric foot-drop from prolonged obstruc-ted labor.

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