Journal Articles

Current Practices in Treatment of Female Genital Fistula: A Cross-Sectional Study
In 2009, 40 surgeons who provide fistula treatment services in Africa and Asia at private and government hospitals completed questionnaires about treatment practices for fistula patients. Respondents were asked about three issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair. The results provide a snapshot of current practices in fistula treatment and care. There was consensus in some treatment areas, while there were wide variations in practice in other areas (e.g., duration of catheter use, surgical treatments for postsurgical incontinence). The findings were based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical research that would contribute to more efficient and effective fistula care.
Link: English

Determinants of Postoperative Outcomes of Female Genital Fistula Repair
This paper described the predictors of fistula repair outcomes three months postsurgery among 1,274 women who underwent fistula repair. Small bladder size (adjusted RR 1.57, 95% CI 1.39–1.79), prior repair (adjusted RR 1.40, 95% CI 1.11–1.76), severe vaginal scarring (adjusted RR 1.56, 95% CI 1.20–2.04), partial urethral involvement (adjusted RR 1.36, 95% CI 1.11–1.66), and complete urethral destruction or circumferential defect (adjusted RR 1.72, 95% CI 1.33–2.23) all predicted failed fistula closure. Women with a closed fistula at the three-month follow-up were included in an analysis of predictors of residual incontinence (n=1,041). Prior repair (adjusted RR 1.37, 95% CI 1.13–1.65), severe vaginal scarring (adjusted RR 1.35, 95% CI 1.10–1.67), partial urethral involvement (adjusted RR 1.78, 95% CI 1.27–2.48), and complete urethral destruction or circumferential defect (adjusted RR 2.06, 95% CI 1.51–2.81) were significantly associated with residual incontinence. The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
Link: English
Abstract: French (PDF, 561KB)

Development and Test of Prognostic Scoring Systems for Surgical Urinary Fistula Closure
This paper describes the testing of the diagnostic performance of five existing classification systems (developed by Lawson, Tafesse, Goh, the World Health Organization [WHO] and Waaldijk) and a prognostic scoring system derived empirically from our data, to predict fistula closure three months following surgery. Among existing systems, the scoring systems representing the WHO, Goh and Tafesse classifications had the highest predictive accuracy: AUC 0.63 (95%CI: 0.57–0.68), AUC 0.62 (95%CI: 0.57–0.68) and AUC 0.60 (95%CI: 0.55–0.65), respectively. The empirically derived prognostic score achieved similar predictive accuracy (AUC 0.62, 95%CI: 0.56–0.67); it included significant predictors of closure found in the other classification systems but contained fewer nonoverlapping components. Differences in AUCs were not statistically significant. The prognostic values of existing urinary fistula classification systems and the empirically derived score were poor to fair. Further evaluation of the validity and reliability of existing classification systems to predict fistula closure is warranted, with consideration given to a prognostic score that is evidence-based, simple, and easy to use.
Link: English
Abstract: French (PDF, 233KB)

Factors Influencing Choice of Surgical Route of Repair of Urinary Fistula and the Influence of Route of Repair on Surgical Outcomes: Findings from a Prospective Cohort Study
The abdominal route of genitourinary fistula repair may be associated with longer term hospitalization, hospital-associated infection, and increased resource requirements. This paper examines: the factors influencing the route of repair; the influence of the route of repair on fistula closure three months following surgery; and if the influence of the route of repair on repair outcome varied by whether women met published indications for abdominal repair. Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location, or other abdominal pathology) predicted the abdominal route [adjusted risk ratio [ARR], 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route. Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
Link: English
Abstract: French (PDF, 561KB)

Factors Influencing Urinary Fistula Repair Outcomes in Developing Country Settings: A Systematic Review
The abdominal route of genitourinary fistula repair may be associated with longer term hospitalization, hospital-associated infection, and increased resource requirements. This paper examines: the factors influencing the route of repair; the influence of the route of repair on fistula closure three months following surgery; and if the influence of the route of repair on repair outcome varied by whether women met published indications for abdominal repair. Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location, or other abdominal pathology) predicted the abdominal route [adjusted risk ratio [ARR], 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route. Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
Link: English
Abstract: French (PDF, 561KB)

Fistula and Traumatic Genital Injury from Sexual Violence in a Conflict Setting in Eastern Congo: Case Studies
In the Eastern region of the Democratic Republic of Congo (DRC), sexual violence has been used as a tool of war. A particularly inhumane public health problem has emerged: traumatic gynecological fistula and genital injury from brutal sexual violence and gang rape, along with enormous psychosocial and emotional burdens. Many of the women who survive find themselves pregnant or infected with sexually transmitted infections (STIs), including HIV, with no access to treatment. This paper compiled data from the Doctors on Call for Service/Heal Africa Hospital in Goma, Eastern Congo, on the cases of 4,715 women and girls who suffered sexual violence between April 2003 and June 2006, of whom 702 had genital fistula. It presents the personal experiences of seven survivors whose injuries were severe and long-term, with life-changing effects. The paper recommends a coordinated effort among key stakeholders to secure peace and stability, an increase in humanitarian assistance, and the rebuilding of the country’s infrastructure, human and physical resources, and medical, educational, and judicial systems.
Files: English (PDF, 587KB)

Non-Inferiority of Short-Term Urethral Catheterization Following Fistula Repair Surgery: Study Protocol for a Randomized Controlled Trial
Providing fistula repair services in developing countries presents numerous challenges, including limited availability of operating rooms, of equipment, of surgeons with specialized skills, and of funding from local or international donors to support surgeries and subsequent postoperative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower the risk of health care–associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term urethral catheterization (over the course of seven days) is no worse (by more than a minimal relevant difference) than longer term urethral catheterization (over the course of 14 days) in terms of the incidence of fistula repair breakdown among women with simple fistula who presented at study sites for fistula repair service. If no major safety issues are identified, the data from this trial may facilitate the adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia.
Link: English
Abstract: French (PDF, 561KB)

Obstetric Fistula and the Challenges to the Maternal Health Systems
This article describes some of the systemic issues faced by fistula interventions, including a shortage of human resources, political instability in countries with high burdens, other medical and nonmedical priorities, poverty, illiteracy, gender norms, and inefficient health referral systems. The article argues for taking a health systems approach to improve prevention, treatment, and reintegration through coordinated efforts.
Link: English

Outcomes in Obstetric Fistula Care: A Literature Review
Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.
Link: English

Profiles and Experiences of Women Undergoing Genital Fistula Repair: Findings from Five Countries
This article presents data from 1,354 women from five countries who participated in a prospective cohort study conducted between 2007 and 2010. Women undergoing surgery for fistula repair were interviewed at the time of admission, at discharge, and at a three-month follow-up visit. While women’s experiences differed across countries, a similar picture emerges across countries: Women married young, most were married at the time of admission, they had little education, and for many the fistula occurred after the first pregnancy. The women’s median age at the time of fistula occurrence was 20.0 years (interquartile range, 17.3–26.8). Half of women attended some antenatal care; among those who attended antenatal care, fewer than 50% recalled being told about signs of pregnancy complications. At follow-up, most women (even those who were not dry) reported improvements in many aspects of social life; however, reported improvements varied by repair outcome. Prevention and treatment programs need to recognize the supportive role that husbands, partners, and families play as women prepare for safe delivery. Effective treatment and support programs are needed for women who remain incontinent after surgery.
Link: English

Striving For Excellence: Nurturing Midwives' Skills in Freetown, Sierra Leone
Midwives provide critical, lifesaving care to women and babies. Effective midwives must be clinically competent, with the required knowledge, skills, and attitudes to provide quality care. Their success depends on an environment of supportive supervision, continuing education, enabling policies, and access to equipment and referral facilities. In Freetown, Sierra Leone, the Aberdeen Women’s Centre launched a maternity unit with an emphasis on striving for excellence and providing ongoing professional development to its staff midwives. This paper describes how they successfully fostered a sense of responsibility and teamwork, providing necessary resources, conforming to evidence-based standards, and building partnerships. An explicit philosophy of care was crucial for guiding clinical decision making. In its first two years of operation, the Aberdeen Women’s Centre assisted 2,076 births, with two maternal deaths and 92 perinatal deaths. In-service education and supportive supervision facilitated the midwives’ professional growth, leading to capable future leaders who are providing exemplary care to delivering mothers and their newborns in Freetown.
Link: English
Abstract: French (PDF, 228KB)