Published online May 10, 2016. doi: 10.5317/wjog.v5.i2.182
Peer-review started: July 5, 2015
First decision: September 17, 2015
Revised: January 26, 2016
Accepted: February 14, 2016
Article in press: February 16, 2016
Published online: May 10, 2016
Processing time: 316 Days and 4.2 Hours
Prolonged and/or obstructed labour is the most common cause of genital tract fistula world-wide, in particular, sub-Saharan Africa and parts of Asia where emergency obstetric services are unavailable or suboptimal to afford timely delivery of the baby. This results in pressure necrosis by the fetal presenting part at the level of the obstruction in the maternal pelvis. Other reasons for obstetric fistula include trauma from vaginal deliveries (spontaneous or instrumental) and iatrogenic from cesarean section/hysterectomy. The majority of women develop the fistula during their first labour and most babies are stillborn. Women with a fistula suffer from leakage of urine and/or faeces from the vagina and surgery is the treatment for an established fistula. Long-term complications of fistulas include recurrent fistula, urinary incontinence, reproductive dysfunction, sexual dysfunction, mental health dysfunction, social isolation and orthopaedic complications such as footdrop. Ongoing urinary symptoms are not uncommon after successful fistula closure. There are various reasons for residual urinary incontinence following obstetric fistula repair including urinary stress incontinence, overactive bladder, mixed urinary incontinence and voiding dysfunction. Urinary incontinence after fistula repair requires careful evaluation prior to further surgery, as in some diagnoses, continence surgery is unlikely to treat and may worsen the condition. Initial results from educational and physiotherapy programs demonstrated a positive impact on post-fistula incontinence.
Core tip: About one quarter of women suffer from residual urinary incontinence after surgical closure of genito-urinary fistula. Women with ongoing urinary incontinence usually complain of continuous urinary leakage and recurrent fistula requires exclusion. Women with fistulas involving the urethra are more likely to have ongoing urinary symptoms. Causes of ongoing urinary incontinence after fistula closure include urodynamic stress incontinence, detrusor overactivity (DO) and voiding dysfunction. Synthetic slings have a high rate of complications in these cases. Suboptimal success from surgery may be due to undiagnosed or untreated DO and marked reduction in urethral function.