Complex Obstetrical Fistula

Complex Obstetrical Fistula

Steven D. Arrowsmith


In the realm of pelvic reconstructive surgery, perhaps the most daunting challenge could be that of the obstetric fistula. In its full-blown form, this entity has virtually and thankfully disappeared from wealthy nations. However, because fistulas do occur from after a variety of injuries (trauma, surgical misadventure, and radiation) in developed countries,1 it is useful to consider principles developed to deal with obstetric fistula, which can still be seen in high volume in endemic areas, and apply the lessons learned to injuries that might be less complex. The subject matter deserves an entire textbook of its own, and so this, overview can only hope to outline some of the challenges complex fistula presents.

One of the unfortunate realities of fistula care has been, because the vast majority of complex fistula care has been delivered in some of the most resourcechallenged areas on earth, quality clinical data collection is one victim of the impoverished context. Many of the assertions presented here would be widely agreed on within the fistula community, but a robust evidence base, although finally starting to accrue, is still essentially lacking.

Fistulas seen in wealthy nations tend to be iatrogenic, resulting from the unintentional, direct cutting of pelvic structures, or devascularization of pelvic structures via ischemia resulting from ligature, indiscrete clamping, or overexuberant cautery. In nonobstetric fistula, these insults are generally limited to an area a few millimeters in size. With untreated obstructed labor, wide areas of pelvic tissue are subject to unrelenting pressure from the presenting fetal part, resulting in the compromise of arterial inflow and finally the ischemic loss of regions, and not small foci, of pelvic tissue. The only equivalent in Western medicine may be fistulas resulting from radiation therapy, especially early in the development in this technology, which caused vascular compromise to wide areas in the pelvis. It is the etiology of obstetric fistula that renders these injuries so severe and so varied. In obstetric fistula, much of the bladder, all of the urethra, the anterior rectum, the cervix, and much of the vagina may simply be lost.

Thankfully, large strides have been made in the prevention of obstetric fistula through the push toward improved access to emergency obstetric services addressed by strategies like the Millennium Development Goals and Sustainable Development Goals.2 These efforts have significantly impacted rates of maternal mortality and morbidity, and after many millennia of despair, the number of obstetric fistula cases may finally be trending downward.


Fistula can be documented back to more than 4,000 years ago, as an Egyptian mummy, thought to possibly be that of a wife of a Pharaoh, was noted to have a complex fistula.5 The basic techniques of fistula repair began to be published in the mid-1800s, and from beginning, it was necessary to address approaches to complex injuries. Indeed, a surgical text in 1846 describes the use of an island flap in fistula repair,6 perhaps one of the earliest examples of the use of this tool from the armamentarium of plastic surgery. Therefore, complex fistula might rightfully be thought of as a major driving force in modern surgical innovation.


In terms of the symptoms a patient may describe, vesicovaginal fistula presents with total urinary incontinence. Generally, there is no difference in the degree of urinary leakage between women with simple fistulas and those whose injuries are more complex. It is astounding to see that a tiny pinhole fistula can destroy quality of life just as effectively as a massive complex fistula.

Women with complex fistula are more likely to present with symptoms and quality of life impacts arising from the presence of comorbidities that are not so commonly seen in association with a simple fistula.4 In addition to urinary incontinence, women suffering complex fistula may present with fecal incontinence from concomitant rectovaginal fistula, impairment of sexual function because of vaginal stenosis, and foot drop resulting from peripheral nerve damage during prolonged labor. Other issues related to severe, complex fistula may not appear until after an initial procedure to close the fistula. Once the defect has been dealt with and continuity of the urinary tract restored, it is only then that the woman may display post-repair incontinence because of damage to the continence mechanism and urethra or debilitating urinary frequency from loss of bladder tissue resulting in reduced bladder capacity. The cause for these ongoing symptoms is present at presentation but not expressed until the patient resumes function of the lower urinary tract.


The initial physical examination in women with fistula should be focused on delineating as completely as possible the extent of injury, all with the intent of planning the best approach to repair.

Factors to be evaluated include the following:

May 1, 2023 | Posted by in GYNECOLOGY | Comments Off on Complex Obstetrical Fistula
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