Obstetric fistula is a condition that is largely found in low-resource countries where access to emergency obstetrics care and cesarean delivery for prolonged obstructed labor does not exist or is delayed. When obstetric fistula occurs in high-resource settings, it is usually during difficult cesarean delivery owing to adhesions from prior surgery or abnormal placentation. Prevention of obstetric fistula as a result of cesarean delivery is almost always possible by employing meticulous surgical technique, a high index of suspicion, and a number of simple diagnostic measures. It is axiomatic that repair of injuries at the time of delivery is better than repairing these at a later date.

Patients with obstetric fistula present at any time after delivery, from immediately to weeks after, depending on the nature of the injury. Typical vesicovaginal fistula (VVF) symptoms include involuntary loss of urine at all times. The patients typically report “urine running down my legs” or standing and a sudden gush of urine from the vagina without any preceding urge. Also, with larger fistulas, women often do not have any spontaneous voiding. The bladder cannot hold any urine because of the position of the fistula so it cannot fill sufficiently to void. In patients who are able to hold any urine and who can void, either a very small fistula or a ureteral fistula is suspected.

Obstetric fistula is fortunately an uncommon occurrence. Therefore, evaluation of the condition is not well taught in training, and most providers in high-resource settings do not routinely see women with fistula. Obstetric fistula can be very complex, especially after prolonged obstructed labor. These two factors encourage referral to a specialist for surgical repair. Typically, obstetric fistula that results from cesarean delivery in high-resource settings is fundamentally different than those resulting from prolonged obstructed labor. Surgeons who have not managed fistula from obstructed labor, even if they are accomplished pelvic surgeons, in general, should not attempt to repair fistula from prolonged obstructed labor.

Ultrasound to visualize kidneys, ureters, and bladder to look for hydronephrosis, hydroureter. In low-resource settings, ultrasound has been found to be helpful in the preoperative evaluation of obstetric fistula, specifically in women with prior laparotomy to exclude ureteric involvement.

Intravenous urogram and CT urogrography can be used similarly. It is tempting to employ these diagnostic modalities in all patients before surgery, but there is generally limited utility with small fistula and capacity for cystoscopy.

Cystoscopy is useful in the management of small fistula to determine the proximity to the bladder trigone and the ureteral orifices. Cystoscopy can be impossible and often unnecessary for large fistula in which the ureters can be seen clearly.

The most common staging systems are those developed by Goh (1) and Waaldijk (2). Staging systems rely on a few critical variables that have been shown to impact the outcome of surgery. Involvement of the continence mechanism of the urethra, size of the fistula, scarring of the vagina and surrounding tissues, and bladder size are key predictors of surgical success; however, no universal system is accepted nor reliable.

A detailed narrative or pictorial description of the fistula preoperatively is essential.

The most important piece of surgical equipment for vaginal fistula surgery is a fine-tipped, mid-length scissors typically reserved for plastic surgery (Figure 6.2.2). These scissors must be capable of both fine dissection and cutting through the dense scar.