2. 2
Contents
• INTRODUCTION
• Historical Survey
• Epidemiology
• Etiology
• Why do fistulas occur in young girls?
• The obstructed labor injury complex
• Management of genitourinary fistula
• Surgical management of urinary incontinence after obstetric
fistula repair
• Prevention of fistula
• References
3. INTRODUCTION
Definition
• An abnormal communication between two epithelial
surfaces
• Obstetric Fistula:
Genitourinary fistula or genito-rectal fistula related to labor and
delivery.
• VVF
abnormal connection between bladder &vagina, leakage of
urine via vagina .
• RVF
abnormal connection between rectum &vagina, leakage of feces
via vagina
4. Historical Survey
• The Ebers papyrus from Egypt
1550 BC contains the earliest
references to the condition,
• while Avicenna the renowned
Arabo-Persian physician (1037 AD)
first realized the relationship with
obstructed labour.
• Professor Derry 1935, of the
medical faculty University in Egypt,
discovered a large VVF in the
mummy of Queen
Henhenit,2050BC, certainly the oldest
fistula discovered
• Pelvis was considerably contracted
in transverse diameter –large
rupture of vagina in to bladder
• Death could be obstructed labour
5. Historical Survey…
In1663 Hendrik van Roonhuyse of Amsterdam
published what was probably the first text on
operative gynaecology. Where in the following
innovations were proposed:
• (i) proper exposure of the fistula with a
speculum;
• (ii) denudation exclusive of the bladder wall;
and
• (iii) approximation of the denuded edges by
means of ‘stitching needles’.
6. Historical Survey…
• In 1675 the Swiss physician Johann Fatio successfully closed
two fistulas using the van Roonhuyse technique and
• 16 79 Christoph Voelter excessive fluid and diet in labour
distends the rectum and the vagina- frequent catheterization
also sugest immediate repair
• In 1766 Levret was first to propose use of the knee–chest
position both to view and operate upon the fistula.
• Henry Levert of Mobile, Alabama was the first to suggest the
use of metal sutures in 1829; and in 1834 Montague Gosset of
London first had success using metal sutures
7. Historical Survey…
• In 1834, De Lamballe was the
first to emphasize tension-free
closures. He also noted that
newly acquired fistulae
without evidence of induration
at the edges might be cured by
prolonged catheterization
alone.
• De Lamballe also made
attempts to cure VVF with
pedicle flaps from labia,
buttocks, and thigh.
• In 1836 Peter Mettauer of
Virginia was first to close a
fistula in the US, followed
closely by George Hayward of
Massachusetts in 1839.
John Peter Mettauer (1787–1875).
9. Historical Survey…
• In 1845, Dr J. Marion Sims of America encountered his first case of
obstetric fistula,
• on his 30th operation on the same patient in 1849, managed to
close the fistula.
• In 1852, he published his article on the principles of fistula repair,
and he has subsequently been called “the father of American
gynecology.”
• On May 4, 1855, he opened the world’s first fistula hospital in New
York. with 30 beds devoted exclusively to fistula surgery
• On the site of the hospital today, however, is the Waldorf Astoria
Hotel, as there is now no need for a fistula hospital in America
10. Historical Survey…
• Later noteworthy
contributions to fistula
surgery were made by
Trendelenburg,
• who pioneered the
transvesical approach in
1890
11. Historical Survey…
• A most important advance was
the Martius graft proposed by
Heinrich Martius in 1928
• a labial fat graft interposed
between the vaginal skin and
bladder wall
• Martius was endeavouring to
improve continence control
using the graft, which
allegedly contained parts of
the bulbocavernosus muscle,
but
• found that this was not so; yet
it greatly improved primary
closure success
Heinrich Martius
12. Historical Survey…
• In 1974,the 2nd fistula hospital
was opened by Drs Rignald and
Catherine Hamlin in AA
• Largest fistula repair service in
the world.
• Operated more than 35000
patients
• Operates 1200-1300
patients/year
• Trains doctors
• Decentralized to regional
Hospitals, 5
13. Historical Survey…
• Comprehensive holistic care
o A village for fistula patients with conduits
o Have school and physiotherapy department where
they exercise for the crippling injuries
o Prevention activities and midwifery school
14. Epidemiology
• Found in all developing countries including South Africa.
• The majority of obstetric fistulae are confined to the “fistula belt”
across the northern half of sub-Saharan Africa from Mauritania to
Eritrea and in the developing countries of the Middle East Asia.
• No accurate data on the incidence and prevalence of the condition
• Incidence being about 2 in every 1000 deliveries in Sub-Saharan
Africa
• UNFPA estimates that fistula may occur at a rate as high as 2 or 3
cases per 1,000 pregnancies in areas with high maternal mortality
• This incidence rate suggested a worldwide incidence of 50,000 to
100,000 new cases annually
• Globally there are at least two million women still waiting
treatment, most of whom live in Africa
• The unmet need for fistula repair is estimated to be as high as 99%
17. Epidemiology…
Ethiopia
• Estimated that 9000 women develop an obstetric
fistula each year, of which only 1200 are surgically
repaired
• 2 million women suffer from obstetric fistula around
the world, and between 26,000 and 40,000 live in
Ethiopia
• Incidence of obstetric fistula in rural Ethiopia was
found to be 2.2 per 1,000 women of reproductive age
• According to EDHS 2005 only 4 percent of the women
reported obstetric fistula
18. Epidemiologic factors
Ethiopia… EDHS 2005
• (56.7%) are living in a union, 52 divorced
• one-third had OF before reaching the age of 24,
• more than two-thirds of the women suffering from OF are
residing in rural areas,
• 79.6% had their first intercourse before the age of 19
years,
• The average age at first marriage among these women is
16.5 years.
• 50.9% of them had no formal education.(92%)
• Most of them (55.6%) had no pre-natal care
• 86% of them had delivered at home
19. Epidemiologic factors…
• on average 22 years old
• 82% Of them had to travel at least 700 kilometrs for
medical care, walking an average of at least 12 hours
and spending an average of 34 hours in a bus
• 94% of Ethiopian fistula patients were married
• 83.3% of OF had occurred during delivery before the
age of 20
• The mean height of the fistula patients was 149 cm
• Labor duration an average of 3.8 days
• 93% stillbirth
• The mean age at first marriage was 14.7 years
20. Etiology
Obstetrics cause:
• Prolonged obstructed labor – predominant
cause
• Other causes include:
o Destructive delivery
o Instrumental vaginal delivery
o Cesarean delivery with or wthout hysterectomy
o Traditional practices (defibulation, Gishiri)
o Symphysiotomy
21. Etiology …
Non Obstetrics cause
• Traumatic (coitus, sexual violence, accidental
trauma, FGM)
• Infection (Granulomatous infection, TB, HIV)
• Congenital
• Neglected pessary, or other foreign bodies
• Malignancy
• Iatrogenic, surgery
• Radiotherapy
22. Source: Lancet 2006; 368: 1201-
1209. 22
Why obstetric fistula common in Africa?
• African women predisposed to dystocia due to narrow
pelvic architecture ,circumcision ,gishiri
• Marriage at early age, before pelvis growth is complete.
• Malnourishment retards maturation.
• Lack of access to emergency obstetric services.
• Poverty, illiteracy and limited educational opportunities
• Note: Maternal mortality rates in Western Europe and the
USA at the beginning of the 20th century were similar to
those in the developing world today…dramatically reduced
between 1935 and 1950 due to access to emergency
obstetric services.
24. COMPLICATION OF OLIC
l Renal damage
l Genital tract injuries
l Nerve damage-AAFH 20%
l Muscle and fascial damage
l Bone damage- AAFH 30%
l Psychological trauma
25. Genital complications
• Uterine rupture
• Fetal loss
• Post-partum Sepsis
• Ischemic processes in pelvic organ tissues
• Spontaneous symphsiolysis
26. Complications after vaginal scarring
• Dyspareunia, can lead to apareunia
• Ammenorrhea: can be secondary to
• Infertility: 60% have amenorrhoea after delivery
– Severe mental stress of losing a child and a husband,
together with the shame of incontinence
– Malnutrition may also be a factor.
– A small number of patients will have Sheehan’s
syndrome,
– The resultant decrease in (FSH) and (LH) .
– Ashermann’s syndrome – scarring of the
endometrium by either repeated infections
endometrial cavity
• Bladder dysfunction-
28. Extra-genital damage
• GI damage
• Anal sphincter damage
• Musculoskeletal damage , damage to levator
ani & contracture
• Neurologic damage 20-65%pts. Can be due to
o Lumbosacral injury,
o vertebral disc prolapse,
o impengement of common peroneal nn
29. Consequence of incontinence
Urine dermatitis
• Many patients restrict their drinking and end up with very
concentrated urine.
• When the patient is incontinent, the phosphates and nitrates
contained in the urine
• Irritate the skin, causing local hyperkeratosis and secondary
ulceration (vulva and skin).
• The condition will improve if the patient can drink more and
dilute her urine
Stone in the bladder or vagina:
• Restrict ion of drinking, Concentrated urine, form stone &
FB inserted to stem urine
30. Psycho-Social consequences
• Decreased in life expectancy
• Social isolation and personal injury- Still birth
,incontinent ,divorce , social outcast
• Depression- 100% has psychological disorder
AAFH
• Suicidal thought - up to 40% thinking seriously of
suicide
• Even after cure 30% go with their psychological
disorder
31. Psycho-Social consequences …
• In this prospective study, 51 consecutive women with
obstetric fistula admitted to the Barhirdar Hamlin Fistula
Centre in the north of Ethiopia were screened using the
General Health Questionnaire (GHQ-28) for potential mental
health disorder before and 2 weeks after fistula surgery. Prior
to surgery, all women screened positive. By 2 weeks after,
this had dropped to 36% (P = 0.005). 27% of the 45 women
who were cured of their incontinence screened positive, while
all 6 of those with severe residual incontinence continued to
screen positive.
• We conclude that surgical treatment of obstetric fistula
results in marked improvements in mental heath.
Browning A, Fentahun W, Goh J. The impact of surgical treatment on the mental health of women with
obstetric fistula. BJOG 2007;114:1439–1441.
32. Malnutrition
• In Ethiopia, in particular, neglect and
depression lead to malnutrition
• one out of five of them have to beg for food to
survive.
• 62% Of the women had no belonging at home
• more than half of them were rejected by their
husband after the fistula developed
33. Reproductive outcomes
• Only about 20% of post-repair patients will achieve a
term pregnancy.
If a patient become pregnant, she has a high chance of
miscarriage or prematurity. This is because of an incompetent
cervix.
• The anterior lip is frequently torn so badly that it will not be
strong enough to hold a pregnancy to term.
• Others have vaginal stenosis that is severe enough to preclude
intercourse.
34. 1966 and 1976, 148 out 162 patients with obstetrically acquired vVF were
successfully repaired in Lagos University Teaching Hospital. The
reproductive performance of these patients after repair has been
reviewed with special regard to menstruation, satisfactory coitus and
childbearing. Before the repair of the fistulae 66 patients (40.6%) had
secondary amenorrhoea ranging from 4 months to 15 years. There were 3
cases each of oligomenorrhoea and cryptomenorrhoea. After repair
menstruation returned within 6 months in 58 pts. 2ry amenorrhoea is
thought to be due to a combination of severe malnutrition, anemia,
endometritis, psychological upsets and occasionally endocrine
malfunction due to focal anterior pituitary necrosis
37. Waaldijk’s system (1995)
use for planning treatment for analysis of the out come
• Type I: not involving closing mechanism
• Type II: involving closing mechanism
• A: not involving (sub) total urethra
a: with out circumferential defect
b: with circumferential defect
• B: involving (sub) total urethra
a: with out circumferential defect
b: with circumferential defect
• Type III: miscellaneous, e.g. ureter fistula
38.
39.
40.
41. High-risk fistulas
• > 4 to 5 cm in diameter
• Involvement of urethra, ureter(s), or rectum
• Juxta cervical location with an inability to
visualize the superior edge
• Recurrence following a failed repair
42. DIAGNOSIS
By history
• young ,primi para ,illiterate ,rural area
NO or poor ANC follow up, HX of prolonged
labor ,home delivery ,still birth
incontinent after 3-10 days of delivery
,weakness of extremities or paralysis ,smell
bad ,neglected ,divorced ,malnourished
,psychologically depressed
45. Pelvic examination
• size and depth of vagina?
• Can the cervix be felt?
• Can a defect be felt in the anterior vaginal
wall?
• consider the margins carefully. Are they soft ,
some what rigid or (in the worst cases) stuck
to the pubic rami?
46. Investigation
• Even if the diagnosis of fistula from hx and p/e
is easy ,investigation is mandatory to R/o
coexistent
• In a series of 43 patients with VVF, Goodwin
and Scardino found 12% to have an associated
ureterovaginal fistula
47. Investigation…
• With the patient in the left lateral position, use a
Sims speculum to expose the anterior vaginal wall.
Ask the patient to cough. A small fistula may be
readily visible.
• Alternatively, perform a dye test in this position
48. Investigation…
Dye test ( or three-swab test is recommended (Moir, 1973).
• Dilute methylene blue (or gentian violet) should be used – if it
is too concentrated, it will stain everything, making
interpretation of the test difficult.
1. Insert a catheter.
2. Fill the catheter balloon with dye and have two or three
moist swabs ready to put into the vagina.
3. Insert the swabs well into the vagina.
4. Slowly instill about 60 ml of dye.
49. Investigation…
5. After 1 minute, ask the patient to cough.
6. Remove the swabs one by one.
7. If any of the swabs are stained, this indicates the presence of a
fistula.
8. If none of the swabs is stained, there could still be a fistula. Repeat
the test using up to 200 cm3 of dye. The patient should walk
around for 20 minutes while the dye is in the bladder. Sometimes
the hole is very small, especially if it is between the cervix and the
bladder. It is easy to overlook a tiny fistula.
9. If this second test is negative but the swab is wet with urine, there
is a ureteric fistula.
53. Cystourethroscopy
• This form of endoscopy is another valuable adjunct to
diagnostic evaluation. It allows localization of the fistula,
determination of its proximity to the ureteral orifices, and
assessment of surrounding bladder mucosa viability.
• Probe through fistulous
Tract to facilitate
Visualization
54. Ureteral Involvement
• IVP and Retrograde pyelography generally has
the same diagnostic value to evaluate the
upper urinary system
• Phenazopyridine hydrochloride
55. Investigation…
• Voiding cystourethrography
• Ultrasound with color Doppler flow
• CT scan
• NB Currently available ultrasonography
and CT are unlikely to replace the
traditional diagnostic methods of IVP,
retrograde pyelograms, and cystoscopy
56. Management of early case
• vaginal examination for assessment
• Insert FOLEY catheter Ch18
• Examine patient fistula once a week
• If it seems healing leave catheter in situ
• If not healing excise slough and prepare for early
closure
• as soon as wound clean perform an early closure
• Mobilize patient at all times
57. Prevention at caesarean section
• The incision in the lower segment should be on the
high side and the lateral ends curved upwards to
minimize inaccessible tears
• When the baby’s head is deeply impacted in the
pelvis, it is better to get help to push up the head
vaginally than to force a hand down between the
head and the lower segment. This may produce
vertical tears
• The alternative is to extract the baby as a breech
birth if possible.
58. When should we repair ?
• The shorter the waiting time the better social and
psychological benefit
• Most surgeons advise waiting at least 3 months from the
injury before operating.
• The first repair always has the best chance of success, and this
should not be compromised.
• The best time to repair a fistula is when the edema and
inflammation subside and there is no infection
• Some recommend steroid improves tissue quality but rather
delays healing
• If no contraindication estrogen increase tissue thickness
vascularity
59. When should we repair ?...
• Reported series of early repair (few weeks of
DX) with steroid therapy do not show superior
results, the use of steroids in early repair is no
longer accepted
• Up to 28% failure rate
• Post surgical fistulas if diagnosed within 48 hrs
can be repaired as tissue is mobile and less
inflamed
• 1year- in radiation induced fistula
63. PREOPERATIVE PREPARATION…
• Bowel preparation
• Hydration
o avoids hypotension during spinal
o avoids difficulty in identifying ureteric orifice
o catheter blockage
64. Choice of Anesthesia
• Spinal anesthesia is
the preferred method
for all fistula cases
• Bupivacaine 0.5%
• Lidocaine 5%
• Gynecologist has to
have a good hand in
spinal
65. Issue of antibiotics
• Most surgeons administer one dose of a broad
spectrum antibiotic prophylactically (eg,
cefazolin 1 gram intravenously).
• Gentamicine 80mg im bid and metronidiazole
500mg iv tid –fecal contamination
66. Antibiotic prophylaxis…
• Objective: To test the hypothesis that intravenous antibiotics given intra-
operatively reduce the failure rate of vesico-vaginal fistula repair.
• Design: A single blind, randomised controlled trial.
• Setting : A district hospital in Benin, West Africa.
• Population: Seventy-nine women undergoing repair of an obstetric vesico-vaginal
fistula by a single surgeon at Hopital Evangelique; two women had repeat
operations.
• Methods: Participants in the treatment group (n = 41) received ampicillin 500 mg
intra-operatively. Controls (n = 40) received no prophylactic antibiotics.
• Main outcome: measures Failure of fistula closure and objective incontinence (a
positive pad test) at hospital discharge. Secondary outcomes: included febrile
morbidity, other antibiotic use and urinary infection.
• Results: Antibiotic prophylaxis did not reduce the odds of failed repair (OR 2.1
95% CI 0.75-6.1) or of objective incontinence (OR 1.9; 95% CI 0.72-51). The women
in the antibiotic prophylaxis group received less post-operative antibiotics and had
less urinary infections at day 10.
• Conclusions : Prophylactic antibiotics should not be used in vesico-vaginal fistulae
repair in the developing world outside randomised controlled trials.
A . J . TOMLINSON & J . G. THORNTON, A randomised controlled trial of antibiotic prophylaxis for vesico-
vaginal fistula repair, British Journal of Obstetrics and Gynaecology April 1998, Vol. 105, pp. 397-399
68. sutures
• Never use non absorbable sutures-stones
• Vicyl or dexon 0 or 2.0 3.o
• The perfect needle for a suture is a ready-
mounted 5/8-circle 26 mm needle, but this Is
expensive. We reserve it for suturing in
difficult corners and deep situations.
70. Basic principle of fistula repair
• Adequate exposure
• Protection of the ureters
• Separation of vagina from the bladder around
the fistula
• Mobilization of enough bladder after excision
of scar
• Tension free closure
• Support of the urethra when needed
71. Transvaginal approach (flap splitting
Technique )
• 1-Good exposure –scar may be difficult
excision or episiotomy
72. Getting the correct tissue plane
• Some surgeon infiltrate the vagina with
haemostatic agents 1:200000 adrenaline thus
aiding in dissection
• Others prefer saline
75. The distal flap must now be dissected off
the proximal urethra and para-urethral
76. • When the surgeon judges that there has been
enough dissection to enable a tension free
• The fistula edge is trimmed of any scar tissue or
residual vaginal skin.
• Corner sutures placed
• The fistula is then repaired with interrupted 00
absorbable sutures.
• Fish-hook (J) needles or 5/8-circle needles are ideal.
78. • Once the repair has been completed, a dye
test is performed to ensure sound closure of
the bladder . A no. 16 Foley catheter is passed,
saline coloured with methylene blue is
introduced into the bladder (around 100 ml
should suffice) and the suture line is checked
for leaks. fig
81. Vaginal closure
• Interrupted suture to
avoid infected
hematoma
• Hemostasis has to be
secured by
adrenaline soaked
swab , head down ,
vaginal packing
82. • Gauze soaked in
antiseptic solution
• May obscure serious
bleeding
• No need to pack in
dry cases
• While inserting sims
speculum has to
protect the site of the
repair
83. Securing the indwelling catheter
• Taping or suturing catheter with labia to avoid
pressure on repair site in case of fistula
involving urethra and bladder neck
• Stay for 2 weeks post procedure
84. SELECTION OF CASES FOR THE BEGINNER
• Attempt a case beyond one’s capabilities is not only
demoralizing for the surgeon but a disaster for the
patient, as the best chance of cure is always the first
operation
• There are some clues that fistula is complex foot
drop ,rectal fistula ,after c/s , following hysterectomy
No vaginal stenosis , easily visible and palpable
,small , minimal scar ,not close to the cervix or EUO
85. Who are at risk of post repair stress
incontinence
• Goh’s type 2-4
• Post repair bladder capacity <150cc
• Severe vesical fistula
• Severe vaginal scarring
86. Surgery to reduce incidence of stress
incontinence
• Urethral lengthening procedure
-severe post-repair stress incontinence , the
average urethral length was 1.4 cm,
-To fashion the bladder side of the anastomosis
into a tube with a diameter approaching that
of the urethra
87. Repair of the pubo-cervical fascia
• It is a fascial sling that
supports the urethra,
the urethro-vesical
junction and bladder
base.
• Thus supporting and
elevating the new
urethro-vesical junction
88. Urethral support with a fibro-muscular sling
• A review by Andrew Browning of 318 consecutive patients
successfully repaired at the Addis Ababa Fistula Hospital in
the year 2000 showed an immediate postoperative
incontinence rate of 33%.
• Repair was by simple closure, with a fat graft added in most
cases. This was a much higher figure for incontinence than
had previously been recognized, and he started to use a fibro-
muscular sling in high-risk cases, i.e. those with a shortened
urethra (<2.5 cm from the external urethral orifice,
• Reduced stress incontinence to 18%
89.
90. Route of repair
• There is no randomized controlled trial
• When access is good and vaginal tissues are
sufficiently mobile ,the vaginal route is usually most
appropriate. If access is poor and the fistula cannot
be brought down, however, the abdominal approach
should be used. Overall, more surgical than obstetric
fistulas are likely to require an abdominal repair,
although in the author’s series of cases from the UK
,and those reviewed from Nigeria two-thirds of cases
were satisfactorily treated by the vaginal route
regardless of etiology
91. The Martius graft
• Described by Martius 1928
• Labial fat as interposition graft
• Supplied by pudendal artery
• The right labia is traditionally used
• The landmark for the incision is - lateral to the base
of the clitoris, down the prominence of the labia for
at least 6 cm
• The Martius graft fixed on the repaired site with 5
anchor sutures
• Improves closure rate, neovascular pedicle ,fills dead
space , mechanical protection
92. • Birkhoff and colleagues reported a 100%
success rate in six patients with transvaginal
repairs of VVF using the Martius technique. In
a series mostly of post obstetric injuries, Elkins
and colleagues reported a successful closure
in 96% (24 of 25 procedures).
93.
94. POSTOPERATIVE NURSING CARE
• Equally important as effective surgery
• A good operation can be ruined by neglectful
aftercare.
• Nurses may unfamiliar with post op care
• Teach to give the three DS
• The patient must at all times be
• Drinking
• Draining
• Dry
95. Principles of catheter care
• Nothing must pull on the catheter.
o secured with a suture with a mons pubis
o secure the catheter to the abd in the midline
• The catheter must not become blocked or fall
out.
96.
97.
98.
99. Pre-discharge advice
• Return back if she leaks
• Abstinence from sex for at least for 3 month
• The surest way of cure is to have no more
delivery but once pregnant C/s for future
deliveries
100. Subsequent pregnancy
• Fertility returns with in 2 yrs in majority after successful repair
• The need for cesarean section in any subsequent pregnancy
has been emphasized
• Kelly , however, reported 33 patients who became pregnant
within 1 year of fistula repair, 12 of whom were delivered
vaginally without damage to the repair
• But he set criteria
o previous cause is non recurring one (contracted pelvis has to be R/O)
o interposition graft
o experienced obstetrician
101. The optimal way to deliver
• very little written about the optimal way to deliver a
patient who previously has had a severe obstructed
labour, obstetric fistula and fistula repair.
• One article pointed out that only 50% of patients were
selected to undergo a trial of vaginal delivery and of
those 50% needed a caesarean; of those delivering
vaginally, 27% had their fistula reopen during the
delivery.
• 24 women after successful repair return with repeat
fistula after delivery (17 SVD, 6c/s ,1 caesarean
hysterectomy after 2 days of labor )
102. optimal way of managing labor….
• The optimal way of managing labor following
obstetric fistula repair is
o to provide a waiting area for women as they
approach term and
o perform a timely caesarean section. At term in
those where dates are known with some
confidence or otherwise at the onset of labor.
103. Prevention
• Almost all obst. fistulas are preventable.
Strategies include
1. Adequate childhood nutrition
2. Delay in child bearing until full pelvic growth is completed.
3. Provision of health education about sexuality child birth and
contraception
4. Universal basic education for women
5. Education of men concerning women’s reproductive health
6. Supervision of labor of every pregnant woman by trained birth
attendant
7. Monitoring of every labor with partograph
8. provision of emergency obstetric service at the community level
106. References
• Brian Hancock , Practical Obstetric Fistula Surgery, 2005
• FIGO and partners, Global competency-based fistula surgery
training manual, 2011
• Brian Hancock , First Steps in VVF Surgery 2005
• Zewdu Gashu Dememew, Obstetric fistula situation in Ethiopia,
Johns Hopkins University-Technical Support for the Ethiopian
HIV/AIDS Initiative, Hawassa Ethiopia
• Browning A, Fentahun W, Goh J. The impact of surgical treatment
on the mental health of women with obstetric fistula. BJOG
2007;114:1439–1441
• Mulu Muleta, Obstetric Fistula in Developing Countries: A Review
Article, J Obstet Gynaecol Can 2006;28(11):962–966
• Browning A. Pregnancy following obstetric fistula repair, the
management of delivery. BJOG 2009;116:1265–1267
107. References…
• ROBERT F. ZACHARIN, A HISTORY OF OBSTETRIC VESICOVAGINAL FISTULA,
Aust. N.Z. J. Surg. (2000) 70, 851–854
• Khalil A A. A Review of Obstetric Fistula in Sudan . Webmed Central
OBSTETRICS AND GYNAECOLOGY 2011;2(9):WMC002222
• Yashar Najiaghdam M.D, GENITO-URINARY FISTULAS, PPT
• Pierre Marie Tebeu et.al, Risk factors for obstetric fistula: a clinical review,
Int Urogynecol J (2012) 23:387–394
• Kees waaldijk, immediate management of the obstetricfistula,
babbarrugafistulahospital, PPT
• Browning et al., The Relationship Between Female Genital Cutting and
Obstetric Fistulas, Obstet Gynecol. 2010 March ; 115(3): 578–583.
doi:10.1097/AOG.0b013e3181d012cd.
• Sunil, Sanga ,Obstetric fistula in Ethiopia , Journal of Family and Reproductive
Health, Vol. 3, No.4 , December 2009 , http://journals.tums.ac.ir/
