Skip to main content

Obstetric Fistula

Obstetric fistula is a urogenital and/or rectovaginal fistula resulting from labor or its management. Prolonged obstructed labor without timely emergency obstetric care causes ischemic injury; cesarean delivery can cause direct urinary tract injury.[2][3] It is the global paradigm of catastrophic obstetric injury, rare in high-income countries but persistent in sub-Saharan Africa, South Asia, and conflict-affected regions, with widely quoted (WHO/UNFPA-attributed) estimates of more than 2 million women living with untreated fistula and 50,000–100,000 new cases per year.[3][38] Wall estimated at least 3 million unrepaired cases and 30,000–130,000 new cases per year in Africa alone.[3] Fistulas caused by prolonged obstruction differ from direct iatrogenic VVF: the ischemic field injury can destroy soft tissue across the maternal pelvis, involve the urethra, and cluster with multisystem injuries known collectively as the obstructed labour injury complex.[3]

For the iatrogenic counterpart and the broader operative principles, see Vesicovaginal Fistula and the Fistulas section landing. For operative selection across all repair routes, see the Female Fistula Repair database.

Epidemiology​

  • Prevalence in the 2013 review. Ten community studies (34,505 women) in sampled low- and middle-income settings yielded 0.29 per 1,000 women of reproductive age (95% CI 0–1.07). Estimates of 1.60 per 1,000 in sub-Saharan Africa and 1.20 per 1,000 in South Asia came from two studies each; the authors judged prevalence lower than previously reported but cautioned against generalizing these regional estimates.[38]
  • Incidence: approximately 0.09 per 1,000 recently pregnant women in three community-based studies (95% CI 0.01–0.25).[38]
  • Burden. Historical estimates of 2–3 million women living with untreated fistula are imprecise, and prevalence remains uncertain. A 2025 survey-based model corrected for clinical misclassification estimated 457,000 current cases (95% CI 303,000–709,000) among women aged 15–64 in 55 Campaign to End Fistula countries.[47] The treatment gap remains large relative to the skilled-surgeon workforce.[3][5][47]
  • Age. Adolescents, including ages 13–14, can be affected; age at onset varies by setting. A multinational 2019–2021 treatment series estimated mean age at onset at 27.4 years from age at surgery minus years of leakage.[3][6] Bimodal distribution with peaks in primigravid women and women with ≥ 4 pregnancies.[3]
  • Time to treatment. In the Fistula Foundation series, women reported an average 5.7 years living with fistula before their current surgery (which could be a repeat repair); 4% of 19,238 women with referral data sought care independently.[6]

Pathogenesis — The Obstructed Labour Injury Complex​

The mechanism is field ischemia, not point injury:[3]

  1. The fetal head impacts in the maternal pelvis under sustained uterine contractions
  2. Soft tissues of the vagina, bladder, and rectum are crushed against the maternal pelvic bones
  3. Perfusion to the compressed tissues is progressively shut off
  4. Widespread ischemic necrosis develops across the pelvis
  5. In a retrospective series of 4,396 women presenting for obstetric fistula repair after facility delivery in nine East/Central African countries, 3,695 (84.1%) reported stillbirth in the index pregnancy.[50]
  6. After prolonged obstruction, delivery may be spontaneous vaginal, assisted vaginal, or cesarean.[50]
  7. Several days later, the necrotic vesicovaginal (and often rectovaginal) tissue sloughs, leaving a fistula

The fistula sits within a much wider zone of sublethal ischemic injury that becomes dense fibrous scar; this is the principal reason obstetric fistula is harder to repair than iatrogenic VVF and the reason recurrence rates are higher.

Multisystem injuries clustered with the fistula​

SystemInjuries
UrologicalVVF; urethrovaginal, vesicocervical, ureterovaginal, complete urethral destruction; stress incontinence; bladder stones; hydroureteronephrosis; chronic pyelonephritis; renal failure
GynecologicSevere vaginal stenosis (sometimes near-obliteration); cervical destruction; secondary amenorrhea; secondary infertility; PID
GastrointestinalRectovaginal fistula; rectal stenosis or atresia; anal sphincter incompetence
MusculoskeletalOsteitis pubis
NeurologicFoot-drop (lumbosacral plexus or common peroneal nerve compression); neuropathic bladder
DermatologicChronic excoriation from urine and fecal maceration
SocialStigma, divorce, abandonment, displacement, malnutrition, depression, suicide

Risk Factors​

A complex interplay of biological, social, and economic forces.[2][3][7][8]

Biological / obstetric​

FactorEffect
Prolonged labor (> 24 h)AOR 4.0[8]
Cephalopelvic disproportionMost common recorded cause in one Ethiopian general-hospital series: 59/91 (64.8%) obstructed-labor cases[9]
Short maternal stature (≤ 150 cm)AOR 2.63[2]
Birth weight ≥ 3.5 kg (study-specific threshold, not a universal definition of macrosomia)AOR 1.52[2]
PrimiparityHighest risk in young primigravidas[3]
Post-term pregnancyAOR 8.0[8]
Malpresentation28/91 (30.8%) obstructed-labor cases in the same Ethiopian general-hospital series[9]

Socioeconomic​

  • Poverty is the fundamental enabling condition[3]
  • Early marriage and childbearing (age < 18 at first pregnancy)
  • Low or no education; post-primary education is protective (AOR 0.31)[2]
  • Rural residence (AOR 4.0)[8]; lack of antenatal care (AOR 5.0); no modern contraception (AOR 5.0)
  • Lack of access to emergency obstetric services (the single most important factor)[3]
  • Adolescent malnutrition and stunted pelvic growth

Iatrogenic contribution​

In some modern series cesarean section itself contributes to fistula. In a western Ugandan case-control study, a surgeon classified 27/109 urogenital fistulas (25%) as iatrogenic after cesarean delivery; cesarean delivery was associated with obstetric fistula (adjusted OR 13.30, 95% CI 6.74–26.39).[2]

Classification​

No single system is universally accepted; Waaldijk and Goh are commonly used obstetric fistula classifications, and the Panzi score combines elements of both.[10][11][12]

Waaldijk (1995)​

TypeDefinition
IFistula not involving the urethral closing mechanism
IIFistula involving the urethral closing mechanism — IIA without (sub)total urethral involvement; IIB with (sub)total urethral involvement; further (a) without and (b) with circumferential defect
IIIUreteral and other exceptional fistulas

Surgical complexity worsens progressively from I to IIBb.[11]

Goh​

Goh classification records distance from the external urethral meatus (Types 1–4), fistula size (a/b/c), and fibrosis or vaginal capacity (i/ii); category iii denotes special circumstances such as circumferential or ureteric involvement.[46] In a head-to-head comparison, Goh outperformed Waaldijk for predicting closure (p = 0.04), and Goh Type 4 fistulas were significantly less likely to close than Types 1 or 2 (p = 0.014).[10]

In Goh and colleagues' original validation cohort of 987 obstetric fistula repairs, repair breakdown and residual urinary incontinence after closure both rose with each axis:[42]

AxisCategoryRepair breakdownIncontinence after closure
SiteType 12%3%
SiteType 21.6%20%
SiteType 33%32%
SiteType 43%46%
Sizea2%10%
Sizeb0.5%22%
Sizec4%30%
Scarringi2%7%
Scarringii2%24%
Special circumstancesiii4%41%

Before discharge, 27 of 987 repairs (2.7%) had not closed; among the 960 women with closure, 229 (23.9%) reported residual urinary incontinence.[42] The study did not report a denominator for each subgroup.[42]

Panzi score​

A parsimonious data-driven score derived from Goh and Waaldijk that distills three predictors of failure: circumferential defect, proximity to the external urethral orifice, and size. Each one-point increase in the 0–3 score multiplies the odds of surgical failure by approximately 1.65.[12]

Prognostic factors regardless of system​

Degree of scarring at the operative field, urethral continence-mechanism involvement, fistula size and bladder tissue loss, and concurrent injuries (especially RVF).[3]

Clinical Presentation​

  • Continuous urinary leakage per vagina. The hallmark; begins approximately 3–10 days postpartum as the necrotic slough separates[3]
  • Concurrent fecal incontinence when RVF is present
  • Foul odor from chronic soiling
  • Severe perineal and inner-thigh skin excoriation
  • Amenorrhea / secondary infertility
  • Foot-drop from intrapartum nerve compression
  • Severe vaginal stenosis with sometimes near-total obliteration
  • Stillbirth. In a nine-country East/Central African retrospective series of women presenting for fistula repair after facility delivery, 3,695/4,396 (84.1%) reported stillbirth in the index pregnancy.[50]

Diagnostic Evaluation​

Diagnosis in low-resource settings is overwhelmingly clinical:

  • Speculum exam. Direct visualization
  • Dye test and cystoscopy. Methylene blue instilled into the bladder can demonstrate vaginal leakage on gauze; the 2026 EAU guideline weakly recommends cystoscopy with retrograde colored-fluid filling to confirm urinary fistula when available.[34]
  • Systematic mapping. Fistula location, size, scarring, urethral involvement, circumferential defect (prognostic finding), concurrent RVF, vaginal canal patency, sphincter integrity
  • Imaging when available: CT urogram or IVP for the upper tracts (rule out ureteral involvement); MRI in complex repairs

Management​

Conservative​

If a patient presents within approximately 3 months of injury, continuous bladder drainage with an indwelling catheter can allow closure of a small fistula (< 1 cm) in selected cases.[3] In a prospective immediate-management series of 1,716 women presenting 3–75 days postpartum, 264 (15.4%) healed with catheter treatment alone.[48] The EAU guideline’s approximately 13% spontaneous-closure estimate concerns VVF across etiologies, largely small defects.[34] In practice, the great majority of patients present months to years after injury and require operative repair.

Surgical repair​

The first operation offers the best chance of success; every subsequent attempt is harder and less likely to close.[3][13]

Timing. Repair when tissue necrosis, edema, inflammation and infection have resolved and the patient is nutritionally and medically ready; a fixed three-month wait is not mandatory. Evidence comparing early and delayed repair is limited to small uncontrolled series, which show no difference in success between repair within four weeks and after three months.[34]

Approach. Most accessible obstetric fistulas can be repaired transvaginally. Choose the route by exposure, ureteric involvement, tissue quality and surgeon expertise.[1] For urinary fistulas, two main vaginal techniques follow. Rectovaginal fistula requires separate assessment of anal sphincter anatomy and function; ASCRS gives a strong recommendation based on low-quality evidence for episioproctotomy in obstetric RVF with an anal sphincter defect. See Rectovaginal Fistula.[51]

  • Latzko partial colpocleisis. Imbrication without tract excision in selected accessible fistulas; consider the risk of shortening an already scarred or short vagina.
  • Layered flap-splitting repair. Mobilize viable bladder and vaginal tissues and close without tension. Routine wide excision of the fistula edge is not required and can enlarge the defect.[34]

Transabdominal repair is selected for a high fistula inaccessible vaginally or when ureteric reimplantation or bladder augmentation is needed; severe vaginal stenosis or inability to tolerate lithotomy may also favor this route.[1][34][53]

Operative principles​

  • Mobilize sufficiently for tension-free closure while preserving viable tissue and blood supply; avoid unnecessary scar or edge excision.
  • Edges must coapt without tension
  • The repair should be watertight at the time of closure
  • Closure pattern. Flap-splitting repair uses layered, non-overlapping suture lines; Latzko partial colpocleisis uses imbrication instead.[34]
  • Circumferential defect (bladder completely detached from the residual urethra). Mobilizing the bladder off the vagina and surrounding tissue and extending the dissection behind the pubic symphysis, high into the space of Retzius, allows the bladder to be advanced as a unit and anastomosed to the remaining urethra; this approach has been described for this rare, severe injury pattern.[43]
  • Continuous drainage until healing is confirmed. WHO recommends 7–10 days as an alternative to longer drainage for simple obstetric fistulas.[35] In the WHO-supported multicountry RCT, 524 women were randomized after a simple repair remained closed on day 7; radiation-related and cancer-related fistulas were excluded; multiple fistulas became an exclusion during enrollment.[39] In the per-protocol analysis, repair breakdown between 8 days after catheter removal and three months after surgery occurred in 10/250 (4%) after 7 days of catheterization versus 8/251 (3%) after 14 days, meeting the prespecified 10% noninferiority margin.[39] The 2026 IUGA/ICS Delphi consensus sets a minimum of 10–14 days of continuous drainage after obstetric VVF repair (statement 37), noting that 7 days may suffice for simple cases; complex repairs need individualized longer drainage.[36] These recommendations have different scopes and evidence bases.[35][36][39] Once the patient begins to mobilize, securing the indwelling catheter with tape or a suture keeps the balloon from pulling on the fresh repair.[43]
  • Tissue interposition (Martius, gracilis, omental flap) for large defects, urethral involvement, recurrent fistula, or radiation; the Browning data suggest interposition is not a default for routine obstetric VVF[1][14]

Adjunctive innovations​

In a 16-year retrospective single-team series of 1,185 female genital fistula repairs across 12 countries (59% obstetric, 34% iatrogenic), adjuncts including platelet-rich plasma, small intestinal submucosa, fibrin glue, and buccal mucosa grafts were used in 71% of complex or recurrent repairs. Closure in that subgroup was 72%.[14]

Outcomes​

Record closure, continence and follow-up separately. The 2025 FIGO expert protocol calls for a dye test before catheter removal, three voided-volume and postvoid-residual measurements over 24–48 hours after removal, and a pad test once emptying is adequate. Residual > 100 mL or > 50% of voided volume prompts clean intermittent catheterization 3–4 times daily until emptying improves.[52] The 2026 IUGA/ICS consensus defines surgical success as anatomical closure without residual urinary incontinence (statement 3), advises a dye test at catheter removal 10–14 days after surgery (statement 2, consensus), and further evaluation for persistent leakage.[36] A fistula that breaks down within 3–6 months is counted as a failed repair (statement 15, near consensus).[36] Large size (> 3 cm), multiple fistulas, scarring, urethral involvement, proximity to the ureteric orifices and bladder capacity < 100 mL predict poorer closure with continence (statement 14).[36] “Incurable” should only be considered after three adequately performed failed repairs plus independent assessments by two expert surgeons.[36]

SourceNReported outcome
Fistula Foundation (2019–2021, 110 hospitals, 27 countries)24,568 supported fistula and related procedures, including perineal-tear repairs; Table 1 reports outcomes for 20,591 in six repair categories87.3% dry/continent at discharge in those six categories[6]
Systematic review / meta-analysis (LMICs)79 studies included; 76 in pooled estimate77.9% pooled reported repair success (closure and urinary and/or fecal continence considered; I² = 94.1%)[13]
Hilton & Ward large series2,484 total; 2,360 operated82.8% apparently dry after one operation (81.2% corrected first-procedure cure); 65% cure per procedure among patients requiring ≥ 2 operations[3][49]
Mekelle Hamlin Center, Ethiopia32889.3% (VVF 86.9%; RVF 100%)[15]
Multinational single-team1,18582% overall closure; 91% simple repairs; 85% primary repairs[14]

Factors associated with reported repair success: primary education or above, married status, live neonatal outcome, and first repair; the review's success definitions varied across studies and included closure and urinary and/or fecal continence.[13]

Predictors of failure: female genital cutting, primiparity, large size, Goh ≥ Type II, urethral involvement, vaginal scarring, circumferential defect, multiple fistulas, prior repair, postoperative complications.[13]

Post-Obstetric-Fistula-Repair Incontinence (POFRI)​

The IUGA/ICS consensus estimates that this "continence gap" affects 15% to 20% of women after repair, with de novo storage symptoms and stress incontinence both contributing.[36]

  • Prevalence of persistent incontinence after successful closure: 16–55%[16][17]
  • Type. Stress, urgency, mixed and overflow incontinence all require consideration. Selected Ugandan and Ethiopian cohorts report symptoms and urodynamic findings; OAB may occur in other women despite absent detrusor overactivity in one cohort.[16][19][36]
  • Severity in a selected Ugandan cohort. Among 36 women with persistent incontinence after closure, 53% rated leakage "very severe" and 86% had > 4 g gain on a two-hour pad test.[16]
  • Risk factors. Fistula in first delivery, younger age at fistula, ≥ 2 prior fistula surgeries, Goh Type 3 or 4.[16][17]

FIGO 2025 expert opinion on POFRI management:[18]

  • Standardized assessment: residual urine, voiding diary, pad test, urodynamics or single-channel cystometry where available. The IUGA/ICS consensus lists history, examination, post-void residual, cough test and bladder diary for evaluation (statement 11), reserving urodynamics for cases where invasive treatment is considered; it regards simple urodynamics as important when further treatment is considered for residual incontinence after successful closure (statement 40); it did not reach consensus that urodynamics separates a closed but severely incontinent woman from one whose fistula cannot be closed (statement 10).[36]
  • Stress incontinence. Offer pelvic floor muscle training when feasible; consider individualized surgery only after confirming closure, adequate emptying and bladder function. Counsel about retention and repeat-fistula risk. FIGO expert opinion advises avoiding synthetic mesh slings after obstetric fistula repair because of high complication risk. In a 140-woman review spanning sling types, synthetic slings had 20% vaginal mesh extrusion; retropubic dissection for autologous slings was associated with 20% urethrotomy/cystotomy and 17% iatrogenic fistula.[18] The IUGA/ICS consensus endorses pelvic floor muscle training as the preferred conservative treatment (statement 23), and it did not reach consensus on a rectus fascial sling as the preferred operation (statement 24).[36]
  • Pure overactive bladder. Conservative therapy (anticholinergics). The IUGA/ICS consensus lists bladder training, pelvic floor muscle training and antimuscarinics or β3-agonists as beneficial for urgency incontinence (statement 13), and reached no consensus on intravesical botulinum toxin as a last resort (statement 26).[36]
  • Mixed (OAB-predominant). Treat OAB first, then reassess before stress-incontinence surgery because surgery may worsen urgency symptoms.[18]
  • Symptomatic bridge. A pilot study describes a urethral plug as a short-term aid to keep women with severe post-repair leakage dry while they return for follow-up and possible secondary continence surgery, with minimal complications in a small sample; longer follow-up in larger numbers is needed.[44] In a separate 6-month follow-up study at an Ethiopian fistula center, 50% of returning patients with mild urethral incontinence were cured after conservative therapy and 18% of those with more severe incontinence improved.[45]
  • In the multinational series, residual incontinence after successful closure affected 12% of patients; among women receiving salvage treatment, 72% improved with bulking agents and 91% with pubovaginal slings.[14]

Pregnancy and delivery after repair​

Women who conceive after repair should be counseled that vaginal delivery and emergency cesarean were associated with stillbirth, fistula recurrence and maternal death in a scoping review of 16 sub-Saharan studies; among 459 postrepair deliveries with mode reported, 45% were elective cesareans and 38% were emergency cesareans, and precise risks remain uncertain.[40] Planned cesarean delivery at a facility able to manage complications is the commonly advised approach.[40][41]

Psychosocial Impact and Reintegration​

The injury is profoundly social as well as physical.[20][21][22][23]

  • Depression. In a Mali repair-program cohort, 36.5% of 167 women screened at intake had moderate or severe depression, compared with 16.9% of 130 screened three months after discharge.[20]
  • Coping behaviors. Restricting fluids, multilayer clothing, self-isolation, allowing the husband to remarry, alcohol use, spiritual seeking[21]
  • Recovery trajectory. Most physical and psychosocial improvement occurs in the first 6 months after repair; by 12 months, urinary incontinence falls from 98% to 33%, while self-rated good, very good or excellent health rises from 0% at baseline to 60% at 3 months and about 69% at 12 months[23]
  • Mental-health intervention. The COFFEE group CBT program (CBT with Obstetric Fistula for Education and Empowerment) was studied in an uncontrolled pilot of 24 postsurgical women; depression, anxiety, and traumatic stress scores declined significantly from pretreatment to discharge.[24]
  • Outcome measurement. The IUGA/ICS consensus treats improvement in quality of life as part of clinical success (statements 1 and 4) and advises assessing it 3–12 months after repair (statement 41) and sexual function with a validated questionnaire at 6–12 months (statement 19). It rated PGI-I, I-QOL, UDI and ICIQ-UI SF as suitable (statements 28, 30, 31, 44) and reached no consensus on KHQ, PISQ-12, SF-36 or EQ-5D (statements 29, 32, 33, 34). It calls for a specialized, validated short fistula questionnaire (statement 43).[36]
  • Reintegration programming. Programs have combined health education, physical therapy, social support, psychosocial counseling, and economic empowerment. The scoping review reports physical and psychosocial improvements and supports holistic adjunct care.[25]

Prevention — The Three Delays​

Prevention requires addressing the Three Delays Model.[26][27][28]

  1. Delay in deciding to seek care. Failure to recognize prolonged labor; competing care pathways (traditional birth attendants); lack of women's autonomy; fear of hospitals; cost
  2. Delay in reaching care. Geographic and transport barriers; distance of 10–50 km from the hospital was associated with obstructed labour (AOR 3.89) in an Ethiopian case-control study[29]
  3. Delay in receiving care once present. Inadequate emergency obstetric services, shortage of skilled providers and gaps in labor monitoring. A survey of partograph use identifies implementation barriers.[30]

Effective interventions: skilled labor monitoring with timely escalation, timely obstetric intervention for obstructed labor with the delivery route guided by fetal status and suspected uterine rupture, skilled birth attendance, family planning, delaying age of first pregnancy, education for girls, community economic development, and gender-equity programming.[3][26][31][50] The WHO Labour Care Guide replaces the traditional WHO partograph; the 2025 implementation package supports its adoption rather than universal reliance on the older 1 cm/hour rule.[37]

Global Health Context​

InitiativeNotes
UN Resolution 2018Called to end fistula by 2030[4]
UNFPA Campaign to End FistulaInternational advocacy and funding[3]
FIGO Fistula Surgery Training Initiative62 Fellows from 22 countries since 2012; > 10,000 repairs performed; Global Competency-Based Fistula Surgery Training Manual[5][32]
Fistula Foundation24,568 supported fistula and related procedures, including perineal-tear repairs, at 110 hospitals in 27 countries (2019–2021); Table 1 reports 87.3% dry/continent at discharge among 20,591 in six repair categories[6]
Kenya Fistula Treatment Network6,223 surgeries over 6 years; among 1,092 women assessed in the community at 12 months, 96% self-reported being dry; trained 11 surgeons and 424 community health volunteers[33]

The 2030 elimination target is unobtainable without sustained funding, surgical-capacity building, and universal access to emergency obstetric care.[5]

See Also​

Videos​

Reconsidering Vesicovaginal Fistula Management
Stanford CME Grand Rounds (2024)

References​

1. Okada Y, Matsushita T, Hasegawa T, et al. "Surgical interventions for treating vesicovaginal fistula in women." Protocol. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

2. Barageine JK, Tumwesigye NM, Byamugisha JK, Almroth L, Faxelid E. "Risk factors for obstetric fistula in western Uganda: a case control study." PLoS One. 2014;9(11):e112299. doi:10.1371/journal.pone.0112299

3. Wall LL. "Obstetric vesicovaginal fistula as an international public-health problem." Lancet. 2006;368(9542):1201–1209. doi:10.1016/S0140-6736(06)69476-2

4. Anastasi E, Asiamah B, Lal G. "Leaving no one behind: is the achievement of the Sustainable Development Goals possible without securing the dignity, rights, and well-being of those who are 'invisible'?" Int J Gynaecol Obstet. 2020;148(Suppl 1):3–5. doi:10.1002/ijgo.13031

5. Slinger G, Trautvetter L. "Addressing the fistula treatment gap and rising to the 2030 challenge." Int J Gynaecol Obstet. 2020;148(Suppl 1):9–15. doi:10.1002/ijgo.13033

6. Pollaczek L, Rajagopal K, Chu J. "Patient characteristics, surgery outcomes, presumed aetiology and other characteristics of fistula surgeries and related procedures supported by Fistula Foundation from 2019 to 2021: a multicentre, retrospective observational study." BMJ Open. 2024;14(3):e078426. doi:10.1136/bmjopen-2023-078426

7. Bulndi LB, Ireson D, Adama E, Bayes S. "Sub-Saharan African women's views and experiences of risk factors for obstetric fistula: a qualitative systematic review." BMC Pregnancy Childbirth. 2022;22(1):680. doi:10.1186/s12884-022-05013-2

8. Tilahun T, Sura B, Merdassa E. "Determinants of obstetric fistula in south-western Ethiopia." Int Urogynecol J. 2021;32(9):2505–2510. doi:10.1007/s00192-021-04690-5

9. Wonde TE, Mihretie A. "Maternofetal outcomes of obstructed labor among women who gave birth at general hospital in Ethiopia." BMC Res Notes. 2019;12(1):128. doi:10.1186/s13104-019-4165-8

10. Capes T, Stanford EJ, Romanzi L, Foma Y, Moshier E. "Comparison of two classification systems for vesicovaginal fistula." Int Urogynecol J. 2012;23(12):1679–1685. doi:10.1007/s00192-012-1671-9

11. Waaldijk K. "Surgical classification of obstetric fistulas." Int J Gynaecol Obstet. 1995;49(2):161–163. doi:10.1016/0020-7292(95)02350-l

12. Mukwege D, Peters L, Amisi C, et al. "Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldijk classifications." Int J Gynaecol Obstet. 2018;142(2):187–193. doi:10.1002/ijgo.12514

13. Zeleke LB, Welsh A, Abeje G, Khejahei M. "Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: a systematic review and meta-analysis." PLoS One. 2024;19(5):e0303020. doi:10.1371/journal.pone.0303020

14. Mourad MS, Malallah M, Mahfouz W, et al. "Sixteen years of multinational experience in female genital fistula repair: integrating traditional and innovative surgical approaches across 12 countries." Neurourol Urodyn. 2026;45(3):583–590. doi:10.1002/nau.70226

15. Kumsa Meikena H, Bihon AM, Serka S. "Predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center, northern Ethiopia." Int Urogynecol J. 2023;34(8):1891–1898. doi:10.1007/s00192-023-05483-8

16. Nardos R, Jacobson L, Garg B, et al. "Characterizing persistent urinary incontinence after successful fistula closure: the Uganda experience." Am J Obstet Gynecol. 2022;227(1):70.e1–70.e9. doi:10.1016/j.ajog.2022.03.008

17. Kopp DM, Tang JH, Bengtson AM, et al. "Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study." BJOG. 2019;126(7):926–934. doi:10.1111/1471-0528.15546

18. Goh J, Browning A, Slinger G, Trautvetter L. "FIGO expert opinion: management of post-obstetric fistula repair incontinence for vesicovaginal fistula." Int J Gynaecol Obstet. 2026;172(1):210–214. doi:10.1002/ijgo.70384

19. Nardos R, Phoutrides EK, Jacobson L, et al. "Characteristics of persistent urinary incontinence after successful fistula closure in Ethiopian women." Int Urogynecol J. 2020;31(11):2277–2283. doi:10.1007/s00192-020-04265-w

20. Watt MH, Nguyen TV, Touré C, et al. "Integrated mental health screening for obstetric fistula patients in Mali: from evidence to policy." PLoS One. 2020;15(9):e0238777. doi:10.1371/journal.pone.0238777

21. Hurissa BF, Koricha ZB, Dadi LS. "Challenges and coping mechanisms among women living with unrepaired obstetric fistula in Ethiopia: a phenomenological study." PLoS One. 2022;17(9):e0275318. doi:10.1371/journal.pone.0275318

22. Hurissa BF, Koricha ZB, Dadi LS. "Quality of life and its predictive factors among women with obstetric fistula in Ethiopia: a cross-sectional study." Front Public Health. 2022;10:987659. doi:10.3389/fpubh.2022.987659

23. El Ayadi AM, Barageine J, Korn A, et al. "Trajectories of women's physical and psychosocial health following obstetric fistula repair in Uganda: a longitudinal study." Trop Med Int Health. 2019;24(1):53–64. doi:10.1111/tmi.13178

24. Gladstone TRG, Ugueto AM, Muleta M, et al. "Development and pilot test of a group cognitive behavioral intervention for women recovering from fistula repair surgery in Ethiopia." Front Public Health. 2022;10:862351. doi:10.3389/fpubh.2022.862351

25. El Ayadi AM, Painter CE, Delamou A, et al. "Rehabilitation and reintegration programming adjunct to female genital fistula surgery: a systematic scoping review." Int J Gynaecol Obstet. 2020;148(Suppl 1):42–58. doi:10.1002/ijgo.13039

26. Wall LL. "Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix." Obstet Gynecol Surv. 2012;67(2):111–121. doi:10.1097/OGX.0b013e3182438788

27. Wall LL. "Overcoming Phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries." BMC Pregnancy Childbirth. 2012;12:68. doi:10.1186/1471-2393-12-68

28. Lufumpa E, Doos L, Lindenmeyer A. "Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review." BMC Pregnancy Childbirth. 2018;18(1):155. doi:10.1186/s12884-018-1787-0

29. Desta M, Mekonen Z, Alemu AA, et al. "Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University Referral Hospital: a case-control study." PLoS One. 2022;17(6):e0268938. doi:10.1371/journal.pone.0268938

30. Zelellw D, Tegegne T. "The use and perceived barriers of the partograph at public health institutions in East Gojjam Zone, northwest Ethiopia." Ann Glob Health. 2018;84(1):198–203. doi:10.29024/aogh.23

31. Miller S, Lester F, Webster M, Cowan B. "Obstetric fistula: a preventable tragedy." J Midwifery Womens Health. 2005;50(4):286–294. doi:10.1016/j.jmwh.2005.03.009

32. Slinger G, Trautvetter L, Browning A, Rane A. "Out of the shadows and 6000 reasons to celebrate: an update from FIGO's Fistula Surgery Training Initiative." Int J Gynaecol Obstet. 2018;141(3):280–283. doi:10.1002/ijgo.12482

33. Pollaczek L, El Ayadi AM, Mohamed HC. "Building a country-wide fistula treatment network in Kenya: results from the first six years (2014–2020)." BMC Health Serv Res. 2022;22(1):280. doi:10.1186/s12913-021-07351-x

34. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: urinary fistula. 2026. Guideline.

35. World Health Organization. WHO recommendation on duration of bladder catheterization after surgical repair of simple obstetric urinary fistula. 2018. Recommendation.

36. Maljaars LP, Corcos J, Ghoniem G, et al. Consensus statements on the definition of surgical success following obstetric urinary pelvic floor fistula repair: an IUGA-ICS proposal. Int Urogynecol J. 2026;37:1193–1205. doi:10.1007/s00192-025-06413-6.

37. World Health Organization. WHO labour care guide: implementation resource package. 2025. Guidance.

38. Adler AJ, Ronsmans C, Calvert C, Filippi V. "Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis." BMC Pregnancy Childbirth. 2013;13:246. doi:10.1186/1471-2393-13-246

39. Barone MA, Widmer M, Arrowsmith S, et al. "Breakdown of simple female genital fistula repair after 7 day versus 14 day postoperative bladder catheterisation: a randomised, controlled, open-label, non-inferiority trial." Lancet. 2015;386(9988):56–62. doi:10.1016/S0140-6736(14)62337-0

40. Delamou A, Utz B, Delvaux T, et al. "Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: scoping review." Trop Med Int Health. 2016;21(11):1348–1365. doi:10.1111/tmi.12771

41. Browning A. "Pregnancy following obstetric fistula repair, the management of delivery." BJOG. 2009;116(9):1265–1267. doi:10.1111/j.1471-0528.2009.02182.x

42. Goh JT, Browning A, Berhan B, Chang A. "Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system." Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12):1659–1662. doi:10.1007/s00192-008-0693-9

43. Browning A. Management of Obstetric Urogenital Fistula. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:1160–1174. doi:10.1201/9781003144243-118

44. Goh JT, Browning A. "Use of urethral plugs for urinary incontinence following fistula repair." Aust N Z J Obstet Gynaecol. 2005;45(3):237–238. doi:10.1111/j.1479-828X.2005.00395.x

45. Browning A, Menber B. "Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment." BJOG. 2008;115(12):1564–1569. doi:10.1111/j.1471-0528.2008.01900.x

46. Goh JTW. "A new classification for female genital tract fistula." Aust N Z J Obstet Gynaecol. 2004;44(6):502–504. doi:10.1111/j.1479-828X.2004.00315.x

47. Ahmed S, Genadry R, Asiamah B, Liang M, Tripathi V, Anastasi E. "Global, regional and national estimates of obstetric fistula prevalence." BMJ Glob Health. 2025;10(12):e020877. doi:10.1136/bmjgh-2025-020877

48. Waaldijk K. "The immediate management of fresh obstetric fistulas." Am J Obstet Gynecol. 2004;191(3):795–799. doi:10.1016/j.ajog.2004.02.020

49. Hilton P, Ward A. "Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in southeast Nigeria." Int Urogynecol J Pelvic Floor Dysfunct. 1998;9(4):189-194. doi:10.1007/BF01901602

50. Ngongo CJ, et al. "Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa." BJOG. 2020;127(6):702–707. doi:10.1111/1471-0528.16047

51. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

52. Browning A, Trautvetter L, Slinger G, et al. "FIGO good practice recommendations to standardize the assessment of outcomes following vesicovaginal fistula surgery." Int J Gynaecol Obstet. 2025;168(2):497–501. doi:10.1002/ijgo.16017

53. El-Azab AS, Abolella HA, Farouk M. "Update on vesicovaginal fistula: A systematic review." Arab J Urol. 2019;17(1):61–68. doi:10.1080/2090598X.2019.1590033