Fistula is an abnormal connection between two organs in the body or between an organ and the exterior of the body. An obstetric fistula specifically refers to a hole between the birth canal and bladder and/or rectum caused by prolonged obstructed labor.
What causes fistula to occur?
Fistula occurs as a result of several factors:
- Prolonged obstructed labor – When the baby’s head puts pressure on the mother’s pelvic bone for an extended period of time, it can cause tissues to become ischemic and necrotic. This can lead to a hole forming between organs.
- Limited access to quality maternal healthcare – Many women in developing countries do not have access to emergency obstetric care. Prolonged labor often goes untreated, increasing the risk of fistula.
- Early child marriage and pregnancy – Girls who become pregnant before their pelvis is fully developed are more likely to experience obstructed labor.
- Malnutrition – Lack of proper nutrition can make tissue less resilient and more prone to damage during childbirth.
- Female genital cutting – Cutting and scarring of genital tissue can make vaginal delivery more difficult and dangerous.
- Limited access to family planning – Lack of contraception increases a woman’s lifetime risk of unintended pregnancies and adverse outcomes.
Why does fistula recur after repair?
There are several reasons why a fistula can reoccur even after surgical repair:
- Residual or overlooked fistula – If any remnants of the original fistula remain after surgery, it can lead to the abnormal opening recurring.
- Poor surgical technique – Improper closure or healing can cause the repair to breakdown.
- Infection – Post-surgical infections disrupt healing and can cause tissue breakdown.
- Scarring and fibrosis – Scarring around the repair site weakens tissues and impedes healing.
- Continued obstructed labor – Women who have had fistula are still at risk of obstructed labor with future deliveries if the underlying risk factors are not addressed.
- Premature sexual activity after repair – Having intercourse before the fistula is fully healed can traumatize tissues.
- Other medical conditions – Conditions like diabetes or malnutrition impair wound healing.
What factors increase a woman’s risk of recurrent fistula?
- Younger age at first delivery – The pelvis may still be underdeveloped, increasing risk of obstructed labor.
- Short interval between pregnancies – Close pregnancies do not allow pelvic floor to recover.
- Lack of family planning – Unintended pregnancies can lead to recurrent fistula.
- Persistent malnutrition – Poor nutrition impedes healing and makes tissue vulnerable.
- Ongoing inadequate maternal care – Lack of quality emergency obstetric care perpetuates risks.
- Complex vaginal scarring – Severe scarring makes subsequent vaginal deliveries more hazardous.
- Poverty – Financial barriers prevent access to skilled care and family planning.
- Illiteracy – Limits health knowledge and awareness of prevention options.
- Rural residence – Isolation from emergency services increases risks.
What screening should happen after fistula repair?
Women should receive comprehensive screening after fistula repair surgery to assess healing and identify any factors that could lead to recurrence, including:
- Pelvic exam to evaluate repair site integrity, residual incontinence, and vaginal scarring.
- Screening for infection through urinalysis and vaginal cultures.
- Assessing continence and voiding patterns.
- Evaluation of nutritional and health status.
- Family planning counseling and contraceptive access.
- Education on avoiding early sexual activity to allow complete healing.
- Pregnancy risk assessment and counseling on timing of future deliveries.
- Linkages to ongoing care such as physical therapy to improve pelvic floor strength.
Regular long-term follow up is also essential to monitor for signs of recurrence.
What surgical precautions can reduce recurrence risk?
Surgeons can take several precautions to optimize fistula repair outcomes:
- Meticulous surgical technique closing all fistula openings and using vascularized flaps if needed.
- Tension-free closure without performing excessive vaginal narrowing.
- Prophylactic antibiotics to prevent post-op infection.
- Using postoperative bladder catheterization to allow complete healing.
- Avoiding overlapping suture lines.
- Careful hemostasis to prevent hematomas.
- Regular quality assurance reviews of surgical outcomes.
- Referring complex cases to specialized fistula centers.
What rehabilitative care is needed after fistula repair?
In addition to surgical repair, holistic rehabilitative care improves outcomes for women with fistula:
- Nutrition support – Adequate nutrition promotes wound healing and reduces risks of recurrence.
- Physical therapy – Strengthens pelvic floor muscles and prevents incontinence.
- Psychosocial counseling – Addresses trauma, stigma, and depression.
- Family planning – Helps optimize timing and safety of future pregnancies.
- Social support networks – Provides connections to other survivors.
- Economic empowerment programs – Improves access to care and prevention.
- Community education – Raises awareness to reduce stigma and encourage seeking care.
What public health initiatives help prevent recurrent fistula?
To create lasting solutions to fistula, broader public health initiatives are needed:
- Improving access to skilled maternity care and emergency obstetric services.
- Increasing availability of family planning resources.
- Raising awareness of early marriage and pregnancy risks.
- Addressing women’s social and economic marginalization.
- Promoting secondary education for girls.
- Investing in nutrition programs for women and girls.
- Conducting research to improve fistula repair outcomes.
- Providing training and resources to expand local fistula treatment capacity.
- Instituting supportive policies to make maternal healthcare more accessible and equitable.
Conclusion
Recurrent fistula remains a significant challenge, particularly for vulnerable women with limited access to quality healthcare. While surgical techniques are improving, holistic rehabilitative care and public health initiatives are equally vital for preventing reoccurrence. Women need continued support long after initial repair to fully heal, safely deliver future pregnancies, and break free from the cycle of repeat fistula injuries. With dedicated and multifaceted approaches, the rates of recurrent fistula can be substantially reduced worldwide.