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Objective: In Uganda, ∼2% of women have had urogenital fistulae. Given that ureteric involvement makes surgical repair more complex, this research was conducted to identify the risk factors for ureteric involvement when evaluating women who have urogenital fistulae to prepare better for surgical planning and counseling. Materials and Methods: This was a retrospective cohort study of women who underwent urogenital fistula repair at Kitovu Mission Hospital in Masaka, Uganda. Results: Of 546 patients with urogenital fistula, 50 (9.2%) had ureteric involvement. Those with ureteric involvement had statistically significantly higher parity (p < 0.0001) and shorter labor duration, compared with patients without ureteric involvement (p = 0.003); and had undergone prior non-fistula operations, compared to patients without ureteric involvement (p = 0.025). Delivery type distribution was significantly different between groups (p = 0.016) with higher rates of cesarean delivery and cesarean hysterectomy in women with ureteric involvement, compared to women without ureteric involvement (73.9% and 13% versus 61.4% and 5.8%). Goh classification of scarring was statistically significant between the groups (p = 0.013). Conclusions: Potential risk factors for ureteric involvement, include higher parity, shorter duration of labor, and history of cesarean or cesarean hysterectomy. There is also a trend toward Goh classification 1aiii. These factors can be used to stratify patients' risk preoperatively and assist surgical planning, especially in resource-limited settings. (J GYNECOL SURG 20XX:000) [ABSTRACT FROM AUTHOR]

Background: Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women's health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3)., Methods: This mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations., Discussion: Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health. Trial Registration ClinicalTrials.gov Identifier: NCT05437939., (© 2024. The Author(s).)

Introduction and hypothesis: Genitourinary fistulas (usually arising following prolonged obstructed labor) are particularly devastating for women in low-income counties. Surgical repair is often difficult and delayed. While much attention has been devoted to technical surgical issues, the challenges of returning to normal personal, family, and community life after surgical treatment have received less scrutiny from researchers. We surveyed young Ugandan women recovering from genitourinary fistula surgery to assess their social reintegration needs following surgery. Methods: A cross-sectional survey of 61 young women aged 14–24 years was carried out 6 months postoperatively. Interviews were carried out in local languages using a standardized, interviewer-administered, semistructured questionnaire. Data were entered using EpiData and analyzed using SPSS. Results: Ongoing reintegration needs fell into interrelated medical, economic, and psychosocial domains. Although >90% of fistulas were closed successfully, more than half of women had medical comorbidities requiring ongoing treatment. Physical limitations, such as foot drop and pelvic muscle dysfunction impacted their ability to work and resume their marital relationships. Anxieties about living arrangements, income, physical strength, future fertility, spouse/partner fidelity and support, and possible economic exploitation were common. Sexual dysfunction after surgery—including dyspareunia, loss of libido, fear of intercourse, and anxieties about the outcome of future pregnancies—negatively impacted women's relationships and self-esteem. Conclusions: Young women recovering from genitourinary fistula surgery require individualized assessment of their social reintegration needs. Postoperative social reintegration services must be strengthened to do this effectively. [ABSTRACT FROM AUTHOR]

Objectives: To explore trajectories of physical and psychosocial health, and their interrelationship, among women completing fistula repair in Uganda for 1 year post-surgery.Methods: We recruited a 60-woman longitudinal cohort at surgical hospitalisation from Mulago Hospital in Kampala Uganda (Dec 2014-June 2015) and followed them for 1 year. We collected survey data on physical and psychosocial health at surgery and at 3, 6, 9 and 12 months via mobile phone. Fistula characteristics were abstracted from medical records. All participants provided written informed consent. We present univariate analysis and linear regression results.Results: Across post-surgical follow-up, most women reported improvements in physical and psychosocial health, largely within the first 6 months. By 12 months, urinary incontinence had declined from 98% to 33% and general weakness from 33% to 17%, while excellent to good general health rose from 0% to 60%. Reintegration, self-esteem and quality of life all increased through 6 months and remained stable thereafter. Reported stigma reduced, yet some negative self-perception remained at 12 months (mean 17.8). Psychosocial health was significantly impacted by the report of physical symptoms; at 12 months, physical symptoms were associated with a 21.9 lower mean reintegration score (95% CI -30.1, -12.4).Conclusions: Our longitudinal cohort experienced dramatic improvements in physical and psychosocial health after surgery. Continuing fistula-related symptoms and the substantial differences in psychosocial health by physical symptoms support additional intervention to support women's recovery or more targeted psychosocial support and reintegration services to ensure that those coping with physical or psychosocial challenges are appropriately supported. [ABSTRACT FROM AUTHOR]

Kitovu Hospital in Masaka, Uganda, is a leading obstetric fistula repair centre in the country with the highest rates of fistula in the world. In this retrospective case review, the regional incidence and causative factors were studied in patients with vesicovaginal fistula (VVF) who were admitted at Kitovu Hospital. Fistula history included severity (ICIQ score), causes and outcomes of VVF were measured. Women suffered with symptoms of VVF for an average of 4.97 years with an average ICIQ severity score of 7.21. Patients travelled an average distance of 153 km and the majority travelled by public transport. Rates of prolonged labour were high. 69% of fistula-causing delivery resulted in stillbirth and 12% resulted in early neonatal death. Following surgery, 94% of patients were dry on discharge. Impact statement What is already known on this subject? Vesicovaginal fistula (VVF) is a severe, life-changing injury. Although largely eradicated from the Western world thanks to modern obstetric practice, VVF is still highly prevalent in developing countries where factors such as young childbearing age and poor access to emergency obstetric care increase the incidence (Wall et al. 2005 ). At the current rate of fistula repair, it is estimated that it would take 400 years to treat those already suffering with fistula, providing that no new cases emerged (Browning and Patel 2004 ). What do the results of this study add? The Ugandan women in this study reiterate tales of foetal loss, social isolation and epic journeys in search of fistula repair, as previously described in the literature. The study offers some hope for prompt help-seeking during labour and after fistulas are developed. It demonstrates the success of fistula repairs at Kitovu Hospital but highlights the paucity of service provision across Uganda. What are the implications of these findings for clinical practice and/or further research? Further epidemiological research is required to quantify the true burden of the disease. Only by raising the profile of VVF in both developing and developed countries, can there be a collaborative effort to make universal change. To embark upon the prevention and cure of the disease it is necessary to continue tackling issues of poverty and gender inequality. [ABSTRACT FROM AUTHOR]

Uganda has one of the highest obstetric fistula rates in the world with approximately 200,000 women currently suffering. Surgical closure successfully treats fistula in the majority of cases, yet there is a severe shortage of facilities and trained surgeons in low-resource countries. The purpose of this study was to examine Ugandan women’s experiences of obstetric fistula with the aim of adding narrative depth to the clinical literature on this devastating birth injury. Data were collected through semistructured interviews, focus groups, and participant observation. Resulting narratives were consensus coded, and key themes were member-checked using reciprocal ethnography. Women who suffered from fistula described barriers in accessing essential obstetric care during labor—barriers that are consistent with the three delays framework developed by Thaddeus and Maine. In this article, we extend this scholarship to discuss a fourth, critical delay experienced by fistula survivors—the delay in the diagnosis and treatment of their birth injury. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the results of Mitrofanoff continent urinary diversion in a group of women with persistent severe incontinence after vesicovaginal fistula (VVF) secondary to obstructed labour. Patients and methods: Seven women with severe incontinence following a VVF were offered the Mitrofanoff procedure after all other attempts had failed to restore continence. In three patients a caecocystoplasty formed the urinary reservoir and in four the bladder was used. In all seven patients the appendix was used as the conduit for self-catheterization. The mean (range) follow-up was 10 (3–14) months. Results: One patient died postoperatively from hepatic failure, which could not be attributed to the particular procedure. One patient required re-operation at 10 days to adjust the conduit, but of the six patients who recovered, all are fully continent and self-catheterizing with no difficulty. Conclusion: The Mitrofanoff procedure appears to be a valuable technique to restore continence in this difficult group of patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of and factors associated with urologic complications among women with advanced cervical cancer before treatment in Uganda.Methods: In total, 283 women with histologically confirmed stage IIB-IVB cervical cancer who were admitted to Mulago Hospital over a 6-month period were studied. Abdominopelvic scan was carried out to check for hydronephrosis and hydroureter and to measure the tumor volume. Serum creatinine and urea levels were measured, and the presence of anuria and vesicovaginal fistula (VVF) was ascertained from self-reporting and clinical records.Results: Urologic complications were present in 138 (48.8%) women. Hydronephrosis, VVF, hydroureter, and anuria were present in 112 (39.6%), 21 (7.4%), 11 (3.9%), and 9 (3.2%) women, respectively; serum creatinine and urea levels were elevated in 48 (17.0%) women. Stage of disease was significantly associated with urologic complications: stage IIIB odds ratio (OR) 3.36 (95% confidence interval [CI], 1.57-7.20); stage IVA OR 17.10 (95% CI, 6.07-48.16); P<0.001.Conclusion: There is a high prevalence of urologic complications among women with advanced cervical cancer; these complications are significantly associated with the stage of cervical cancer. [ABSTRACT FROM AUTHOR]

Obstetric fistula is among the most severe maternal morbidities. It is caused directly by obstructed labour, and indirectly by social, political, and economic factors. Effects of obstetric fistula include chronic urinary incontinence. Urinary incontinence often leads to isolation and death if left untreated. Death of women during childbirth is detrimental to both social economic transformation and shift of poor economies to middle income status. In this study, we estimate the burden of obstetric fistula on Ugandan women, and the effect of educating these women on its causes. We hypothesise that symptomatic women seek treatment after interactions with a treated woman. We consider one cycle of fistula and seek to determine how many women will eventually seek treatment, when one woman is treated in a population. We further assume that each treated woman becomes the educational resource for more symptomatic women. We then invest in getting women into treatment, providing treatment, or educating them about prevention and treatment of obstetric fistula. Results show that for each investment strategy, there exists a unique maximal solution that remains bounded. It is also shown from the model that high investment rates leads to high treatments rates. However, the highest treatment output is obtained when the level of investment is 44.9%. We also see from the results that for every one woman treated, 17 more seek treatment. However, as investment increases, the number of women that are eventually treated reduces due to lack of further investment into treatment and therefore no more women to treat. Results also show that educating women reduced fistula prevalence although the magnitude of reduction depended on the level of education coverage. These results show that an optimal strategy to reduce fistula prevalence would require achieving a balance between the two desirable but incompatible health outcomes. This will help maximise the total return or effectiveness under given circumstances such as continued women that develop fistula due to lack of skilled healthcare or lifetime incontinence due to lack of treatment. From this study we conclude that improving access to quality health education will contribute to the elimination of obstetric fistula in Uganda. [ABSTRACT FROM AUTHOR]

A photograph by Karen Roush about a girl waiting for surgery in Uganda is presented.