European Journal of Cardiovascular Medicine

Urogynecologic fistulae (UGF) are among the most distressing complications faced by women, particularly in regions where access to modern obstetric and gynaecologic care is limited. These fistulae, which include vesicovaginal, ureterovaginal, urethrovaginal, and vesicouterine fistulae, result in continuous urinary leakage, leading to significant physical discomfort, social ostracization, and psychological trauma. Zacharin described the condition as a tragic affliction that historically plagued women long before surgical remedies were developed and refined [1].

In many parts of the developing world, obstructed labour continues to be the leading cause of UGF. In contrast, in developed nations where skilled surgical care is standard, the etiology has shifted toward iatrogenic injuries during gynaecologic surgeries, particularly hysterectomies [2]. Despite this shift, the global burden remains disproportionately high in low-resource settings, where millions of women remain at risk each year [3].

Vesicovaginal fistula (VVF), the most common type of UGF, often arises as a consequence of prolonged obstructed labour, especially in the absence of timely medical intervention. First described in surgical literature as a postoperative complication [4], it has remained a persistent clinical challenge. Successful surgical management hinges on adherence to classical principles: adequate visualization, meticulous dissection, watertight closure, and proper drainage—a framework established by Couvelaire in 1953[5].

In India, accurate prevalence data are scarce due to social stigma and underreporting. However, the estimated prevalence ranges from 0.3% to 7.6%, with an overall national estimate of 2.2%[6]. This lack of data has prompted international and national bodies such as the United Nations Population Fund (UNFPA) to advocate for surveillance mechanisms like a fistula registry to inform prevention and management strategies [7].

The present study aims to assess the demographic profile, clinical features, causes, management strategies, and surgical outcomes of UGF in a tertiary care centre in India, contributing to the much-needed body of research on this underrepresented health issue.

Aims and Objectives

The primary aim of this study was to evaluate the clinical profile and surgical outcomes of patients with Urogynecologic fistulae (UGF) managed at a tertiary care centre in India.

The specific objectives were as follows:

1. To analyze the demographic characteristics and clinical presentation of women with various types of Urogynecologic fistulae.
2. To determine the underlying etiological factors contributing to fistula formation, including obstetric and gynaecologic causes.
3. To describe the diagnostic methods employed for identifying and characterizing fistulae.
4. To evaluate the surgical approaches used for fistula repair and assess their efficacy based on fistula type, size, and complexity.
5. To document postoperative outcomes, including continence status, complications, and recurrence rates.
6. To compare the findings with existing literature and assess the effectiveness of management strategies employed at the study centre.

This prospective observational study was conducted in the Department of Urology at King George Hospital, Visakhapatnam, a tertiary care referral centre in Andhra Pradesh, India. The study was carried out over a 30-month period, from September 2013 to February 2016.

A total of 34 female patients with confirmed Urogynecologic fistulae (UGF) were enrolled in the study. Inclusion criteria encompassed women presenting with urinary fistulae following obstructed labour, hysterectomy (abdominal or vaginal), lower segment caesarean section (LSCS), instrumental delivery, trauma, or radiotherapy. Women with urinary incontinence due to non-fistulous causes were excluded from the study.

Socioeconomic status was assessed using the modified Kuppuswamy scale, and malnutrition was defined by a low body mass index (BMI). All patients were evaluated through a structured clinical questionnaire, including detailed history (age, parity, antecedent event), general examination, and basic investigations such as hemoglobin level, blood sugar, renal function tests, and urine culture. Anemia and infections were corrected prior to surgery.

Diagnosis of UGF was established by clinical history, physical examination, ultrasonography, excretory urography, and endoscopic assessment. Cystoscopy and examination under anaesthesia (EUA) were performed to determine the size, location, number of fistulae, and associated complications such as calculi or infection.

All patients underwent surgical management tailored to the type and site of the fistula:

• Vesicovaginal fistulae (VVF) were repaired via either an abdominal approach (O’Conor technique) or a vaginal approach (vaginal flap technique).
• Ureterovaginal fistulae (UVF) were managed with either ureteral stenting or ureteric reimplantation using Paquin’s technique.
• Urethrovaginal fistulae (URVF) were treated via vaginal repair, and in cases with concurrent VVF, a combined abdominal and vaginal approach was employed. Martius flaps were used as interpositional grafts where applicable.

All patients were catheterized preoperatively and received continuous bladder drainage using suprapubic or perurethral catheters. Postoperative care included appropriate antibiotic therapy, management of complications, and follow-up in outpatient settings.

Patients were followed up regularly and assessed for urinary continence, lower urinary tract symptoms, and sexual function. Surgical success was defined as urinary continence at 3 months postoperatively.

A total of 34 women with 36 Urogynecologic fistulae were evaluated during the study period. The most common type observed was the vesicovaginal fistula (VVF), accounting for 29 cases (80.5%). Less frequent presentations included urethrovaginal fistulae (URVF) in 4 patients (11%) and ureterovaginal fistulae (UVF) in 3 patients (8.5%). Notably, two patients had more than one type of fistula concurrently, resulting in a total of 36 fistulous tracts among the 34 patients. The detailed distribution is shown in Table 1 and Figure 1.

Table 1. Distribution of Fistula Types Among Patients

Age Distribution

The age of the patients ranged from 20 to 69 years, with a mean age of 37 years. The highest frequency of cases was observed in the 40–49-year age group (11 patients), followed by 20–29 years (10 patients), and 30–39 years (8 patients). Older patients were less common, with only one case reported above 60 years of age. The detailed distribution is presented in Table 2 and illustrated in Figure 1.

Table 2. Age Distribution of Patients

Parity Distribution

Parity analysis revealed that the majority of the patients were multiparous. Among the 34 women included in the study, 10 had two children, 9 had three children, and 7 had four children. Only 8 patients (23.5%) were uniparous. This trend highlights the association between higher parity and the risk of developing Urogynecologic fistulae. The details are presented in Table 3 and Figure 1.

Table 3. Parity Distribution of Patients

Figure1.  Distribution of Fistula Types, Age Groups, and Parity Among Patients

This grouped bar chart illustrates the distribution of fistula types (VVF, UVF, URVF), age groups (20–69 years), and parity (1–4) among the study population. Each category is color-coded to visually separate the three variables while maintaining compactness.

Socioeconomic and Nutritional Profile

Of the 34 patients included in the study, 18 women (52.9%) were from rural backgrounds, while 16 women (47.1%) were from urban areas. A significant proportion were from lower socioeconomic strata, with 14 patients (41.2%) being illiterate. Additionally, 20 patients (58.8%) were of short stature (height <150 cm), and 9 patients (26.5%) were found to be malnourished, based on body mass index (BMI) assessments. These findings underscore the strong association between poor nutritional status, limited education, and the incidence of Urogynecologic fistulae. Details are provided in Table 4 and illustrated in Figure 2.

Table 4. Socioeconomic and Nutritional Characteristics of Patients

Figure 2. Socioeconomic and Nutritional Characteristics

Etiology of Fistulae

The analysis of causative factors revealed that the majority of urogynecologic fistulae in this study were iatrogenic, resulting from surgical interventions. Abdominal hysterectomy was the most common etiology, accounting for 22 cases (61.1%). Two cases (5.5%) were attributed to vaginal hysterectomy.

Obstetric trauma was responsible for a significant portion of cases as well. These included lower segment caesarean sections (LSCS) and instrumental deliveries, each contributing 5 cases (13.9%), and one case (2.8%) following a prolonged home delivery. Additionally, one case (2.8%) was linked to pelvic radiation therapy administered for carcinoma cervix. The detailed breakdown is presented in Table 5 and Figure 3.

Table 5. Etiology of Urogynecologic Fistulae

Figure 3. Etiology of Urogynecologic Fistulae

Fistula Characteristics: Size

The size of the fistulae was an important parameter in determining the complexity and approach to surgical repair. Among the 36 fistulae studied (including recurrent and multiple fistulae in some patients), the majority were between 1–2 cm in diameter (14 cases; 38.9%). This was followed by 7 fistulae (19.4%) measuring 2–3 cm, 5 fistulae (13.9%) less than 1 cm, 4 fistulae (11.1%) in the 3–4 cm range, and 3 fistulae (8.3%) exceeding 4 cm in size. The data are summarized in Table 6 and Figure 4.

Table 6. Size Distribution of Fistulae

Figure 4. Fistula Size Distribution

Fistula Characteristics: Type, Location, Number, and Complexity

Among the 29 cases of vesicovaginal fistulae (VVF) analyzed, the most common anatomical location was supratrigonal (16 cases), followed by trigonal (10 cases). Three cases exhibited combined involvement of both supratrigonal and trigonal regions.

With regard to the number of fistulae, 26 patients had a single VVF, while 3 patients had multiple fistulae.

Based on clinical and intraoperative findings, 20 VVFs were classified as simple, and 9 were categorized as complex. Complex fistulae included those with large size (>4 cm), proximity to the ureteric orifice or bladder neck, associated calculi, prior failed repairs, or post-radiation changes. The data are summarized in Table 7 and Figure 7.

Table 7. Characteristics of Vesicovaginal Fistulae (VVF)

Surgical Management and Techniques

All 29 patients with vesicovaginal fistulae underwent surgical repair. The majority of cases (22 patients; 75.9%) were treated using the transabdominal O’Conor technique, which was selected for fistulae that were complex, large, supratrigonal, or associated with prior surgical failure.

Five patients (17.2%) underwent vaginal flap repair, which was preferred for infratrigonal fistulae and those accessible with minimal scarring. An additional two cases (6.9%) required a combined abdominal and vaginal approach, due to the complex or multiple nature of the fistulae.

Interpositional tissue grafts were utilized to improve surgical outcomes: omentum was used in abdominal repairs, while the Martius flap was employed during vaginal and combined repairs. Details of the surgical approach are presented in Table 8.

Table 8. Surgical Approaches Used in VVF Repair

Postoperative Complications and Outcomes

The overall success rate of fistula repair in this study was 97%, defined by the absence of urinary incontinence at three months postoperatively. Only one patient experienced a recurrence of vesicovaginal fistula after initial vaginal repair, which was successfully managed with a subsequent abdominal repair.

Postoperative complications were observed in several cases:

• Wound infection was the most common complication, occurring in 5 patients.
• Bladder dysfunction, characterized by symptoms such as urgency and frequency, affected 4 patients and was managed with anticholinergic medications.
• Sexual problems including dyspareunia were reported by 3 patients; these were managed conservatively with vaginal dilation.
• Wound dehiscence occurred in 1 patient, who was re-operated with successful outcome.
• Fistula recurrence was also reported in 1 patient.

The complete data are presented in Table 9.

Table 9. Postoperative Complications

Final Outcome Summary and Follow-Up

Of the 34 women treated for urogynecologic fistulae, the overall success rate was 97%, defined as continence at three months postoperatively. Only one patient experienced recurrence of a vesicovaginal fistula following a prior vaginal repair. This patient subsequently underwent successful repair via an abdominal approach.

Follow-up duration ranged from 3 to 25 months, with more than half of the patients followed for at least one year. Patients with ureterovaginal fistulae demonstrated favourable long-term outcomes, with all three achieving continence following surgical intervention (two managed with ureteral stenting and one with ureteroneocystostomy).

Among patients with urethrovaginal fistulae, two underwent concomitant anti-incontinence procedures (McGuire’s pubovaginal fascial sling) due to fistula location near the bladder neck. Both recovered well, with transient urinary retention managed successfully using clean intermittent catheterization (CIC).

Throughout follow-up, patients were assessed for:

• Recurrent incontinence – none reported post-successful repair.
• New onset lower urinary tract symptoms – managed medically where necessary.
• Sexual health issues – addressed with counselling and conservative therapy (vaginal dilation).

This high success rate reflects the importance of first-attempt precision in surgical management, proper use of interpositional grafts (omentum, Martius flap), and comprehensive perioperative care

Urogynecologic fistulae (UGF) continue to represent a major public health issue in developing countries, including India, where obstetric and surgical care disparities remain prominent. As highlighted by Singh et al., obstetric fistula in India persists due to inequities in maternal healthcare, particularly in rural and low-resource areas【8】. This is further corroborated by Gulati et al., who analyzed data from the District Level Household and Facility Survey (DLHS-3) and identified low maternal age, poor socioeconomic conditions, and limited access to institutional deliveries as significant correlates of fistula occurrence【9】

Our study adds to this evidence by identifying abdominal hysterectomy as the most common cause of UGF (61%), followed by obstructed labor-related injuries (30.5%). This shift toward gynecologic iatrogenesis is consistent with findings in surgical literature, such as those reported in Campbell–Walsh Urology, which describes increasing rates of iatrogenic urinary tract injuries in developing regions undergoing surgical transitions【10】. Nonetheless, the burden of VVF resulting from obstetric trauma remains substantial, especially in multiparous, malnourished, and short-statured women—demographics mirrored in our patient cohort

Gerber and Schoenberg’s classification of urinary tract fistulae based on etiology and anatomical location remains clinically useful in guiding diagnostic and surgical strategies【11】. In our series, detailed preoperative evaluation including cystoscopy and imaging enabled effective surgical planning, consistent with Sims’ early principles of meticulous anatomical assessment for successful fistula repair【12】.

The predominant fistula type in our study was vesicovaginal fistula (80.5%), with supratrigonal and trigonal locations most commonly affected. These findings align with the anatomical susceptibility described by Lee et al., who noted increased incidence of supratrigonal involvement due to its proximity to surgical fields during hysterectomy【13】. We observed a 97% success rate, emphasizing the importance of first-attempt repair. This is comparable to other reported outcomes in the literature, including those by Miller and Webster, who highlighted high closure rates with well-executed primary surgeries【14】.

Proper case selection, use of interpositional grafts, and route-specific techniques contribute significantly to outcomes. Armenakas et al. and Eilber et al. both reported excellent long-term results with transvaginal repairs when reinforced with tissue interposition, such as Martius flaps or omental grafts【15】【16】. Our surgical choices reflected similar principles, with omental grafts used in abdominal repairs and Martius flaps in vaginal or complex procedures.

The risk of injury to the bladder or ureters during gynaecologic procedures is not negligible. Carley et al. reported a notable incidence of such complications during hysterectomy, underlining the need for intraoperative vigilance and prompt postoperative recognition to prevent delayed fistula presentation【17】. In our series, ureterovaginal fistulae (8.5%) and urethrovaginal fistulae (11%) were managed successfully with appropriate endourologic or reconstructive approaches, reinforcing the importance of tailored intervention strategies.

In summary, the findings of this study align well with national and international literature on urogynecologic fistulae. The key to successful outcomes remains early diagnosis, individualized surgical planning, use of vascularized grafts, and long-term follow-up. Importantly, strengthening maternal and surgical care systems is vital to prevent the occurrence of these debilitating conditions

Urogynecologic fistulae remain a significant clinical and social burden, particularly in resource-limited settings. This study highlights the changing trends in etiology, with abdominal hysterectomy now emerging as the leading cause over traditional obstetric trauma. Most fistulae in this cohort were vesicovaginal, and surgical outcomes were highly favourable when principles of meticulous dissection, proper timing, and the use of interpositional grafts were adhered to.

A 97% success rate achieved on the first attempt reinforces the importance of accurate preoperative evaluation and individualized surgical planning. The use of vascularized flaps such as omentum and Martius fat pad proved instrumental in complex cases, enhancing healing and reducing recurrence.

Preventive strategies, including improved surgical training, heightened intraoperative awareness, and accessible maternal healthcare services, are vital to reducing the incidence of these devastating conditions. Continued documentation and outcome-based studies are essential for refining management protocols and improving the quality of life for affected women.

Limitations

This study was limited by its single-centre design and relatively small sample size. The follow-up period varied among patients, potentially affecting long-term outcome assessment. Additionally, the absence of urodynamic evaluation limited detailed analysis of postoperative bladder function.

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