Urogenital fistula (UGF) can arise under various circumstances, and its incidence is influenced by the level of medical development across different countries. The treatment of women with fistulas involves surgical intervention aimed at closing the fistula and restoring urinary continence, employing different techniques based on individual cases
[1]
. In situations where fistula closure is unfeasible due to repeated interventions or damage caused by obstructed labor or trauma, urinary diversion remains the final option
[2]
. Managing fistulas necessitates a multidisciplinary approach, integrating medical, surgical, and psychological treatments. Specific objectives of this study include: Determining the prevalence of UGF at Cheikh Zayed Hospital, Describing the clinical characteristics, Cataloging the surgical techniques employed, Assessing the treatment outcomes. This study was carried out at Cheikh Zayed Hospital in Nouakchott. Inclusion criteria encompassed all women who underwent surgery for isolated or non-isolated urogenital fistula, documented from January 2020 to December 2022. Exclusion criteria included cases with incomplete records. This retrospective, descriptive study evaluates the comprehensive management of urogenital fistula. The study population consisted of women who underwent surgery for urogenital fistula between January 1, 2020, and December 31, 2023. Data were collected using a pre-established data sheet (Appendix). The parameters examined included: epidemiological data and medical history; clinical data; therapeutic and outcome data; and social reintegration data. Data entry and analysis were performed using Excel 2016 and SPSS software.
2. Results
Frequency of Urogenital Fistulas (FUG): Over a span of three years, we documented 182 cases of urogenital fistulas, representing 6.01% of the total 3025 surgical procedures performed in the urology department at CHZ. Age of Fistula Occurrence: The mean age of the patients was 30 years, with the youngest and oldest patients being 17 and 45 years old, respectively. The most frequently affected age group was 31 to 35 years, accounting for 33.52% of the cases, equivalent to 61 women (
Figure 1
).
Figure 1. Distribution of patients by age group.
Primiparas are 65.93% of women, which is 120 women; 17.58% are few parities; 9.90% are multiparas and grand multiparas in 6.59% of cases (
Table 1
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 1. Distribution of patients by parity.
Parity
Frequency
Percentage
Primiparous
120
65.93%
Pauciparous
32
17.58%
Multiparous
18
9.90%
Grand multiparous
12
6.59%
Total
182
100%
In our series, 90% of patients were uneducated, 164 women; 6.59% at primary level and only 3.29% at secondary level (
Figure 2
).
Figure 2. Distribution according to the level of education.
The average duration of carrying the fistula before treatment was 2 years with extremes of 5 months to 6 years (
Table 2
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 2. Distribution of patients according to the age of the fistula in years.
Age of the fistula
Frequency
Percentage
≤1
28
15%
1 - 3
135
75%
4 - 6
19
10%
Total
182
100%
The most common recruitment method was through healthcare personnel, accounting for 53.85%, or 98 women, followed by health facilities at 17.58%; the patients themselves in 10.44% of cases; former patients in 8.24% of cases; and other recruitment methods in 9.89% of cases (
Table 3
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 3. Methods of patient recruitment.
Méthods of recruitment
Frequency
Percentage
Health worker
98
53.85%
Health facility
32
17.58%
Former patient
15
8.24%
Patient herself
19
10.44%
Others
18
9.89%
Total
182
100%
Patients from rural areas are 90%, there are 164 women; the most affected areas are respectively (Hodh Ech Chargui, Hodh Elgharbi, Gorgol, Assaba, Guidimaka…); 10 from urban areas (Nouadhibou and Nouakchott) (
Figure 3
).
Figure 3. Distribution of patient by geographic origin.
Complementary test was performed for 19.78% of the patients for detecting complications or associated pathologies (
Table 4
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 4. Distribution according to complementary examinations.
Examination
Frequency
Percentage
Cystoscopy
8
4.39%
Ultrasound
25
13.74%
IVP
3
1.65%
No examination
146
80.22%
Total
182
100%
Obstetric causes were the most common with a percentage of 78%, or 142 cases; followed by iatrogenic causes in 20% of cases and traumatic causes in 2% of cases (
Figure 4
).
Figure 4. Distribution according to the etiology of the fistula.
Simple fistula were at 90% of the fistulas; 8% were intermediate and complicated forms in 2% of cases.
Associated pathologies obseved at 20.34%, or 37 patients, presented with a perineal tear; 6.05% presented with a meatal dilation; 4.39% had bladder stones, and 1.09% had vaginal stenosis (
Table 5
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 5. Distribution according to associated pathologies.
Pathology
Frequency
Percentage
Perineal tear
37
20.34%
Urethral meatus gaping
11
6.05%
Bladder stone
8
4.39%
Vaginal stenosis
2
1.09%
No associated pathology
124
68.13%
Total
182
100%
Spinal anesthesia was at 98% of our patients, which is 178 women, and 2%, or 4 patients, received general anesthesia. Surgical approach: the most commonly practiced surgical approach was the low route in 90.10% of cases; the high route in 6.05% of cases, and the mixed route in 3.85% of cases.
The most commonly performed surgical procedure was fistulorraphy, with a percentage of 70.33%, which is 128 patients (
Table 6
).
The average length of hospitalization was 15 days with extremes of 10 to 21 days.
After the surgical intervention, the fistula was closed in 77% of our patients, or 140 women. 12% of our patients experienced urinary incontinence, which amounts to 22 women, and we observed therapeutic failure in 20 cases, or 11% (
Figure 5
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 6. Distribution according to technical procedures.
Technical procedures
Frequency
Percentage
Partial or total cervico-urethral anastomosis
15
8.24%
Fistulorraphy + cervico-urethral anastomosis
4
2.20%
Fistulorraphy
128
70.33%
Uretroplasty
35
19.23%
Total
182
100%
The cost of caring for a single patient with a FUG is at least 16,000 MRU or $420 (
Table 7
).
<xref ref-type="bibr" rid="scirp.143702-"></xref>Table 7. The cost of care.
Type
Cost MRU
Cost $
Preoperative assessement
1500 MRU
$40
Surgical procedure and hospitalization
8000 MRU
$210
Transport and accommodation
6500 MRU
$170
Total
16,000 MRU
$420
Figure 5. Distribution of patients according to treatment outcome at discharge.
3. Discussion: Frequency of Urogenital Fistulas (UGFs)
We collected 182 cases of urogenital fistulas (UGFs) over a 3-year period, out of a total of 3030 surgical procedures performed in the Urology Department at CHZ. This represents 6% of the department’s surgical activity. Notably, this frequency is comparable to findings by Traoré M.
[3]
and Dalenda C.
[1]
, who reported rates of 9.1% and 7%, respectively.
The mean age of our patients was 30 years, with an age range of 17 to 45 years. The most affected age group in our series was 31 - 35 years, accounting for 33.52% (61 women). In contrast, in sub-Saharan Africa, UGFs tend to occur more frequently among younger women—Traoré M.
[3]
reported a mean age of 19 years.
Parity among UGF patients is interpreted differently across studies. In our series, primiparous and pauciparous women represented 65.93% and 17.58% respectively, while multiparous women accounted for only 9.90%. This predominance of primiparous and pauciparous women aligns with several studies in the literature. For instance, Sanda G.
[4]
[5]
in Niger and Zoung-Kanyi J.
[6]
in Cameroon reported primiparity rates of 79% and 86.51%, respectively. These findings suggest that primiparity may be one of the “profiles” of UGF patients in African settings.
Contrary to these findings, other studies report a higher proportion of multiparous women. Moudouni S.
[7]
in Morocco and Akodjenou E.
[8]
challenge the notion that primiparity is a predisposing factor for UGF. In such cases, the high rate of multiparity may be explained by the occurrence of progressive dystocia. Our study suggests that regardless of parity, any woman of reproductive age experiencing dystocic pregnancy without qualified obstetric care is at risk of developing a UGF
[8]
.
In our study, 90% of patients were from rural areas, compared to only 10% from urban or semi-urban settings. This distribution aligns well with the existing literature. Rural women—isolated from health centers and lacking transport or emergency evacuation options—often give birth without obstetric assistance, making them particularly vulnerable to complications like UGF. Similar findings were reported by Falandry L. and Gueye S.M.
[9]
[10]
, who found 90% and 75% of their patients, respectively, originated from rural areas.
3.1. Socioeconomic and Educational Level
The majority of our patients (95%) had a low socioeconomic status and 90% had no formal education. One major barrier to their care in our facility was financial inaccessibility. Educational level, an indirect reflection of occupation and socioeconomic status, further explains the challenges these patients face in managing their healthcare expenses. This observation is echoed by other African authors.
In Mali, Ouattara K.
[11]
found that most UGF patients were from low-income backgrounds. In southeastern Nigeria, Hilton P.
[12]
reported an illiteracy rate of 71% among UGF patients. Similarly, Wassatu E.
[13]
in Burkina Faso noted in 2009 that around 80% of her patients came from economically disadvantaged groups. According to Dekou A.
[14]
, low socioeconomic and educational levels are defining characteristics of UGF patients in our context. Therefore, improving socioeconomic conditions and raising educational levels could be key strategies in preventing this condition
[15]
.
3.2. Social Impact
UGF often results in social exclusion. In our sample, 27% of women (50 patients) were divorced. According to Soumano A.
[16]
and Harouna YD
[17]
in Niger, 51.92% and 61.6% of patients, respectively, were no longer sexually active. In our series, the most frequent mode of patient recruitment was through healthcare personnel, accounting for 53.85% (98 women), which is comparable to the findings of Dalenda C.
[1]
and Traoré M.
[3]
, who reported recruitment rates of 40% and 51%, respectively.
3.3. Clinical Presentation and Diagnosis
Urinary leakage—with or without preserved micturition—was the primary symptom in 95% of cases in our study. This finding is consistent with previous reports. For example, Lugagne PM
[18]
in France found that urinary leakage is almost always the primary presenting symptom of UGF. Similarly, Sanda G.
[5]
in Niger and Traoré M.
[3]
in Bamako reported urinary leakage as the presenting symptom in all cases.
A thorough physical examination led to a UGF diagnosis in 80.22% of our patients. This is consistent with data from Traoré M. (78%)
[3]
, Dalenda C. (83%)
[1]
, and Gueye S.M. (75%)
[9]
. Complementary tests were necessary in 19.78% of our cases—this rate was 10% in the Democratic Republic of Congo in 2005
[19]
. These tests were used to confirm the diagnosis and assess the impact of the condition on the rest of the urogenital tract.
3.4. Fistula Characteristics and Associated Lesions
In our series, 90% of UGFs were simple, 8% were of intermediate complexity, and 2% were classified as complicated. These findings align with the existing literature
[3]
. Associated lesions in our patients included perineal tears (37 cases), urethral meatus laxity (11 cases), bladder stones (8 cases), and vaginal stenosis (2 cases), totaling 20.34% of associated lesions. This is higher than the 11% reported by Benchekroun A.
[20]
.
3.5. Etiology
Obstetric causes predominated in our series, accounting for 78% of UGF cases—whether from pure obstetric causes, cesarean section, or instrumental extraction maneuvers. Only 20% were iatrogenic, and 2% were traumatic. This distribution is similar to that reported by most African authors. For instance, Gueye S.M.
[9]
in Senegal and Falandry L.
[10]
in Niger reported obstetric causes in 96% and 93% of cases, respectively. Some authors even found exclusive obstetric etiology—Ouattara K.
[11]
in Mali and Guirassy S.
[21]
in Guinea both reported 100% obstetric origins.
This predominance of obstetric causes in our series likely reflects the frequency of unsupervised pregnancies complicated by dystocia, often occurring outside healthcare settings and without qualified assistance. It also highlights the rural residency of most patients, who live in remote, isolated areas with poor road infrastructure, making emergency evacuations for dystocia difficult or delayed.
3.6. Anesthesia and Surgical Approach
Spinal anesthesia was the most commonly used technique in our series (98%), compared to 2% for general anesthesia. Dieng A.
[22]
reported similar findings with 98.7% spinal anesthesia and 1.3% general anesthesia.
The surgical approach to UGF is not uniform. It can be transvaginal (low), transabdominal (high), or mixed. In our series, 90.10% of fistulas were approached vaginally, 6.05% abdominally, and 3.85% using a mixed route.
[23]
The vaginal approach is generally preferred, as most fistulas can be treated through this route, except for some high fistulas. Most authors also favor the vaginal approach
[2]
[11]
[24]
. It offers good operative comfort, direct access to cervical and urethral lesions, and lower vital risks, particularly where aseptic conditions are suboptimal. However, it does not always allow visualization of the ureters, except in large fistulas with significant tissue loss
[25]
.
3.7. Surgical Techniques and Outcomes
The most commonly used surgical technique was fistulorrhaphy using the Chassar-Moir method (70.33% of cases), followed by urethroplasty (19.23%) and vesico-cervico-urethral anastomosis (partial or complete) in 8.24% of cases. These results are consistent with literature data
[1]
[7]
[12]
[15]
.
Postoperative hospitalization lasted between 15 and 30 days in 86% of patients, and between 6 and 15 days in 14% of cases. These findings are close to those reported by Soumano A. in Mali
[16]
, who found hospital stays of 15 - 20 days in 74% of cases.
3.8. Fistula Closure Rate
Our study showed a fistula closure rate of 89%, with 77% of fistulas completely closed and dry, and 12% closed with sphincter dysfunction. We observed an 11% failure rate. From 1993 to 2007, the surgical team in Mopti reported a closure rate of 86.08%
[22]
. Dieng A.
[22]
reported a 76.33% success rate at Pt. G, Coulibaly M.
[24]
in Ségou reported 65.7%, Berthe H.
[25]
reported 68.75%, and Diagne A. in Senegal
[26]
reported 86%.
4. Conclusion
Urogenital fistulas, especially obstetric fistulas, represent a significant public health issue. While nearly absent in developed nations, these fistulas remain one of the least addressed health concerns in our sub-region. Women afflicted with fistulas often face severe social exclusion, including abandonment, divorce, and exclusion from cultural and religious activities. Efforts to eradicate this condition should focus on improving socioeconomic living conditions in our regions, providing ongoing training for medical personnel, and raising awareness about the importance of prenatal care. The primary symptom, persistent urinary leakage through the vagina, may occur alone or alongside other clinical symptoms. Diagnosis is confirmed through clinical examination, which also facilitates lesion assessment, further refined by additional investigations to evaluate the impact on the upper urinary tract and identify other associated lesions. The most common surgical intervention is via the lower approach, typically involving simple repair through fistuloraphy.
Appendix
Annexes Aspects Epidemio-Cliniques et Therapeutiques Des Fistules Urogenitales Feminines Annexes 33
Fiche d’enquête 1—Numéro du téléphone; 2—Nom et Prénom; 3—Age: sexe; 4—Statut matrimonial:
Mariée Célibataire Divorcé Veuve;
5—Parité; 6—zone de résidence; 7—Niveau d’instruction:
Primaire Secondaire Supérieur Coranique;
8—Profession; 9—Etiologie de la fistule:
Obstétricale Iatrogène Traumatique;
10—Rang de la grossesse causale; 11—Duree du travail de l’accouchement causal (en heure); 12—Lieu et Mode d’accouchement de la grossesse causale:
Domicile Centre de santé
Aspects Epidemio-Cliniques et Therapeutiques Des Fistules Urogenitales Femi-nines Annexes 34
13—voie d’accouchement:
Spontané Instrumental Césarienne;
14—Age de la fistule (en année); 15—Date de la1ere consultation; 16—Méthode de recrutement:
Personnel de santé Centre de santé Media Ancienne patiente;
17—Type de fuite:
Urinaire Fécale Les deux;
18—Déjà opérée par le passé pour fistule?
OUI NON;
19—Motif de consultation; 20—Examen sous valve; 21—Examen complémentaire; 22—Diagnostic et classification de la fistule; 23—Date de l’intervention; 24—Type d’anesthésie
Aspects Epidemio-Cliniques et Therapeutiques Des Fistules Urogenitales Feminines Annexes 3.
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