The World Health Organization (WHO) has listed findings associated with difficulty in repairing an obstetric fistula. A woman who is at risk for a difficult repair should be referred to a specialist for management.
Features of an obstetric fistula associated with difficult repair:
(1) multiple fistulas
(2) any rectovaginal component
(3) involvement of the cervix
(4) diameter > 4 cm
(5) involvement of the urethra and/or urethral sphincter
(6) presence of a circumferential defect (complete separation of the urethra from the bladder)
(7) scarring of vaginal tissue
(8) extensive tissue loss
(9) ureters draining into the vagina with or without bladder stones
(10) previous attempts at repair that have failed
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