Introduction Women with vesicovaginal fistulas often experience a disruption in their normal lives, including sexual relationships, because of urinary incontinence. Aim Although surgery repairs the urinary leakage, it is not known how surgery might affect sexual function positively or negatively. Methods 119 women were enrolled before surgery and interviewed including a revised Female Sexual Distress Scale (FSDS-R) score and examined for vaginal length, caliber, and pelvic floor strength. Main Outcome Measures Approximately one third of women return to normal sexual function after repair, although a minority experience de novo dysfunction. Results 115 women completed follow-up 6 to 12 months after surgery. Approximately one third (35.6%, n = 41) stated that intercourse had returned to the way it was before a fistula. Forty-four women (40%) report sexual problems after the fistula developed; 15% due to incontinence and 23.5% due to pain. Fourteen women (12.2%) stated that they experienced problems with intercourse since surgery; 50% due to incontinence during intercourse and 50% due to pain. Nineteen of the participants (16.5%) scored in the range of dysfunction as assessed by the FSDS-R tool after surgery. Fibrosis did not significantly change and was not found to be associated with sexual function. Vaginal length was found to decrease on average by 5 mm. Of the variables examined, the factors statistically significantly associated with dysfunction included a larger-size fistula as determined by the Goh classification (> 3 cm diameter) and decreased vaginal caliber. FSDS-R scores drastically decreased from before to after surgery and the reason for problems with intercourse changed from leaking urine before surgery to lack of partner and concern for HIV infection. Clinical Implications Women with large fistulas and decreased vaginal calibers are at high risk for sexual dysfunction and should be counseled appropriately preoperatively and offered surgical and medical interventions. Strengths & Limitations Physical parameters were combined with qualitative interviews and FSDS-R scores to contextualize sexual health before and after surgery. Limitation is the brief follow-up of 6-12 months after surgery as many women were still abstaining from sexual activity. Conclusion Sexual dysfunction is a complex issue for women with obstetric fistulas; although many women do not continue to experience problems, several need ongoing counseling and treatment.

Objective: To identify criteria to guide surgeons regarding indications for use of the Singapore and gracilis muscle flaps in obstetric fistula repair. Methods: This is a retrospective case series. Obstetric fistula surgeons in Lilongwe, Malawi, have been incorporating plastic surgery techniques with the Singapore and gracilis muscle flaps since collaborating with plastic surgeons in 2016. We describe the surgical outcomes of procedures utilizing each flap individually and those using both. Results: Between February 2016 and June 2019, 69 patients received a flap at the time of obstetric fistula repair at the Fistula Care Center in Lilongwe, Malawi. A total of 32 (46.4%) received a Singapore flap, 20 (29.0%) received a gracilis flap, and 17 (24.6%) received both types of flap.Conclusion: Based on our outcomes, we note the possible advantage of incorporating the gracilis flap even when it is thought that the Singapore flap is sufficient. However, more data are needed. K E Y W O R D S

The gracilis muscle flap as vascularized healthy tissue gives patients with otherwise irreparable obstetric fistulas another option before urinary diversion as 95% are healed.

Obstetric fistula is a condition that continues to mar the quality of the lives of approximately 2 million women worldwide. 1 The United Nations has issued a call to end obstetric fistula by 2030. Currently, only a fraction of women who need surgical repair receive it and there is little follow up on surgical outcomes. 2 It is of utmost importance to train more high-quality surgeons, as the first attempted repair is the best chance at lasting success.One of the most difficult aspects of surgical training is identifying which cases are appropriate for what level of expertise. Bengtson et al. 3 looked for prediction of incontinence after surgery using Goh's classification. Using a scoring algorithm based on clinical and demographic characteristics, they found age over 50 years, length of time with a fistula more than 20 years, previous surgical attempts, advanced Goh classification relative to the urethra, moderate to severe scarring, circumferential fistula, and urethral length of 1.5 cm or less were all highly predictive of residual incontinence within 120 days of surgery. The authors found that a risk score of 20 or more had a sensitivity of 82% and specificity of 63% in predicting residual incontinence. The positive predictive value for this cut-point was 43% and negative predictive value was 91%, meaning that the risk score

ObjectiveTo describe and compare baseline renal anatomy and renal function in patients with obstetric fistulas, and to evaluate whether preoperative renal testing and imaging may aid with operative decision making.DesignA prospective cohort study.SettingFistula Care Centre in Malawi.PopulationWomen with an obstetric fistula.MethodsBaseline creatinine testing and renal ultrasounds were performed. Surgeons completed a short questionnaire on the usefulness of creatinine and renal ultrasound on operative decision making.Main outcome measuresBaseline creatinine and renal ultrasound findings.ResultsFour surgeons performed operations on 85 patients. The mean creatinine in patients with vesicovaginal fistulas (VVF) was 0.60 ng/ml versus patients with uretero‐vaginal fistulas (UVF) (0.79 ng/ml, P = 0.012). When a grade 3 or more hydronephrosis is absent on renal ultrasound, the negative predictive value of the presence of UVF is 93.3% (95% confidence interval [CI] 88.6–96.2) with a specificity of 97.2% (95% CI 90.3–99.6). In cases of UVF, surgeons found the renal ultrasound results useful or very useful 87.5% of the time, and the creatinine useful or very useful 75% of the time.ConclusionIn this pilot study, most patients with obstetric fistulas presented with a normal creatinine. In the absence of a grade 3 hydronephrosis or above on renal ultrasound, the probability of not having a UVF is 93.3%. Surgeons should consider performing preoperative renal ultrasound testing in all patients with an obstetric fistula, particularly in women with a prior laparotomy, as this population has risk factors for ureterovaginal fistula.Tweetable abstractMost patients with obstetric fistulas have normal renal function. Preoperative renal ultrasounds should be performed.