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A systematic review and meta-analysis of urinary incontinence following successful obstetric fistula repair: findings from five countries in sub-Saharan Africa

BMC Women's Health volume 25, Article number: 165 (2025) Cite this article

Abstract

Background

Obstetric vesico-vaginal fistula is a known complication that can occur following damage to the bladder wall during prolonged obstructed labor and operative delivery. Urinary incontinence following the repair of obstetric fistula remains a significant health problem and can greatly damage a women’s ability to function confidently. There are approximately two million women suffering from urinary incontinence following obstetric fistula repair, most of whom are primarily in Africa.

Objective

We aimed to systematically review and conduct meta-analysis on the magnitude of urinary incontinence among women following successful obstetric fistula repair in sub-Saharan African countries.

Methods

We thoroughly searched online database including Medline, Scopus, Science Direct, Excerpta Medica Database, African Journals Online and Google Scholar for eligible articles from their inception to November 10, 2024. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 checklist. To generate pooled prevalence of urinary incontinence, we used random-effects model. The presence of publication bias was determined using a funnel plot and Egger’s regression test.

Results

Out of 1044 articles found following our initial search and after titles and abstracts review, we considered 277 full text articles for inclusion. Lastly, a total of 12 articles from five sub-Saharan African countries comprising 6,104 participants met the inclusion criteria for quantitative meta-analysis. The pooled prevalence of urinary incontinence following obstetric fistula repair was 16.32% (95%CI: 11.80, 20.84; I2 = 96.5%, P < 0.001).

Conclusion and implications

Overall, our findings show post-fistula repair incontinence remains an important clinical problem. Therefore, we believe that policy planners and researchers of sub-Saharan African nations may use the findings of the current study for evidence based care planning and patient counseling strategy.

Registration

Registered in PROSPERO under protocol number CRD42023416541.

Peer Review reports

Background

Obstetric vesico-vaginal fistula (VVF) is a known complication that can occur following damage to the bladder wall during prolonged obstructed labor and operative delivery [1, 2]. In 2003, the United Nations Population Fund (UNFPA) and partners launched the global campaign to end obstetric fistula; a vision that aligns with the timeline to achieve the 2030 agenda for Sustainable Development Goal 3 of improving maternal health [3]. Significant progress has been made in the effort to end fistula. Nevertheless, according to the World Health Organization (WHO) 2018 report, an estimated two million women live with untreated obstetric fistula in resource-poor countries [4,5,6,7]. Yearly, an estimated 50,000 to 100,000 women globally are affected by obstetric fistula [7]. Women with obstetric fistulas often experience distressing conditions, including significant psychosocial impacts [8, 9]. Obstetric fistulas are completely preventable through the provision of adequate and timely obstetric care; however, the condition continues to be a significant cause of morbidity worldwide [1, 2]. In sub-Saharan Africa (SSA), the lifetime prevalence of obstetric fistula is as high as three per 1,000 reproductive-age women [10].

Surgery is a common approach to treat women with obstetric fistula [11]; yet, once a fistula has developed, surgical correction is challenging to achieve. A study reported that regardless of the skills of the surgeon, approximately 25-35% of repaired cases can fail [11]. Surgical management of obstetric fistula includes fistula closure through transabdominal, transvaginal and advanced techniques, such as robotic or laparoscopic surgical repair [12]. Treatment outcomes vary. The three possible outcomes for women who undergo obstetric fistula repair surgeries are: (i) Closed fistula and continents (closed and dry), (ii) failed fistula closure (failed repair), and (iii) persistent incontinence after successful fistula closure (closed but wet) [13, 14]. Urinary incontinence following the closure of vesicovaginal fistula was characterized as any involuntary urine leakage from the vagina that a patient reported after a successful repair of an obstetric VVF repair [15, 16].

Although timely surgical repair of VVF is largely successful in more than 90 to 95% of cases, as evidence suggests, a substantial number of women continue to report persistent urinary incontinence following the repair [1, 13, 17,18,19]. Spontaneous healing occurs in 15% of cases with primary conservative treatment, which involves drainage using a urinary catheter [20]. Urinary incontinence following the repair of obstetric fistula remains a significant health problem and can greatly damage a women’s ability to function confidently. The condition remains a significant cause of female urinary incontinence worldwide [4, 17, 21]. Supporting this, a study by Goh JT et al. [1] reported that approximately one in four women experience significant urinary symptoms following obstetric fistula repair. Evidence also indicates that post-surgery UI can lead to painful thigh lesions caused by urine acidity, as well as issues such as infection, stigmatization, divorce, prolonged emotional trauma, social withdrawal, and neurological sequelae. These factors, in turn, can significantly alter a woman’s overall well-being and quality of life [18, 19, 22]. The few studies that focused on UI after successful reconstructive surgery found that 8 to 16% of patient reported development of UI [4]. Another study reported the estimated prevalence of post-fistula repair UI to be 7 to 40% [17].

To date, little has been written about the prevalence of urinary incontinence rate, and there are currently no comprehensive data available on the magnitude of this problem following the repair of obstetric fistula in sub-Saharan Africa. Therefore, the aim of this work was to determine the pooled magnitude of urinary incontinence following successful repair of obstetric fistula in sub- Saharan Africa through conducting a systematic review and meta-analysis.

Methods

Study design and reporting

A systematic review and meta-analysis of observational studies was conducted on urinary incontinence among women who underwent obstetric urogenital fistula repair in sub-Saharan Africa. All studies on urinary incontinence among women who underwent obstetric urogenital fistula repair in sub-Saharan Africa, published up to November 10, 2024 were retrieved following the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2020 guideline [23]. We used PRISMA-P flow diagram to illustrate article screening and selection process. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42023416541.

Search strategies

To identify all relevant observational studies on urinary incontinence among women who underwent obstetric urogenital fistula repair in sub-Saharan Africa, we conducted a systematic review and a comprehensive search in the electronic databases of Medline, Scopus, Science Direct, Excerpta Medica Database, African Journals Online and Google Scholar. Additionally, cross-referencing, or so-called pearl growing, was used to retrieve additional studies that were missed in the initial search or relevant studies that had not been captured via the database searches. All relevant articles were searched from the earliest available date to November 10, 2024. Both unpublished and published studies were sought. English language restrictions were applied. The search was carried out using the following key words: ‟magnitude”, ‟prevalence”, ‟urinary incontinence”, ‟fistula repair”, ‟vesicovaginal fistula”, ‟ureterovaginal fistula”, ‟obstetric fistula”, ‟urinary fistula”, ‟rectovaginal fistula”, ‟urogenital fistula”, ‟fistula closure”, ‟post-fistula repair”, ‟surgical repair”, ‟surgical closure”, ‟Africa”, ‟sub-Saharan Africa”. The following search strategies were developed using MeSH (Medical Subject Headings) terms and Boolean operators to search Medline database:

(((((magnitude) OR (proportion)) OR (prevalence[MeSH Terms])) AND (((urinary[MeSH Terms]) OR (incontinence)) OR (urinary incontinence[MeSH Terms]))) AND (((((((Vesico- vaginal fistula[MeSH Terms]) OR (Vesicovaginal fistula[MeSH Terms])) OR (Uretero-vaginal fistula[MeSH Terms])) OR (Ureterovaginal fistula[MeSH Terms])) OR (Obstetric fistula[MeSH Terms])) OR (Urogenital[MeSH Terms])) OR (urogenital fistula[MeSH Terms]))) AND ((((((Burkina Faso) OR (Democratic Republic of the Congo)) OR (Ethiopia)) OR (Guinea)) OR (Malawi)) OR (sub-Saharan Africa)).

Eligibility criteria

We used the PICOS model to determine the eligibility criteria: Population (studies conducted on women who underwent obstetric fistula repair), Content of the study (this study included articles that reported on obstetric fistula successful repair), Comparison (not applicable), Outcome (studies reporting the magnitude of urinary incontinence), and Study design (original human observational studies, including case-control, cross-sectional or cohort studies).

Original studies reporting the prevalence of urinary incontinence in women who underwent urogenital fistula repair were included. Specifically, we included studies in the analysis based on the following criteria: [1] Study type: observational studies that provided sufficient data on the magnitude of urinary incontinence after successful fistula repair; [2] Study period: studies published until November 10, 2024; [3] Population: studies conducted on women who underwent successful obstetric fistula repair; [4] Place of the study: studies conducted in sub-Saharan Africa; [5] Study publication status: both published and unpublished studies. Exclusion criteria were as follows: Conference papers, abstracts, letters to editors, case series and case reports, studies with no appropriate outcome measures, non-original full-text articles, articles sharing the same data set, and review articles. Articles had to be published in English.

Outcome of interest

The primary outcome of this study was to determine the pooled prevalence of urinary incontinence following obstetric fistula successful repair from studies conducted across sub-Saharan Africa.

Study selection and extraction

To remove duplicates, retrieved articles from different database were exported to EndNote (V.20, for Windows, Thomson Reuters, Philadelphia, and Pennsylvania) reference manager. We used a Microsoft Excel spreadsheet to extract data from each study. All relevant data were extracted, including: [1] Author name; [2] Year of publication; [3] Study design; [4] Sample size; [5] Sampling procedure; [6] Cases (magnitude) of urinary incontinence among women who underwent successful obstetric fistula repair. Two authors (GAA and SSK) did a search for all relevant published quantitative studies that reported the magnitude of urinary incontinence in women who underwent urogenital fistula repair. Teams of three independent reviewers (GAA, TGT and SSK) screened titles and abstracts, then full texts of articles that were judged to be relevant. Disagreements during data extraction were resolved through group consensus. Figure 1 illustrates the procedure for conducting the literature search.

Fig. 1
figure 1

PRISMA flow diagram of the selection process of studies on urinary incontinence following obstetric fistula repair

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Quality assessment

Two authors (GAA and SSK) independently assessed the quality of the included studies using the Newcastle-Ottawa quality assessment checklist, which was developed as a quality appraisal tool for systematic reviews of observational studies. The following parameters were included in the appraisal checklist [24]: (i) inclusion criteria, (ii) description of study subjects and setting, (iii) valid and reliable measurement of exposure, (iv) objective and standard criteria used, (v) identification of confounders, (vi) strategies to handle confounders, (vii) outcome measurement, and (viii) appropriate statistical analysis. Two authors (GAA and SSK) conducted data extraction using a standardized data extraction checklist in Microsoft Excel. Disagreements were resolved by consensus. Supplementary file 2 presents details of the quality assessment.

Statistical analysis

We used I2 statistics to investigate heterogeneity between studies; which estimates the overall percentage of variation across individual studies due to true differences between studies rather than chance. I2 values of 25%, 50%, and 75% represent low, medium and high heterogeneity, respectively. Subgroup analysis was used to investigate the origins of heterogeneity. We also conducted a leave-one-out sensitivity analysis; one study was excluded each time to assess that study’s impact on the pooled prevalence. The objective use of Egger’s and Begg’s Rank test and visual inspection of funnel plot were used to determine publication bias. To adjust for potential publication bias, Trim and fill analysis was performed. A P-value of less than 0.05 was considered statically significant. All analysis was conducted using Stata statistical software (V.15, StataCorp LP, College Station, TX, USA). Data were pooled using random-effects model.

Results

In our initial and updated search, we retrieved a total of 1044 articles from electronic database and research networks. After removal of duplicates and review of titles and abstracts, 133 articles remained. After reviewing their title and abstracts, 121 studies were excluded in the subsequent detailed assessment. Finally, 12 articles with 6,104 study participants met the inclusion criteria and included in the meta-analysis (Fig. 1).

Characteristics of included studies

Articles included in the current systematic review and meta-analysis had been conducted in five different sub-Saharan African countries. Overall, four studies were conducted in Ethiopia [15, 25,26,27], three studies in Malawi [10, 28, 29], two studies in Guinea [16, 30], two studies in Democratic Republic of Congo [18, 31], and one study from Burkina Faso [32]. Five publications [15, 25,26,27, 32] were cross-sectional in design and seven [10, 16, 18, 28,29,30,31] were retrospective cohort studies. We excluded one article that reported duplicate data from an included study [14]. Characteristics of the studies included in the meta-analysis are reported in Table 1.

Table 1 Baseline characteristics of included studies for the prevalence of urinary incontinence among women with obstetric fistula repair in sub-Saharan Africa, 2024
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Prevalence of urinary incontinence following obstetric fistula repair

The pooled prevalence of urinary incontinence following obstetric fistula repair in sub-Saharan African nations was 16.32% (11.80, 20.84) (Fig. 2).

Fig. 2
figure 2

Forest plot of the pooled prevalence of urinary incontinence among women who underwent obstetric fistula repair in sub-Saharan Africa (ES: Effect Size)

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Subgroup analysis

Due to the observed very high statistical heterogeneity (I2 statistics = 96.3%, and P < 0.001), we conducted subgroup meta-analysis to explore the source of statistical heterogeneity. We grouped studies based on country, and based on our findings, the highest pooled prevalence of urinary incontinence among women who underwent obstetric fistula repair was from Malawi 19.91 (16.66, 23.15) while the lowest prevalence was obtained from Democratic Republic of Congo (Fig. 3).

Fig. 3
figure 3

Subgroup analysis of urinary incontinence among women who underwent successful obstetric fistula repair in sub-Saharan Africa, 2024 (ES: Effect Size)

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Sensitivity analysis

The results of sensitivity analysis showed that the omission of each study did not affect the overall outcome and that the overall results were not influenced by a specific study (Fig. 4).

Fig. 4
figure 4

Sensitivity analysis of urinary incontinence among women who underwent urogenital fistula repair in sub-Saharan Africa, 2024 (s.e: Standard Error)

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Publication bias

To evaluate the presence of publication bias, Funnel plot and Egger and Begg rank statistical test at a 5% significance level were used. As shown in Fig. 5, the funnel plot shows asymmetry for pooled estimates (Fig. 5). However, the objective assessment of publication bias, the Egger’s and Begg rank test, shows no evidence of publication bias since both the Egger’s test and Begg’s rank test did not indicate statistically evidence (P = 0.1 and 0.33, respectively). Moreover, we employed the trim and fill method to assess publication bias. The result shows the absence of six potential studies; however, after the inclusion of six virtual studies, the result remained unaffected (Fig. 6).

Fig. 5
figure 5

Funnel plot for publication bias for systematic review and meta-analysis of urinary incontinence among women who underwent successful obstetric fistula repair in sub-Saharan Africa, 2024 (s.e: Standard Error)

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Fig. 6
figure 6

Trim and fill analysis of publication bias in studies reporting prevalence of urinary incontinence following successful obstetric fistula repair in sub-Saharan African countries. The vertical axis displays theta (filled) while the horizontal axis shows the effect size‟s standard error. A dotted diagonal line represents the 95% confidence interval funnel, and a horizontal line indicates no effect. Small dotes denotes unreported articles while large dots represent missed publications documenting urinary incontinence in post-fistula repair

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Discussion

Obstetric fistula is a devastating childbirth injury caused by unrelieved, prolonged and obstructed labor. The condition has likely existed for as long as women have been giving birth [5, 6]. Surgical management of obstetric fistula has been proven to be effective management. Urinary incontinence after a successful closure of an obstetric vesico-vaginal fistula is poorly understood and is a source of frustration to patients and fistula surgeons [33]. Although surgical techniques consistently result in fistula closure rates of 80–95%, there has been no research conducted on the problem of persistent urinary incontinence after successful fistula closure [2]. With that in mind, our aim was to determine the magnitude of urinary incontinence following obstetric fistula closure in sub-Saharan African countries.

The magnitude of urinary incontinence following obstetric fistula repair varies widely in the literature. In our study, we found a magnitude of UI (16.3%, 95%CI: 11.80, 20.84) among women who underwent successful obstetric fistula repair in selected sub-Saharan African nations. Subgroup analysis shows the pooled prevalence rates by country. Accordingly, the prevalence of urinary incontinence among women following successful closure of obstetric fistula was 19.9%, 17.9%, 15.3%, 12.6% and 11.1% in Malawi, Ethiopia, Guinea, Burkina Faso and the DRC, respectively. Although once common in developed countries, including Western Europe and United States, obstetric fistula is virtually unknown in these regions today [2]. The observed differences in findings between our study and developed countries might be due to significant medical advances in those from developed countries, which may include the development of obstetrics and safer cesarean section deliveries [5].

Our finding is lower than study from a systematic review and meta-analysis that sought to ascertain the pooled prevalence of obstetric fistula repair failure across 13 sub-Saharan African countries, which reported an overall estimate of 25% [11]. This discrepancy may arise from the fact that the aforementioned study assessed obstetric fistula repair failure in broad context, whereas our study specifically focused on urinary incontinence as a distinct manifestation of obstetric fistula repair failure. On the other hand, our findings aligns with a systematic review and meta-analysis conducted in Africa [34], where the pooled estimated rate of successfully closed vesico-vaginal fistula but with ongoing or residual incontinence (wet) was revealed as 13.4%.

Implication for policy, clinical practice and research

This study highlights the important role of encouraging planned deliveries in health care facilities attended by skilled birth attendants to reduce obstetric complications, the most disabling of which is obstetric fistula. Additionally, the study underscores the critical importance of providing ongoing medical, surgical and rehabilitative care that obstetric fistula patients endure even after a successful fistula repair. As has been explained elsewhere [35], the care model for these specific cohorts need to encompass more than merely the surgical “closure of the hole” which is evident in most of resource-limited settings. In terms of future research implications, conducting a comprehensive study with a long-term follow-up of women who have undergone obstetric fistula repair would facilitate an accurate assessment of the prevalence of post-operative urinary incontinence. Additionally, further study is needed to explore the types and severity of urinary incontinence that may occur after successful closure of obstetric fistula.

Our findings are important for explaining to patients the nature of their injuries and in providing them pre-operative counseling on the risk of UI and on care planning with realistic expectations regarding the outcome of surgeries. Specialized skills and training is an important step forward in obstetric fistula care, especially to handle more complex cases. Improving patient education to deliver clear and understandable information regarding the condition and treatment options available is essential for achieving successful outcomes. Pelvic floor muscle training, with proper guidance and supervision, emerges as a primary management approach that demonstrates effectiveness in alleviating symptoms [36]. After the closure of fistula, stress UI repair can be done with either an autologous fascial sling or a synthetic mesh sling [37, 38].

Ministry of Health of the respective countries should provide the necessary facilities and could allocate resources towards research and development endeavors for diagnosing and managing urinary incontinence. To properly assess the post-surgical progress, healthcare providers should instruct women who underwent obstetric fistula repair for further long-term follow-up appointments. Although the success rate of obstetric fistula repair is high, yet the attempt should be focused on prevention [39]. Additionally, health related quality of life of women with postoperative urinary incontinence after a successful closure of an obstetric vesico- vaginal fistula should prospectively be assessed using validated questionnaire. Since our study did not seek to determine the cause of post-surgical repair urinary incontinence, future studies are required to assess urge, stress and/or residual incontinence.

To the best of our knowledge, the present systematic review and meta-analysis was the first to pool the findings of different primary studies reporting the prevalence of urinary incontinence among women who underwent urogenital fistula repair in sub-Saharan Africa. Although our study provides important insights, we acknowledge several limitations. One of the limitations was the small number of articles with inconsistent data preclude multivariable risk factor analysis. In addition, because of the high heterogeneity, findings of this study should be reported with caution. The use of non-validated questionnaire of included studies for assessing the magnitude of urinary incontinence following obstetric fistula repair has to be mentioned. The other limitation is that the current study did not investigate the severity and type of incontinence, including stress, urgency or overflow from incomplete bladder emptying limits our understanding of underlying causes and hindering targeted interventions. Moreover, only few studies have evaluated post-fistula repair magnitude of urinary incontinence and we were also limited by the lack of complete data on obstetric fistula repair outcome.

Conclusion

Overall, these results shows urinary incontinence after obstetric fistula repair remains an important clinical problem. Therefore, we believe that policy planners and researchers of sub- Saharan African nations may use the findings of the current study for evidence based care planning and patient counseling strategy to prevent or reduce the magnitude of post-fistula repair incontinence among birth injured women, by creating effective and efficient system of maternity health care. To fully understand the issue and ensure consistency and acceptance across various evaluations, it is essential to use standardized outcome measures for reliable objective and subjective assessment of women experiencing urinary incontinence.

Data availability

All relevant data are within the manuscript and its Supporting Information files.

Abbreviations

SSA:

sub-Saharan Africa

UI:

Urinary Incontinence

VVFs:

Vesico-vaginal Fistulas

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Acknowledgements

We acknowledge the authors of primary studies included in this review.

Funding

The authors declare that no financial support was received for this systematic review and meta- analysis research, authorship and/or publication of this study.

Author information

Authors and Affiliations

  1. Department of Midwifery, College of Medicine and Health Sciences, Hawassa University, Hawassa city, Sidama Region, Ethiopia

    Gedion Asnake Azeze, Sintayehu Solomon Kena, Tewodros Getachew Tsegaye & Yitateku Alelgn

  2. School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, P.O.Box: 138, Wolaita Sodo town, Southern Region, Ethiopia

    Kirubel Eshetu Haile

  3. School of Midwifery, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo Town, Ethiopia

    Natnael Atnafu Gebeyehu

  4. School of Public Health, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo Town, Ethiopia

    Amanuel Yosef Gebrekidan, Gizachew Ambaw Kassie & Yordanos Sisay Asgedom

Authors
  1. Gedion Asnake Azeze
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  2. Kirubel Eshetu Haile
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  3. Natnael Atnafu Gebeyehu
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  4. Sintayehu Solomon Kena
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  5. Tewodros Getachew Tsegaye
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  6. Amanuel Yosef Gebrekidan
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  7. Yitateku Alelgn
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  8. Gizachew Ambaw Kassie
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  9. Yordanos Sisay Asgedom
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Contributions

GAA: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. KEH, AYG, YA and GAK: Software, Supervision, Validation, Visualization, Formal analysis, Writing original draft, Writing – review & editing. TGT, SSK, NAG and YSA: Methodology, Software, Project administration, Visualization, Writing original draft, Writing – review & editing.

Corresponding author

Correspondence to Kirubel Eshetu Haile.

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Ethics approval and consent to participate was not necessary since the study was a systematic review and meta-analysis.

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The authors declare no competing interests.

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Azeze, G.A., Haile, K.E., Gebeyehu, N.A. et al. A systematic review and meta-analysis of urinary incontinence following successful obstetric fistula repair: findings from five countries in sub-Saharan Africa. BMC Women's Health 25, 165 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03701-7

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03701-7

Keywords

BMC Women's Health

ISSN: 1472-6874

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