Genital Fistula Research Articles

The increasing number of surgical procedures for female genital fistula in England: Analysis of Hospital Episode Statistics (HES) data

The aim of this study was to describe the number and trend of surgical procedures for female genital fistula in England. An online search of Hospital Episode Statistics (HES) data was carried out. Data were available for the 4-year period from 2002–03 until 2005–06. The total number of surgical procedures carried out for female genital fistula steadily increased by 28.7% from 616 in 2002–03 to 793 in 2005–06. The number of surgical procedures performed for rectovaginal fistula exceeded the total number of surgical procedures carried out for vesicovaginal and urethrovaginal fistula in each year of the study period. This pattern needs to be monitored and investigated further.

Clinical procedures and practices used in the perioperative treatment of female genital fistula during a prospective cohort study.

BackgroundTreatment and care for female genital fistula have become increasingly available over the last decade in countries across Africa and South Asia. Before the International Federation of Gynaecology and Obstetrics (FIGO) and partners published a global fistula training manual in 2011 there was no internationally recognized, standardized training curriculum, including perioperative care. The community of fistula care practitioners and advocates lacks data about the prevalence of various perioperative clinical procedures and practices and their potential programmatic implications are lacking.MethodsData presented here are from a prospective cohort study conducted between September 2007 and September 2010 at 11 fistula repair facilities supported by Fistula Care in five countries. Clinical procedures and practices used in the routine perioperative management of over 1300 women are described.ResultsMore than two dozen clinical procedures and practices were tabulated. Some of them were commonly used at all sites (e.g., vaginal route of repair, 95.3% of cases); others were rare (e.g., flaps/grafts, 3.4%) or varied widely depending on site (e.g. for women with urinary fistula, the inter-quartile range for median duration of post-repair bladder catheterization was 14 to 29 days).ConclusionsThese findings show a wide range of clinical procedures and practices with different program implications for safety, efficacy, and cost-effectiveness. The variability indicates the need for further research so as to strengthen the evidence base for fistula treatment in developing countries.

Mortality risk associated with surgical treatment of female genital fistula

ObjectiveTo describe the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors. MethodsIn a descriptive study, confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries between January 2005 and March 2013. Data collection included interviews with key personnel involved in the clinical management of the deceased, and a review of hospital records and patient files following an audit protocol. ResultsOverall, 26060 fistula repairs were performed at 44 sites located in 13 countries; 30 deaths were reported in this period. Twenty-one deaths were attributable to surgery, yielding a case fatality of 0.08 per 100 procedures. The cause of death in nearly half of the cases was various manifestations of sepsis and inflammation. ConclusionThe case fatality rate for fistula repair surgery in resource-poor countries was in the same range as that for comparable gynecologic operations in high-resource settings. Clinical and systemic issues to be addressed to reduce the case fatality rate include improvement of perioperative care and follow-up, assuring prudent referral or deferral of difficult cases, and maintaining better records.

P339 Surgical treatment of female genital fistula in Crohn's disease

tions, or recent use of anti-TNF agents) were included in this prospective, multicentre, IOIBD sponsored trial. Patients were randomized to systematic AZA initiated 2 weeks from surgery (SYS-AZA), or endoscopy-driven AZA (ED-AZA). Patients in the ED-AZA arm underwent ileocolonoscopy at 6 and 12 months, and AZA was initiated at a standard dose of 2.0 2.5mg/kg in case of endoscopic recurrence ( i2). The primary endpoint was the proportion of patients with endoscopic remission at 24 months, defined as a post-operative endoscopic recurrence score of i0 or i1. Secondary endpoints included the proportion of patients with i0, and the proportion of patients in clinical remission (CDAI <150) at 24 months. We estimated that 100 patients were required in each group to show superiority of SYS-AZA for the primary endpoint (power 80%, alpha 5%). Only patients in whom the primary endpoint was accessible or who developed clinical recurrence within 24 months, were included in the per-protocol (PP) analysis. Results: Due to slow recruitment, only 59 patients (26 male, median age 36.5 years, 22 smokers, 19 with previous resections) were randomized between 2005 2011 and included in the intention-to-treat (ITT) analysis. Eighteen of the 59 patients withdrew prematurely from the study (7 clinical recurrence, 5 adverse events due to AZA, 6 patient’s preference). Of the 30 patients included in the ED-AZA group, 10 and 4 patients initiated AZA at months 6 and 12, respectively. Both ITT and PP analyses revealed no difference in primary and secondary endpoints between the SYS-AZA and ED-AZA group (Table). In the ITT analysis, endoscopic remission was achieved by 52% in the SYS-AZA and 43% in the ED-AZA group (p = 0.519). Conclusions: Although this study was underpowered, we could not observe a benefit of systematic post-operative prophylactic therapy with AZA in patients at high risk of post-operative CD recurrence. Early post-operative endoscopic evaluation to guide further therapy seems most appropriate, but more studies are warranted.

Indications for Gynaecological Consultation by Women at a Rural Outreach Centre in North-Central Nigeria

Aims: To identify the reasons for consultations, the common clinical diagnosis and disease pattern at a rural gynaecologic outreach clinic. Study Design: Descriptive Retrospective Study. Place and Duration of Study: NKST Hospital Mkar-Gboko, Benue state, North-central Nigeria, in seven years (1 April 2005 to 31st July 2012). Methodology: Information from the case notes of patients who attended the outreach clinic over the study period were retrieved and analysed. Majority of the patients came by self-referral. Results: Of the 1,733 women that attended the clinic during the study period, 1,605 (92.6%) women made the inclusion criteria and formed the study population. The age Original Research Article International Journal of TROPICAL DISEASE & Health, 4(6): 696-712, 2014 697 range was 15 to 78 years; mean value of 33.6 +/9.5 year; 78% of the women were ages 21 – 40 years. The mean parity was 2.1 +/2.7and ranged between 0 to 13 children. 68% of the women were para 0 – 2 whilst 18% had parity of 5 and above. The women had 73 reasons and 2,390 presenting complaints, 49.6% of them had multiple presenting complaints (average 1.5 complaints per woman).Most common complaints were inability to conceive, lower abdominal pain and leaking of urine and /or faeces amongst 38%, 11% and 10% of the women respectively. There were 63 disease conditions with 1,793 clinical diagnoses. About 12% of the women had multiple clinical diagnoses. The three leading clinical diagnoses were infertility, genital fistulae and uterine myoma, in 46%, 12% and 10% of the women respectively; followed by sundry other gynaecological disorders (9%) and medical disease conditions (5%) in which hypertension, diabetes mellitus and retroviral diseases were more frequent in that order. Some women (n = 21; 1%) came for second opinion. Conclusion: Gynaecological diseases are diverse and common among women in rural central Nigeria. Inability to conceive, lower abdominal pain and incontinence of urine and or faeces were the three main reasons women sought consultation with the gynaecologist at Mkar. Infertility, genital fistulae, uterine myoma, non-communicable medical disorders and retroviral diseases were leading clinical diagnoses. Extending the services of Gynaecologist to the rural areas in the region may reduce the access gap to women’s health and enhance national development.

Profiles and experiences of women undergoing genital fistula repair: Findings from five countries

This article presents data from 1354 women from five countries who participated in a prospective cohort study conducted between 2007 and 2010. Women undergoing surgery for fistula repair were interviewed at the time of admission, discharge, and at a 3-month follow-up visit. While women's experiences differed across countries, a similar picture emerges across countries: women married young, most were married at the time of admission, had little education, and for many, the fistula occurred after the first pregnancy. Median age at the time of fistula occurrence was 20.0 years (interquartile range 17.3–26.8). Half of the women attended some antenatal care (ANC); among those who attended ANC, less than 50% recalled being told about signs of pregnancy complications. At follow-up, most women (even those who were not dry) reported improvements in many aspects of social life, however, reported improvements varied by repair outcome. Prevention and treatment programmes need to recognise the supportive role that husbands, partners, and families play as women prepare for safe delivery. Effective treatment and support programmes are needed for women who remain incontinent after surgery.

Urinary symptoms and urodynamics following obstetric genitourinary fistula repair

The aim of this study was to evaluate urinary symptoms and urodynamic diagnoses in women following repair of obstetric fistula of the lower urinary tract. Women with previous genital tract fistula and ongoing urinary symptoms were evaluated at the Addis Ababa Fistula Hospital. The women were referred to the Urodynamic Unit by doctors reviewing women at the hospital. Consecutive women between December 2008 and September 2009 were assessed (including urodynamic studies) and data collected One hundred and fifty-four women were referred for urodynamic assessment. Only women with previous obstetric fistula were included in the study. Of the 154 women, 5 were excluded from the study-1 declined the assessment, 1 had a non-obstetric fistula and 3 were found to have recurrence of the fistula. Forty-nine percent had urodynamic stress incontinence only, 3 % had detrusor overactivity only and 43 % had both urodynamic stress incontinence and detrusor overactivity. Five percent of women had neither detrusor overactivity nor urodynamic stress incontinence. Seven percent had post-void residual volume of 150 ml or more. Non-surgical management of post-obstetric fistula urinary symptoms may be neglected. The reduced success rates in surgery for post-obstetric fistula urinary incontinence may be due to the lack of attention to the other reasons for urinary symptoms and markedly impaired urethral function. Urethral closure pressures in this group of women often did not reflect the severity of urinary incontinence.

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Retrospective cohort study on patterns of care and outcomes of surgical treatment for lower urinary–genital tract fistula among English National Health Service hospitals between 2000 and 2009

To examine patterns of care among women with urogenital fistula treated in the English National Health Service (NHS) between 2000 and 2009. To assess whether failure of repair was associated with hospital or surgeon workload. We conducted a retrospective cohort study using data from Hospital Episode Statistics on women undergoing vesicovaginal or urethrovaginal fistula repair between January 2000 and December 2009 in English NHS hospitals. The main outcome measure was the number of fistula repairs and the incidence of re-repair; re-repair rates were stratified by age, NHS trust and consultant team volume. Between 2000 and 2009, 1194 women underwent surgical repair (n = 905) or ileal conduit (n = 289) for urogenital fistula under the care of 490 consultant teams. A total of 281 teams performed only a single index procedure, and only three consultant teams performed a mean of >3 per year. The rate of unsuccessful repair was 11.9% (108/905). The rate of re-operation at NHS trusts who performed over 30 procedures over the 10-year study period was 7.4% compared with 13.2% at those undertaking fewer (P = 0.02). A similar difference in re-operations between consultant teams performing > or <30 procedures did not reach significance (8.4% v 12.7%, P = 0.13). One in nine women required re-operation after surgical repair of a urogenital fistula. Our results lend weight to the argument for a 'minimum workload' for fistula management; given the number of fistulae occurring in England currently, this would best be provided by a network of supra-regional centres.

Determinants of Postoperative Outcomes of Female Genital Fistula Repair Surgery

To determine predictors of fistula repair outcomes 3 months postsurgery. We conducted a multicountry prospective cohort study between 2007 and 2010. Outcomes, measured 3 months postsurgery, included fistula closure and residual incontinence in women with a closed fistula. Potential predictors included patient and fistula characteristics and context of repair. Multivariable generalized estimating equation models were used to generate adjusted risk ratios (RRs) and 95% confidence intervals (CIs). Women who returned for follow-up 3-month postsurgery were included in predictors of closure analyses (n=1,274). Small bladder size (adjusted RR 1.57, 95% CI 1.39-1.79), prior repair (adjusted RR 1.40, 95% CI 1.11-1.76), severe vaginal scarring (adjusted RR 1.56, 95% CI 1.20-2.04), partial urethral involvement (adjusted RR 1.36, 95% CI 1.11-1.66), and complete urethral destruction or circumferential defect (adjusted RR 1.72, 95% CI 1.33-2.23) predicted failed fistula closure. Women with a closed fistula at 3-month follow-up were included in predictors of residual incontinence analyses (n=1,041). Prior repair (adjusted RR 1.37, 95% CI 1.13-1.65), severe vaginal scarring (adjusted RR 1.35, 95% CI 1.10-1.67), partial urethral involvement (adjusted RR 1.78, 95% CI 1.27-2.48), and complete urethral destruction or circumferential defect (adjusted RR 2.06, 95% CI 1.51-2.81) were significantly associated with residual incontinence. The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.

Fertility desires and the feasibility of contraception counseling among genital fistula patients in eastern Democratic Republic of the Congo

Objective To determine the fertility and contraceptive desires of genital fistula patients in eastern Democratic Republic of the Congo (DRC) and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use. Methods Group contraceptive counseling was offered to fistula patients at HEAL Africa Hospital between February and May 2010. Fertility desires and contraceptive knowledge were assessed via verbally administered questionnaires before and after counseling, and use of modern contraceptive methods was tracked. Results Of the 61 participants, 22/34 (64.7%) of those who desired children wanted to wait at least 1 year after repair before attempting pregnancy. Overall, 31/58 (53.4%) women had heard of birth control, although only 15 (24.6%) knew any specific methods, and none had ever used contraception. After counseling, all participants could recall 1 or more methods. Of the 25 participants discharged over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern method of contraception. Conclusion Desire for contraception and birth spacing among women with fistula is significant. Basic group contraception counseling and access are feasible and lead to increased contraceptive knowledge and use.

Current practices in treatment of female genital fistula: a cross sectional study

BackgroundMaternal outcomes in most countries of the developed world are good. However, in many developing/resource-poor countries, maternal outcomes are bleaker: Every year, more than 500,000 women die in childbirth, mostly in resource-poor countries. Those who survive often suffer from severe and long-term morbidities. One of the most devastating injuries is obstetric fistula, occurring most often in south Asia and sub-Saharan Africa. Fistula treatment and care are available in many countries across Africa and Asia, but there is a lack of reliable data around clinical factors associated with the success of fistula repair surgery. Most published research has been retrospective. While these studies have provided useful information about the care and treatment of fistula, they are limited by the design. This study was designed to identify practices in care that could lead to the design of prospective and randomized controlled trials.MethodsSelf-administered questionnaires were completed by 40 surgeons known to provide fistula treatment services in Africa and Asia at private and government hospitals. The questionnaire was divided into three parts to address the following issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair.ResultsThe results provide a glimpse into current practices in fistula treatment and care across a wide swath of geographic, economic, and organizational considerations. There is consensus in treatment in some areas (routine use of prophylactic antibiotics, limited bed rest until the catheter is removed, nonsurgical treatment for postsurgical incontinence), while there are wide variations in practice in other areas (duration of catheter use, surgical treatments for postsurgical incontinence). These findings are based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical trial research that would contribute to more efficient and effective fistula care.ConclusionsThe findings from the survey allowed us to consider clinical practices most influential in the cost, efficacy, and safety of fistula treatment. These considerations led us to formulate recommendations for eight randomized controlled trials on the following subjects: 1) Efficacy/safety of short-term catheterization; 2) efficacy of surgical and nonsurgical therapies for urinary incontinence; 3) technical measures during fistula repair to reduce the incidence of post-surgery incontinence; 4) identification of predictive factors for "incurable fistula"; 5) usefulness of urodynamic studies in the management of urinary incontinence; 6) incidence and significance of multi-drug resistant bacteria in the fistula population; 7) primary management of small, new fistulas by catheter drainage; and 8) antibiotic prophylaxis in fistula repair.

Surgical repair of genital fistulae — analysis of 62 cases in a tertiary hospital

ObjectivesTo determine the etiology of genital fistulae and the outcome of treatment.MethodsA total number of 62 women with genital fistulae were managed during the period of January 2001 to December 2007. Fifty seven cases were urogenital and five cases were rectovaginal fistulae. They were analyzed with regards to the age, parity, etiology, mode of treatment and outcome. The route of repair was individualized according to the appropriate access of fistulae.ResultsObstetric complications were the leading cause (79.03) of genital fistula. Majority (78.94%) of urogenital fistulae were treated surgically through vaginal route. Out of 57 cases of urogenital fistulae, 51 cases were repaired successfully in the first attempt and three patients were cured at the second repair. The overall cure rate achieved was 94.8%. All of the five rectovaginal cases were closed after a single attempt.ConclusionsA high percentage of patients with genital fistulae can be repaired by the experience of surgeon, team work and meticulous surgery with conventional approach.

Urogenital fistulae: A prospective study of 50 cases at a tertiary care hospital

Introduction:The misfortunate incident of formation of a urogenital fistula remains a major challenge for surgical urologists worldwide. Such fistulae may not be a life-threatening problem, but surely the women face demoralization, social boycott and even divorce and separation. The fistula may be vaginal, recto-vaginal or a combination of the two. The World Health Organization (WHO) has estimated that in the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. The objective of our study was to enunciate the patient demography, patient profile, incidence, type of surgery, as well as the long-term outcomes encountered in the management of all types of genital fistulae at a tertiary care centre.Materials and Methods:50 consecutive patients, attending the outpatient department with urogenital fistulae, were studied during the period of 5 years from July 2005 to July 2009. All female patients with complaints of urinary incontinence and fecal incontinence and dribbling, patients having a history of obstructed labor, radiotherapy, instrumental delivery, foreign body or trauma and with a history of hysterectomy (abdominal/ vaginal) and lower segment caesarean section (LSCS) were included. A thorough urological examination included a dye study using methylene blue, Renal function tests, X-ray KUB and intravenous urography (IVU). Cystoscopy along with examination under anaesthesia (EUA) were done to assess the actual extent of injury. All patients were subjected to appropriate surgical interventions via the same combination of surgeons . Post operatively, prophylactic antibiotics were administered to all patients and patients were managed till discharge and followed thereafter via regular outpatient visits for a period of 3 years.Results:Age of patients ranged from 21 to 40 years. 64% patients hailed from rural areas, 76% were from the lower socio-economic strata, 40% illiterate and 69% were short Statured. Vesico vaginal fistulae (VVF) was seen in 64% cases of which 50% were due to obstructed labor, 19% cases post LSCS and 31% cases post total abdominal hysterectomy (TAH). 68% of urogenital fistulae were between 1 to 3 cms. We obtained a 75% cure rate in UVF, 87.5% cure rate in RVF while a 93.75% cure rate was observed in patients with VVF. 76% of all patients were cured while 8% had a recurrence, probably due to the large size of fistula.Conclusion:Genital fistula is preventable, yet it remains a significant cause of morbidity among females of reproductive age group. Despite facilities available, certain conditions like physical, social, economic, illiteracy, and a very casual attitude towards maternal health and children birth practices limit utilization of services for women. It is important that the modern health care providers should be aware of these aspects, so that they can recognize services that are appropriate and acceptable to the people. Thus, one must agree that in cases of urogenital fistulae, "prevention is better than cure".

Surgical repair of genitourinary fistulae: comparison of our experience at Turkey and Niger

Report of the personal experience at repairing urogenital fistulae comparing the etiology, management, and outcomes in a developed and underdeveloped countries. Fifty-three patients with urogenital fistulae were surgically repaired at two different countries. Twenty-nine of those were treated in Istanbul, Turkey during last 10-year period and the other 24 patients were operated in Maradi, Niger in August 2007. Detailed information on obstetric history and previous surgical procedures were questioned in all of the patients. Specific evaluation included instillation of dye in the bladder to locate the site of the fistula and intravenous urography were applied to patients with suspected urogenital fistula to confirm the fistula tract. The site, number and the size of fistula, as well as the pliability of tissues was assessed before the operation. The position of patients for surgery and the route of repair were individualized according to the appropriate access to the fistulae. Patients were reviewed 4-10 weeks after surgery to determine the end results of the operations. Over all, obstetric complications (47%) were the most common cause of urogenital fistulae. Gynecologic surgeries were responsible for 41% of the cases. Although obstetric causes were prominent at patients in Niger, gynecological surgery was the main cause in Turkey. The most common type of fistulae was vesicovaginal. With regard to surgical approach to urogenital fistulae; the transabdominal approach was chosen in 12 (22.6%) of patients and transvaginal repair was performed in 41 (77.4%) of patients; 94.34% of the patients were completely dry after the first attempt. A high percentage of patients with genital fistulae can be rendered dry and continent by assessment of these conditions; meticulous attention must be applied for the absence of inflammation and infection at the fistula site before the operation. Surgical team must be experienced at both abdominal and vaginal repair. Broad-spectrum antibiotics and continuous bladder drainage must be applied to all patients for at least 2 weeks. Interposition flaps must be used in complex cases.

Obstetric fistula in India: current scenario

India lacks prevalence and incidence data on obstetric fistula, a near miss maternal mortality. Retrospective data were collected on obstetric fistula cases from hospital records of 24 tertiary care facilities during the period 2000-2006. Overall, 717 women underwent genital fistula repair, but medical records could be retrieved for only 401 (56%) cases. States of Bihar, Uttar Pradesh, and West Bengal had more than 100 cases each, while Karnataka had none. Obstructed labor caused nearly 97% of genital fistulae while pelvic surgery and accidental trauma contributed to 1.5% cases each. Commonest type of fistula was genitourinary (86.6%), others included rectovaginal (12.1%) and both genitourinary and rectovaginal fistulae (1.2%). Fistula repair was attempted in 322 (83%) cases of whom 289 (89.71%) were successfully repaired. There is a need for ongoing systematic data collection mechanism like a fistula registry that would provide facility-based prevalence and incidence, time trends, and changes in etiology of fistula. This information could be used for implementation of prevention and treatment strategies.

A Review of Clinical Pattern and Outcome of Vesicovaginal Fistula

ObjectivesThe aim of this study was to determine the incidence, sociodemographic parameters, and outcome of surgical repairs of obstetric fistula in our center. MethodsCase files of patients managed for genital tract fistula over a 10-year period (January 1, 1997 to December 31, 2006) were retrieved and analyzed. ResultsFifty-five patients with of genital tract fistula were managed in the period under review, constituting 1.17% of total gynecological admissions. Obstetric fistula accounted for 51 (93%) of genital fistula, and 92.7% of cases were caused by prolonged obstructed labor. The most common form of fistula was the midvaginal type, and 89% of affected women were married with primiparous women mostly affected (43.6%). Menstrual function was lost in 51% of the patients, while obstetric palsy complicated 18.2% of the cases. Half of the women (51%) were abandoned by their spouses, and surgical repair was successful in only 32% of the cases. ConclusionObstetric fistula continues to show the deficiency in women’s general health status occasioned by poor childbirth attendance in developing countries. Affected women suffer double jeopardy as a result of dearth of appropriate experts in fistula repair.

Classification of female genito‐urinary tract fistula: Inter‐ and intra‐observer correlations

Currently, there is no accepted standardized classification for genital tract fistulae. Many classifications have been proposed previously, mainly based on anatomical locations. This is the first paper on inter- and intra-observer correlations using a recently published classification system based on fixed reference points. To assess intra- and inter-observer reliability of a new classification for genito-urinary fistula. This is a prospective assessment of women with genito-urinary fistula. Women attending the Fistula Clinic in Ethiopia and Liberia were assessed by three fistula surgeons. The women were assessed in the outpatients and the fistulae were staged. In Liberia, where two surgeons were working together, inter-observer reliability was assessed. All women had the fistulae restaged in the operating theatre and intra-observer concordance was assessed. The clinicians were blinded to the outpatient results. A total of 119 women were recruited. All women had intra-observer assessment and had the fistula examined by the same clinician in the outpatients and in the operating theatre. Fifty of these women had inter-observer assessment with two clinicians assessing the same women. The results demonstrated that this classification system had high concordance in intra- and inter-observer reproducibility. The new classification for genito-urinary fistulae utilizing fixed reference points is a useful tool in describing fistulae. This study has shown that this classification produced consistency in description amongst different clinicians and also by the same clinician in a different consultation. This therefore allows more precise communication of clinical findings.

Rectovaginal fistula following sexual intercourse: A case report

Female genital fistula is an important feature of the developing countries gynecology. Most of the rectovaginal fistulae encountered in the tropics are due to obstetrics causes and genital malignancies. In developed countries, radiation injury and Crohn's disease are also common etiological factors. The index case is reported to highlight the rare situation, where a 24-year old married nullipara sustained low rectovaginal fistula following normal coitus. She was later divorced by her husband.

Fistula and Traumatic Genital Injury from Sexual Violence in a Conflict Setting in Eastern Congo: Case Studies

The Eastern region of the Democratic Republic of Congo (DRC) is currently undergoing a brutal war. Armed groups from the DRC and neighbouring countries are committing atrocities and systematically using sexual violence as a weapon of war to humiliate, intimidate and dominate women, girls, their men and communities. Armed combatants take advantage with impunity, knowing they will not be held to account or pursued by police or judicial authorities. A particularly inhumane public health problem has emerged: traumatic gynaecological fistula and genital injury from brutal sexual violence and gang-rape, along with enormous psychosocial and emotional burdens. Many of the women who survive find themselves pregnant or infected with STIs/HIV with no access to treatment. This report was compiled at the Doctors on Call for Service/Heal Africa Hospital in Goma, Eastern Congo, from the cases of 4,715 women and girls who suffered sexual violence between April 2003 and June 2006, of whom 702 had genital fistula. It presents the personal experiences of seven survivors whose injuries were severe and long-term, with life-changing effects. The paper recommends a coordinated effort amongst key stakeholders to secure peace and stability, an increase in humanitarian assistance and the rebuilding of the infrastructure, human and physical resources, and medical, educational and judicial systems.RésuméLa région orientale de la République démocratique du Congo (RDC) connaît actuellement une guerre particulièrement brutale. Des groupes armés de la RDC et des pays voisins commettent des atrocités et utilisent systématiquement la violence sexuelle comme arme de guerre pour humilier, intimider et dominer les femmes, les jeunes filles, leurs partenaires masculins et les communautés. Les combattants armés jouissent de l’impunité, sachant qu’ils ne devront pas répondre de leurs actes et ne seront pas poursuivis par la police ou les autorités judiciaires. Un problème de santé publique particulièrement atroce est apparu : les fistules gynécologiques traumatiques et les lésions génitales causées par les violences sexuelles et les viols collectifs, avec des conséquences psychosociales et psychologiques tragiques. Beaucoup de victimes se retrouvent enceintes ou infectées par des IST ou le VIH, sans accès au traitement. Ce rapport a été préparé à l’hôpital Heal Africa/Doctors on Call for Service à Goma, en RDC orientale, à partir de 4715 cas de femmes et de jeunes filles ayant subi des violences sexuelles entre avril 2003 et juin 2006, dont 702 présentaient une fistule génitale. Il décrit les expériences personnelles de sept victimes dont les blessures étaient si graves qu’elles ont changé leur vie. L’article recommande aux principales parties prenantes de coordonner leurs efforts pour garantir la paix et la stabilité, accroître l’assistance humanitaire et reconstruire l’infrastructure, les ressources humaines et matérielles ainsi que les systèmes médicaux, éducatifs et judiciaires.ResumenLa región oriental de la República Democrática del Congo (RDC) actualmente se encuentra asolada por una guerra brutal. Grupos armados de RDC y países vecinos están cometiendo atrocidades y utilizando la violencia sexual sistemáticamente como un arma de guerra para humillar, intimidar y dominar a las mujeres, niñas, sus hombres y comunidades. Los combatientes armados sacan provecho con impunidad, sabiendo que no se les hará responsable ni serán perseguidos por la policía o autoridades judiciales. Ha surgido un problema de salud particularmente inhumano: fístula ginecológica traumática y lesión genital a consecuencia de actos brutales de violencia sexual y violación en grupo, así como enormes secuelas psicosociales y psicológicas. Muchas de las mujeres que sobreviven se encuentran embarazadas o infectadas con ITS/VIH, sin acceso a tratamiento. Este informe fue compilado en el Hospital Doctors on Call for Service/Heal Africa Hospital, en Goma, Congo oriental, de los casos de 4,715 mujeres y niñas que sufrieron violencia sexual entre abril de 2003 y junio de 2006, de las cuales 702 tenían fístula genital. Se exponen las experiencias personales de siete sobrevivientes cuyas lesiones eran graves y de largo plazo, con efectos que les cambiaron la vida. Se recomienda un esfuerzo coordinado entre las partes interesadas clave a fin de lograr paz y estabilidad, un aumento en ayuda humanitaria y reconstrucción de la infraestructura, recursos humanos y físicos, y sistemas médicos, educativos y judiciales.