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Rehabilitative care practices in the management of childbirth-related pelvic fistula: A systematic review


Introduction and hypothesis

Childbirth-related pelvic fistula (CRF) often requires surgery, yet even with successful repair, mental health conditions, musculoskeletal impairments, urinary and fecal incontinence and sexual dysfunction persist for many women. Postoperative rehabilitation, (i.e., physiotherapy, mental health counseling) may address these concerns and has been reported for this population. This review aims to summarize the literature and level of evidence of rehabilitative care practices in fistula care to inform clinical practice, research and policy recommendations.


A systematic literature review was conducted using Africa-Wide Information, CINAHL, Cochrane, Embase, Global Health, PAIS Index, PubMed and SCOPUS searching keywords and MeSH terms to identify women with CRF admitted for surgery. Two researchers progressively screened titles, abstracts and full-text articles. Eligible articles were classified primary if intervention details and outcomes were reported or secondary if rehabilitation was described, but no specific outcomes reported. Relevant study details, strengths and limitations, and key findings were extracted.


Eighteen articles were included: eight primary, ten secondary. Primary articles reported on urethral plugs for postoperative urinary incontinence (UI) (2/8), menstrual cup to manage UI (1/8), physiotherapy and health education (3/8) and mental health counseling (2/8). Secondary articles describe rehabilitation components in the context of program descriptions, qualitative analyses or reviews. All evidence was low or very low quality.


Research on rehabilitative care is very limited and highlights inconsistencies in practice. This review provides support for the feasibility of rehabilitation and establishes the need for future interventional studies that involve a comparator and reliable outcome measures.

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Author information




Preliminary results of data from Rwanda were presented at the conference of the International Federation of Gynecology and Obstetrics, FIGO World Congress in Rio de Janeiro, Brazil, October 2018.

Keyser: Protocol/project development, Data collection and management, Data analysis, Manuscript writing/editing

McKinney: Protocol/project development, Data collection and management, Data analysis, Manuscript writing/editing

Hosterman: Data collection and management, Data analysis

Chen: Protocol/project development, Manuscript writing/editing

Corresponding author

Correspondence to Laura Keyser.

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Financial disclaimer/Conflict of interest

Laura Keyser and Jessica McKinney are co-founders of Mama LLC, a consulting firm providing expertise in women’s health and development. Mama LLC has partnered with EngenderHealth and received USAID funding through the Fistula Care Plus program to develop educational materials and build capacity for women’s health physiotherapy services at partner sites in Africa. Lauren Hosterman provides ad hoc consulting services to Mama LLC on a very limited basis. No funding was provided to/from Mama LLC or any of the authors for this study. Jessica McKinney is also the Vice President of Medical Affairs for Renovia, Inc., a digital health company focused on innovation for female pelvic floor disorders. This work is unrelated to the current paper; no funds were received for this research. Remaining authors claim no conflict of interest.

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Appendix 1

Appendix 1

Table 6 Final search strategy

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Keyser, L., McKinney, J., Hosterman, L. et al. Rehabilitative care practices in the management of childbirth-related pelvic fistula: A systematic review. Int Urogynecol J 32, 2311–2324 (2021).

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  • Fistula
  • Rehabilitation
  • Physiotherapy
  • Reintegration
  • Counseling
  • Mental health