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INTRODUCTION

This document was first issued in 2006 (Lewis and de Bernis, 2006). It is truly remarkable to read it today and to see the amazing degree to which the situation of fistula has changed. In 2006, the original groundbreaking work raised the profile of obstetric fistula as an urgent public health problem, and provided the first practical guidance for those involved in the care of women with the condition. In 2018, the international community called for obstetric fistula to be eliminated within a decade, aligning with the 2030 Agenda for Sustainable Development and its 17 global goals.

In so many ways, the unique set of challenges surrounding fistula have been a catalyst for change in the development world. The response to fistula was, along with responses to HIV and AIDS, tuberculosis and other conditions, an early example of a marriage between public health and clinical medicine. Fistula furthered this interface through community-based public-health interventions and institutionally-tied surgical care. Fistula required thought and programmes for both dealing with and preventing the condition, and these were based not in immunization or focus groups, but in institutionally-bound surgery. As a surgical issue, there have been tremendous hurdles to overcome, as fistula repair inconveniently straddles traditional boundaries in pelvic surgery training. Repair involves a mixture of techniques native to gynaecology, urology, general surgery and plastic surgery. It calls for significant capacity-building to conduct highly complex procedures in some of the world’s most resource-poor areas.

In 2006, the number of women affected by fistula was unknown. While this is still true to some extent, substantial progress is being made. Then, there was almost no body of data upon which to base rational clinical care and programming. Now, there has been significant movement towards evidence-based care. Then, a small number of individual programmes struggled in isolation. Now, fistula care has a presence in the teaching and study of reconstructive surgery, development and social sciences. Networking and the emergence of a professional community have, as a result of concerted effort, begun to replace isolation.

In the past, most programmes existed through external support. Now, while support from international organizations remains critical, there is increasing involvement of national governments and professional bodies. Then, international surgeons dominated leadership of clinical fistula care. Now, African and Asian medical personnel have taken up the reins. Then, the term “fistula” was synonymous with obstetric fistula. Now, while obstetric fistula continues to be an issue, iatrogenic fistula has grown rapidly as a significant concern. Then, fistula prevention meant dealing with obstetric fistula by reducing maternal morbidity. Now, iatrogenic fistula requires entirely new approaches. These are but a few of the major changes occurring in recent years, and motivating a second edition of this manual.

This is not an exhaustive textbook on fistula care, but rather functions as a “manual”, aimed at giving a broad view of the issue and practical instruction on fistula programming and treatment. The manual is not specifically about fistula repair, epidemiology, programming, prevention or nursing, but briefly touches on all of these topics and more.