A 28-year-old woman has a large vesicovaginal fistula following prolonged obstructed labour. She is haemodynamically stable and the local tissues are inflamed and oedematous. According to standard practice, when should definitive surgical repair be attempted?

• A Immediately, within 24 hours of diagnosis
• B After 6 weeks, once inflammation has settled and slough has separated
• C After approximately 3 months, allowing full demarcation and vascularisation of tissues ✓
• D Only after urinary diversion by suprapubic cystostomy

Explanation

For an obstetric fistula presenting late with unhealthy, inflamed margins, conventional teaching is to wait about 3 months so that slough separates, inflammation resolves and the tissues become well vascularised, giving the repair the best chance of success. Immediate repair is reserved for fistulas recognised intraoperatively or within the first 24 to 48 hours when tissues are still healthy. Suprapubic drainage may be used temporarily to keep the patient dry but is not a prerequisite for repair.

Reference: Shaw's Textbook of Gynaecology, 18th ed.

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