Vesico-Vaginal Fistula, Violence, and Voluntourism

Abstract & Commentary

By Jennifer S. Hsu and Philip R. Fischer, MD, DTM&H

Jennifer S. Hsu is a Mayo Medical School student in Rochester, MN. Dr. Fischer is Professor of Pediatrics, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN.

Ms. Hsu and Dr. Fischer report no financial relationships relevant to this field of study.

Synopsis: More than a million women currently suffer with vesico-vaginal fistula. Increasingly, "medical voluntourism" provides a means for compassionate professionals to helpfully visit afflicted people.

Source: Kirschner CV, Yost KJ, Du H, et al. Obstetric fistula: The ECWA Evangel VVF Center surgical experience from Jos, Nigeria. Int J Urogynecol J 2010; 21:1525-1533.

In areas of limited maternal care across Africa, obstructed labor leads to stillbirth and necrosis of maternal tissues. Resulting vesico-vaginal fistulas can be amenable to surgical repair. In central Nigeria, 926 women underwent fistula repair during a six-year period, 90% via a trans-vaginal approach. Continence was achieved in 71% of patients and was most likely if there was an intact urethra, an upper or mid-vaginal fistula, and limited fibrosis. Surgical morbidity was low.


Obstetric fistula is an abnormal opening either between the vagina and urinary bladder (vesico-vaginal fistula, VVF) or between the vagina and rectum (recto-vaginal fistula, RVF). Generally caused by prolonged obstructed labor, obstetric fistulas affect adolescent and adult females (average age 15 years at marriage), particularly those who are poor, illiterate, and living in rural areas.1 Underlying child malnutrition and poverty often stunt the growth of affected girls' skeletal structures, including the pelvis, contributing to obstructed labor during childbirth and to obstetric fistula. The World Health Organization (WHO) estimates that there are more than two million young women in sub-Saharan Africa and Asia living with obstetric fistula.2

Another, less widely recognized cause of VVF and RVF is sexual violence. Sexual violence often is used as a weapon of war to spread terror, fear, and humiliation among civilians. After being raped by armed groups, a woman may have objects such as tree branches and bottles forced into her vagina. Some are shot, with a gun barrel forced into the genitourinary area. As a result, women suffer from genital injuries and traumatic gynecological fistula. At one hospital in the Democratic Republic of the Congo (DRC), between April 2003 and June 2006, 702 of the 4,715 women and girls who were victims of sexual violence had genital fistulas.3 Another study showed that 36 of 2,020 sexual violence survivors seen between 2002 and 2004 had suffered from traumatic fistula.4 Rape of young adolescents with small pelvises also can lead to obstructive labor and obstetric fistulas, even if the original violent rape did not leave traumatic physical damage.

Fistulas can lead to urinary incontinence and persistent urine or feces leaking uncontrollably through the vagina. The effects on the health and well-being of sexual violence victims are devastating. Besides physical harm, VVF and RVF are also linked to severe psychological consequences for victims, including depression and post-traumatic stress disorder, as well as social and emotional consequences such as social ostracism and rejection by their families and friends. Because of the stench resulting from constant uncontrollable flows of waste, victims who have VVF or RVF often are shunned.

Traumatic gynecological fistula is a problem that remains relatively unknown since it affects those who are powerless in society.5 Sexual violence is under-reported because women often are reluctant to disclose and receive treatment due to shame, stigma, feelings of self-blame, and fear of reprisals.6 Thus, the majority of data is based on sexual violence victims seeking treatment at health facilities. Currently, much of the reported work on obstetric and traumatic fistulas comes from Nigeria,2 Ethiopia,7 and Democratic Republic of the Congo3,8-11; humanitarian groups can be helpfully involved.12

Sexual violence is an ongoing global public health issue that not only affects women in every country, but also the communities, making it an "effective" weapon of war. For more than a decade, the Democratic Republic of the Congo has experienced continuous civil conflict and violence. According to UN Emergency Relief Coordinator John Holmes, "sexual violence in the Congo is the worst in the world."13 According to the United Nations Population Fund (UNFPA), there are roughly 1,100 rape cases reported each month in the DRC.14 The eastern part of the DRC is likely to have the world's highest number of traumatic gynecologic fistula injuries.15

The humanitarian community has an important role to play in preventing and responding to sexual violence crises. The first is to raise awareness of traumatic gynecological fistula, its etiology, and opportunities for treating it. Health care workers should be aware of the problem and know how to respond properly. Comprehensive protocols addressing the medical, psychological, and legal consequences of rape as relevant to victims could also be useful.16

Stories of traumatized girls and women touch our hearts. Consider the excerpted testimony of 12-year-old Byamungu: "One day when we were returning from the market, I felt a need to open my bowels. Since the only place to go was in the forest, I entered to relieve myself. But my hour of darkness had come. Suddenly a group of men appeared behind me. One of them grabbed me by the hand. I screamed, but my frightened companions were already running away. I was facing eight beasts who first robbed me, then dragged me into the bush, stripped me naked and raped me repeatedly. When they were done they left me there bleeding until a group of women found me. Feces and urine flowed out of the same opening in my body."3

Eco-tourism became popular as travelers saw informational and service trips as a means to promote conservation of natural resources. Increasingly now, pre-travel consultation is sought by professionals engaged in "medical voluntourism" as they seek to use their knowledge and skills to help victims of poverty, war, and even sexual violence.

Unfortunately, even well-intentioned individuals can intervene in ways that hurt patients, weaken health care systems, and foster dependency. Written from Christian perspectives, three books can help guide voluntourists either of any, or of no particular faith-base, toward less harmful and more helpful interventions. Ministering Cross-Culturally 17 helps travelers identify cultural variations as distinct from compromised values. Compassion, Justice, and the Christian Life 18 and When Helping Hurts 19 help medical voluntourists appropriately target whether interventions should be focused on rescue and relief (in the early days after an earthquake, for instance), recovery (possibly weeks after a disaster, when services are still compromised), or development (such as when chronic poverty and limited health infrastructure are the main problems).


  1. Wall LL, Karshima JA, Kirschner C, et al. The obstetric vesicovaginal fistula: Characteristics of 899 patients from Jos, Nigeria. Am J Obstetr Gynecol 2004;190:1011-1019.
  2. World Health Organization. Ten Facts on Obstetric Fistula., accessed 12-15-2010.
  3. Longombe AO, Claude KM, Ruminjo J. Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: Case studies. Reproductive Health Matters 2008;16:132-141.
  4. The ACQUIRE Project. Traumatic gynecologic fistula as a consequence of sexual violence in conflict settings: A literature review. New York, NY: EngenderHealth; 2005., accessed 12-15-2010.
  5. Doughty P. Responding to consequences of sexual violence: traumatic gynecologic fistula.,%20Traumatic%20Gynacological%20Fistula,%20nd.doc, accessed 12-15-2010.
  6. Reis C. Addressing sexual violence in emergencies., accessed 12-15-2010.
  7. Hamlin C. The Hospital by the River. Pan Macmillan Australia, 2001.
  8. Johnson K, Scott J, Rughita B, et al. Associations of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010;304:553-562.
  9. Mukwege DM, Nangini C. Rape with extreme violence: the new pathology in South Kuvu, Democratic Republic of Congo. PLoS Medicine 2009;2(12):e1000204.
  10. Bartels SA, Scott JA, Mukwege D, et al. Patterns of sexual violence in Eastern Democratic Republic of Congo: Reports from survivors presenting to Panzi Hospital in 2006. Conflict and Health 2010;4:9.
  11. Mukwere DM, Mohamed-Ahmed O, Fitchett JR. Rape as a strategy of war in the Democratic Republic of the Congo. International Health 2010;2:163-164.
  12. VDay web site. and Accessed 12-15-2010.
  13. Gettleman J. Rape epidemic raises trauma of Congo war. Oct. 7, 2007. Accessed 12-15-2010.
  14. "Campaign says 'no' to the sexual violence that rages in the DRC." April 4, 2008. United Nations Population Fund web site. Accessed 12-15-2010.
  15. Onsrud M, Sjoveian S, Luhiriri R, et al. Sexual violence-related fistulas in the Democratic Republic of Congo. Int J Gynaecol Obstet2008;103:265–269.
  16. Shanks L, Schull MJ. Rape in war: The humanitarian response. CMAJ 2000;163:1152-1156.
  17. Lingenfelter SG, Mayers MK. Ministering Cross-Culturally. Baker Academic, 2003.
  18. Lupton RD. Compassion, Justice, and the Christian Life. Regal, 2007.
  19. Corbett S, Fikkert B. When Helping Hurts. Moody Press, 2009.