Restoring Continence After Devastating Post‐Obstetric Fistula Repair Incontinence: A Pilot Study Comparing Cystoscopic vs Periurethral Bulkamid
Aidan J. Kennedy, Michael Breen, Nikta Rezakahn Khajeh, Bernadette M. M. Zwaans, Kenneth M. Peters, Larry T. SirlsABSTRACT
Introduction
Post‐obstetric fistula repair incontinence (POFRI) refers to persistent urinary leakage after successful fistula closure. This study evaluated Bulkamid for POFRI using two techniques: cystoscopic‐guided injections versus periurethral injections without cystoscopy.
Materials and Methods
We performed a prospective study of women with POFRI and persistent stress urinary incontinence (SUI) treated with Bulkamid at the Freedom from Fistula unit in Tamatave, Madagascar. Cohort 1 underwent cystoscopic Bulkamid injection; Cohort 2 underwent periurethral Bulkamid injection without cystoscopy. The International Consultation on Incontinence Questionnaire‐Urinary Incontinence Short Form (ICIQ‐UI SF), Questionnaire for Urinary Incontinence Diagnosis (QUID), and pad weight testing were obtained at baseline, discharge, and 3 months postoperatively. The primary outcome, Patient Global Impression of Improvement (PGI‐I), was collected at discharge and 3‐month follow‐up.
Results
In January 2025, Cohort 1 ( n = 11) underwent cystoscopic injection, and in June 2025, Cohort 2 ( n = 17) underwent periurethral injection. The primary outcome was met by 8/11 (72.7%) patients in Cohort 1 at discharge and 2/5 (40%) at 3 months. In Cohort 2, 11/17 (64.7%) patients met the primary outcome at discharge and 6/10 (60%) at 3 months. Combined, 19/28 (67.9%) patients achieved “success” at discharge and 8/15 (53.3%) at 3 months. At 3 months, both cohorts demonstrated significant reductions in mean QUID ( p < 0.001) and ICIQ‐UI‐SF scores ( p = 0.011). Two patients developed recurrent vaginal fistulas, both successfully repaired.
Conclusions
Bulkamid provided promising short‐term outcomes for SUI in women with POFRI. Both cystoscopic and periurethral approaches were effective, the periurethral technique was simpler and avoided cystoscopy. Larger studies with longer follow‐up are needed.