1 in 3 African women who had successful obstetric fistula repair have post-obstetric fistula repair incontinence (POFRI). Managing stress urinary incontinence (SUI) in patients with POFRI presents unique surgical challenges. These patients typically have shortened and scarred urethras due to tissue devascularization and denervation. Vaginal and autologous slings for POFRI can have high complication rates. Bulkamid is a low risk, minimally invasive option for SUI in POFRI patients. This study aims to evaluate the viability of Bulkamid in scarred urethras and investigate the efficacy utilizing cystoscopic and periurethral (PU) injection techniques in Madagascar.

A two-phase prospective study on African women with POFRI was performed with Bulkamid. The first cohort underwent Bulkamid injections using the standard cystoscopic technique. This came with several challenges leading us to re-adopt the PU injection technique for the second cohort. This relied on tactile guidance alone and eliminated the need for cystoscopy completely. A metal sound was inserted into the urethra to define and fix the urethra in space. A 12-inch needle was inserted parallel to the urethra along the 3, 5, 7, and 9 o clock urethral positions. The sound was moved back and forth to ensure the needle tip was submucosal and not in the urethral lumen. The sound was removed, the needle stabilized with a hemostat, and 0.5 cc of Bulkamid was delivered at each site. Symptom surveys were obtained at baseline, discharge, and 3 months follow up. The primary outcome, Patient Global Impression of Improvement Survey (PGI-I) was obtained at discharge, and 3 months follow up.

Every symptom outcome tool was significantly improved (p<0.01) after cystoscopic and PU injections. The primary outcome was met by 72.7% of patients treated cystoscopically and 62.5% of those with PU injections at discharge. 53.5% of all patients reported primary outcome success at 3 months. In 91% of cystoscopic cases, the surgeon rated the procedure as “difficult” or “moderately difficult” reflecting the complexity associated with stricture-related scarring. Due to significant scarring, the surgeon often had to hunt for viable injection sites. In 73% of cases, this search resulted in 8 injection sites. PU needle placement was noted easier in urethras <2 cm compared to cystoscopic needle placement.

POFRI is difficult to treat. Through cystoscopic injection was effective; urethral scarring limited this technique and drove the re-adoption of PU injection. Both cystoscopic and PU Bulkamid injections were effective at 3-month follow up. Future studies are needed to assess long-term effects.

Continence 19S (2026) 102521
DOI: 10.1016/j.cont.2026.102521