eMedicine Specialties > General Surgery > Colorectal

Rectovaginal Fistula

Author: Dana Taylor, MD, FACS, Assistant Professor of Surgery, Graduate School of Medicine, University of Tennessee; Consulting Surgeon, University General Surgeons, PC
Coauthor(s): Jan Rakinic, MD, Chief, Section of Colorectal Surgery, Southern Illinois University; Program Director, SIU Residency in Colorectal Surgery
Contributor Information and Disclosures

Updated: Feb 11, 2009

Introduction

History of the Procedure

For thousands of years, women simply tolerated the distressing symptoms generated by rectovaginal fistulas (RVFs). This is no longer necessary because most RVFs can be surgically corrected via a number of approaches. A small percentage, however, cannot be corrected because of patient comorbidity or disease-related factors; in such cases, patients can be helped only by fecal diversion.1

Problem

A rectovaginal fistula (RVF) is an epithelial-lined tract between the rectum and vagina. This article discusses only acquired RVFs. Most RVFs are located at or just above the dentate line. Fistulas below the dentate line are not true RVFs but are instead anovaginal fistulas; these require different treatment than do RVFs.

Frequency

Among reported series, the frequency with which rectovaginal fistulas (RVFs) occur varies according to etiology. RVFs are classified on the basis of location, size, and etiology, each of which affects the treatment plan and prognosis. Low RVFs—which are located between the lower third of the rectum and the lower half of the vagina—are closest to the anus and can be corrected with a perineal approach. High fistulas—which occur between the middle third of the rectum and the posterior vaginal fornix— require a transabdominal approach for repair.

RVFs may vary greatly in size, but most are less than 2 cm in diameter. Small-sized fistulas are less than 0.5 cm in diameter, medium-sized fistulas are 0.5-2.5 cm, and large-sized fistulas exceed 2.5 cm.

Etiology

The most common etiology for rectovaginal fistula (RVF) of traumatic origin, and probably for all RVFs, is obstetric injury.2,3 Other etiologies for RVF include radiation injury,4 inflammatory bowel disease ([IBD], most often Crohn's disease5 ), operative trauma, infectious etiologies, and neoplasm.

Pathophysiology

Several traumatic causes of rectovaginal fistula (RVF) exist. Perineal lacerations during childbirth, especially those due to episioproctotomy, predispose patients to RVFs. Perineal lacerations are more common in primigravidas, in precipitous births, or when forceps or vacuum extraction is used. Failure to recognize and correctly repair perineal lacerations, or secondary infection of perineal lacerations, further increases the chance of RVF. Prolonged labor with pressure on the rectovaginal septum can produce necrosis and result in RVF. Vaginal or rectal operative procedures, especially those performed near the dentate line, may cause RVFs. Pelvic operations can be complicated by the development of a high RVF. Traumatic injury (penetrating or blunt) and forceful coitus also have produced RVFs.

Crohn's disease5 and, less often, ulcerative colitis have been associated with RVFs. The fistula may arise primarily or, more often, in relation to a perirectal abscess and/or fistula, manifesting as complicated perianal sepsis.

Radiation used in the treatment of pelvic malignancies may result in RVF.4 Fistulas that occur during such therapy usually result from tumor regression. Most other fistulas become apparent 6 months to 2 years after completion of treatment. Diabetes, hypertension, smoking, and previous abdominal or pelvic surgery increase the risk of fistula formation. The use of biopsy to differentiate radiation-related change at the fistula from a recurrent tumor is imperative, because neoplasms (primary, recurrent, metastatic) can produce RVFs.

A variety of infectious conditions can produce RVF. The most common are perirectal abscess/fistula and diverticulitis. Less commonly, tuberculosis, lymphogranuloma venereum, and Bartholin gland abscess can cause RVFs.

Presentation

The clinical presentation of rectal vaginal fistula (RVF) varies little. A few patients are asymptomatic, but most report the passage of flatus or stool through the vagina, which is understandably distressing. Patients may also experience vaginitis or cystitis. At times, a foul-smelling vaginal discharge develops, but frank stool per vagina usually occurs only when the patient has diarrhea. The clinical picture may include fecal incontinence due to associated anal sphincter damage or bloody, mucus-rich diarrhea caused by the underlying clinical etiology.

Indications

Because the symptoms of rectovaginal fistula are so distressing, surgical therapy is almost always indicated. Exceptions include patients who are moribund or those with prohibitive risks for the proposed anesthesia and surgery. Note that surgical therapy means repair in most cases. Some patients, however, are better served by a diverting stoma than by an ill-advised repair attempt.

Relevant Anatomy

The rectovaginal septum is the thin septum separating the anterior rectal wall and the posterior vaginal wall. The caudal portion of the septum is the perineal body. The anal sphincters are located in the posterior portion of the perineal body. The transverse perinei muscle traverses the perineal body and is often used in anal sphincteroplasty and rectovaginal fistula repair.

The dentate line is the grossly visible demarcation between the squamous anal epithelium and the transitional-columnar epithelium of the rectum. The anal glands open into the bases of the anal crypts at this location.

The lowest extent of the peritoneal cavity in the female lies in the pelvis and may be anterior to the cervix uteri and/or posterior to it. The occupation of this space by the small bowel is called an enterocele; when the space is occupied by the sigmoid colon, this is termed a sigmoidocele.

Contraindications

See Medical Therapy and Intraoperative Details.

More on Rectovaginal Fistula

Overview: Rectovaginal Fistula
Workup: Rectovaginal Fistula
Treatment: Rectovaginal Fistula
Follow-up: Rectovaginal Fistula
References
Further Reading
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References

  1. Galandiuk S, Kimberling J, Al-Mishlab TG, et al. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg. May 2005;241(5):796-801; discussion 801-2. [Medline]. [Full Text].

  2. Bangser M. Obstetric fistula and stigma. Lancet. Feb 11 2006;367(9509):535-6. [Medline].

  3. Browning A, Menber B. Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment. BJOG. Nov 2008;115(12):1564-9. [Medline].

  4. Bricker EM, Johnston WD. Repair of postirradiation rectovaginal fistula and stricture. Surg Gynecol Obstet. Apr 1979;148(4):499-506. [Medline].

  5. Cohen JL, Stricker JW, Schoetz DJ, et al. Rectovaginal fistula in Crohn''s disease. Dis Colon Rectum. Oct 1989;32(10):825-8. [Medline].

  6. Shobeiri SA, Quiroz L, Nihira M. Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas. Int Urogynecol J Pelvic Floor Dysfunct. Jan 22 2009;[Medline].

  7. Gonzalez-Lama Y, Abreu L, Vera MI, et al. Long-term oral tacrolimus therapy in refractory to infliximab fistulizing Crohn's disease: a pilot study. Inflamm Bowel Dis. Jan 2005;11(1):8-15. [Medline].

  8. Laurent S, Barbeaux A, Detroz B, et al. Development of adenocarcinoma in chronic fistula in Crohn's disease. Acta Gastroenterol Belg. Jan-Mar 2005;68(1):98-100. [Medline].

  9. Kumaran SS, Palanivelu C, Kavalakat AJ, et al. Laparoscopic repair of high rectovaginal fistula: is it technically feasible?. BMC Surg. 2005;5:20. [Medline]. [Full Text].

  10. Casadesus D, Villasana L, Sanchez IM, et al. Treatment of rectovaginal fistula: a 5-year review. Aust N Z J Obstet Gynaecol. Feb 2006;46(1):49-51. [Medline].

  11. Khanduja KS, Yamashita HJ, Wise WE Jr. Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach. Dis Colon Rectum. Apr 1994;37(4):344-9. [Medline].

  12. Jasonni VM, La Marca A, Manenti A. Rectovaginal fistula repair using fascia graft of autologous abdominal muscles. Int J Gynaecol Obstet. Jan 2006;92(1):85-6. [Medline].

  13. Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum. Jul 2008;51(7):1084-8. [Medline].

  14. Ulrich D, Roos J, Jakse G, et al. Gracilis muscle interposition for the treatment of recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases. J Plast Reconstr Aesthet Surg. Jan 20 2009;[Medline].

  15. Loffler T, Welsch T, Muhl S, et al. Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn's disease. Int J Colorectal Dis. Jan 27 2009;[Medline].

  16. Burke C. Rectovaginal fistulas. Clin J Oncol Nurs. Jun 2005;9(3):295-7. [Medline].

  17. Fry RD, Kodner IJ. Rectovaginal fistula. Surg Annu. 1995;27:113-31. [Medline].

  18. Hilger WS, Cornella JL. Rectovaginal fistula after posterior intravaginal slingplasty and polypropylene mesh augmented rectocele repair. Int Urogynecol J Pelvic Floor Dysfunct. Jan 2006;17(1):89-92. [Medline].

  19. Husain A, Johnson K, Glowacki CA, et al. Surgical management of complex obstetric fistula in Eritrea. J Womens Health (Larchmt). Nov 2005;14(9):839-44. [Medline].

  20. MacRae HM, McLeod RS, Cohen Z. Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum. Sep 1995;38(9):921-5. [Medline].

  21. Miklos JR, Kohli N. Rectovaginal fistula repair utilizing a cadaveric dermal allograft. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(6):405-6. [Medline].

  22. Moore RD, Miklos JR, Kohli N. Rectovaginal fistula repair using a porcine dermal graft. Obstet Gynecol. Nov 2004;104(5 Pt 2):1165-7. [Medline].

  23. Nowacki MP. Ten years of experience with Parks' coloanal sleeve anastomosis for the treatment of post-irradiation rectovaginal fistula. Eur J Surg Oncol. Dec 1991;17(6):563-6. [Medline].

  24. Steichen FM, Barber HK, Loubeau JM, et al. Bricker-Johnston sigmoid colon graft for repair of postradiation rectovaginal fistula and stricture performed with mechanical sutures. Dis Colon Rectum. Jun 1992;35(6):599-603. [Medline].

  25. Tsang CB, Madoff RD, Wong WD. Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum. Sep 1998;41(9):1141-6. [Medline].

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Keywords

rectovaginal fistula, fistula, Crohn's disease, IBD, fistulas, fistula surgery, inflammatory bowel disease, fistula repair, Crohn disease, ulcerative colitis, advancement flap, obstetric fistula, anovaginal fistulas, obstetric injury, radiation injury, operative trauma, perineal lacerations, forceful coitus, perirectal abscess, diverticulitis, tuberculosis, lymphogranuloma venereum, Bartholin gland abscess, vaginitis, cystitis, sigmoid-vaginal cuff fistulas, proctosigmoidoscopy, sigmoidoscopy, colonoscopy, colostomy

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Contributor Information and Disclosures

Author

Dana Taylor, MD, FACS, Assistant Professor of Surgery, Graduate School of Medicine, University of Tennessee; Consulting Surgeon, University General Surgeons, PC
Dana Taylor, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Eastern Association for the Surgery of Trauma, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Coauthor(s)

Jan Rakinic, MD, Chief, Section of Colorectal Surgery, Southern Illinois University; Program Director, SIU Residency in Colorectal Surgery
Jan Rakinic, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society of Colon and Rectal Surgeons, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine
Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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