Rectovaginal Fistula Workup

  • Author: Dana Taylor, MD, FACS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jul 22, 2011
 

Laboratory Studies

  • Laboratory studies (eg, complete blood cell [CBC] count, blood cultures, electrolytes, blood urea nitrogen [BUN], creatinine, type and screen) are obtained to assess for sepsis, which is extremely rare in fistulas between the GI and female genital tracts. Laboratory studies are also helpful in the establishment of preoperative baselines.
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Imaging Studies

  • Ancillary studies may illustrate a rectovaginal fistula (RVF) that is elusive on physical examination.[6]
    • Barium enema can demonstrate RVF or the more common sigmoid-vaginal cuff fistula observed in diverticulitis.
    • Computed tomography (CT) scanning often shows perifistular inflammation, identifying the responsible digestive organ.
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Other Tests

  • Physical examination is essential. This usually confirms the diagnosis of rectovaginal fistula (RVF) and affords much information regarding its size and location, the function of the sphincters, and the possibility of IBD or local neoplasm. (Anal sphincter disruptions are commonly seen in association with RVFs of obstetric origin. Sphincter function should be evaluated prior to any repair.)
  • Office examination usually consists of a rectovaginal examination (visual and palpation) and proctosigmoidoscopy. The fistula opening may be seen as a small dimple or pit and occasionally can be gently probed for confirmation.
  • The suspicion of Crohn disease should be high if there is any other abnormality of the rectal mucosa or a previous or currently coexisting fistula-in-ano. Failure to recognize Crohn disease can lead to inappropriate operative intervention and can worsen the patient's situation.
  • Placing a vaginal tampon, instilling methylene blue into the rectum, and examining the tampon after 15-20 minutes can often establish the presence of RVF. If the tampon is unstained, another part of the GI tract may be involved.
  • Endorectal and transvaginal ultrasonography may be used to help identify low fistulas.
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Diagnostic Procedures

  • Flexible endoscopy (sigmoidoscopy or colonoscopy) is used to fully evaluate the possibility of IBD. Because treatment varies according to the diagnosis, endoscopy with biopsies must precede any operative approach to the fistula, when IBD is in the differential diagnosis.
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Histologic Findings

Histology is most important in the evaluation of possible IBD. Neither a diagnosis of ulcerative colitis nor of Crohn disease completely excludes operative repair of a rectovaginal fistula (RVF), but operative planning is altered, as is the prognosis. If the rectum is grossly normal in Crohn disease, the prognosis of RVF repair is fair. When the rectum is abnormal, prognosis is considerably worse. The histopathology of any fistula considered suggestive of primary or recurrent neoplasm is of the utmost importance.

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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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

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 Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, 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 Consulting; ARdelyx Ownership interest Board membership

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of the previous author, Carol EH Scott-Conner, MD, PhD, to the development and writing of this article.

References

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