Rectovaginal Fistula Clinical Presentation

Updated: Jul 29, 2022
  • Author: Dana Taylor, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
  • Print


The clinical presentation of rectovaginal 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 through the 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.


Physical Examination

Physical examination is essential. This usually confirms the diagnosis of RVF and provides a great deal of information regarding the size and location of the fistula, the functioning of the sphincters, and the possibility of inflammatory bowel disease (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 gastrointestinal (GI) tract may be involved.