History

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.

Workup

Tuma F, McKeown DG, Al-Wahab Z. Rectovaginal Fistula. Treasure Island, FL: StatPearls; 2022. [Full Text].
Abu Gazala M, Wexner SD. Management of rectovaginal fistulas and patient outcome. Expert Rev Gastroenterol Hepatol. 2017 May. 11 (5):461-471. [QxMD MEDLINE Link].
Galandiuk S, Kimberling J, Al-Mishlab TG, Stromberg AJ. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg. 2005 May. 241 (5):796-801; discussion 801-2. [QxMD MEDLINE Link]. [Full Text].
Giordano P, Gravante G, Sorge R, Ovens L, Nastro P. Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch Surg. 2009 Mar. 144 (3):266-72. [QxMD MEDLINE Link].
Cohen JL, Stricker JW, Schoetz DJ Jr, Coller JA, Veidenheimer MC. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum. 1989 Oct. 32 (10):825-8. [QxMD MEDLINE Link].
Bricker EM, Johnston WD. Repair of postirradiation rectovaginal fistula and stricture. Surg Gynecol Obstet. 1979 Apr. 148 (4):499-506. [QxMD MEDLINE Link].
Dawes AJ, Jensen CC. Rectovaginal Fistulas Secondary to Obstetrical Injury. Clin Colon Rectal Surg. 2021 Jan. 34 (1):28-39. [QxMD MEDLINE Link].
Bangser M. Obstetric fistula and stigma. Lancet. 2006 Feb 11. 367 (9509):535-6. [QxMD MEDLINE Link].
Browning A, Menber B. Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment. BJOG. 2008 Nov. 115 (12):1564-9. [QxMD MEDLINE Link].
Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum. 2008 Jul. 51 (7):1084-8. [QxMD MEDLINE Link].
Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum. 2009 Nov. 52 (11):1877-81. [QxMD MEDLINE Link].
Raju R, Linder BJ, Bews KA, Tappy E, Habermann EB, Occhino JA. Perioperative Outcomes of Rectovaginal Fistula Repair Based on Surgical Approach: A National Contemporary Analysis. Female Pelvic Med Reconstr Surg. 2021 Feb 1. 27 (2):e342-e347. [QxMD MEDLINE Link].
Ulrich D, Roos J, Jakse G, Pallua N. Gracilis muscle interposition for the treatment of recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases. J Plast Reconstr Aesthet Surg. 2009 Mar. 62 (3):352-6. [QxMD MEDLINE Link].
Schouten WR, Oom DM. Rectal sleeve advancement for the treatment of persistent rectovaginal fistulas. Tech Coloproctol. 2009 Dec. 13 (4):289-94. [QxMD MEDLINE Link].
Byrnes JN, Schmitt JJ, Faustich BM, Mara KC, Weaver AL, Chua HK, et al. Outcomes of Rectovaginal Fistula Repair. Female Pelvic Med Reconstr Surg. 2017 Mar/Apr. 23 (2):124-130. [QxMD MEDLINE Link].
Shobeiri SA, Quiroz L, Nihira M. Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas. Int Urogynecol J Pelvic Floor Dysfunct. 2009 May. 20 (5):571-3. [QxMD MEDLINE Link].
VanBuren WM, Lightner AL, Kim ST, Sheedy SP, Woolever MC, Menias CO, et al. Imaging and Surgical Management of Anorectal Vaginal Fistulas. Radiographics. 2018 Sep-Oct. 38 (5):1385-1401. [QxMD MEDLINE Link].
Hauch A, McKee RM, Li WY, Crowley JS, Ramamoorthy S, Dobke M. Rectovaginal Fistula Repair 1 Year Later: Lessons Learned. Ann Plast Surg. 2021 Aug 1. 87 (2):187-193. [QxMD MEDLINE Link].
[Guideline] Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1. 65 (8):964-985. [QxMD MEDLINE Link]. [Full Text].
González-Lama Y, Abreu L, Vera MI, Pastrana M, Tabernero S, Revilla J, et al. Long-term oral tacrolimus therapy in refractory to infliximab fistulizing Crohn's disease: a pilot study. Inflamm Bowel Dis. 2005 Jan. 11 (1):8-15. [QxMD MEDLINE Link].
Nirei T, Kazama S, Hiyoshi M, Tsuno NH, Nishikawa T, Tanaka T, et al. Successful treatment of rectovaginal fistula complicating ulcerative colitis with infliximab: a case report and review of the literature. J Clin Med Res. 2015 Jan. 7 (1):59-61. [QxMD MEDLINE Link]. [Full Text].
Laurent S, Barbeaux A, Detroz B, Detry O, Louis E, Belaiche J, et al. Development of adenocarcinoma in chronic fistula in Crohn's disease. Acta Gastroenterol Belg. 2005 Jan-Mar. 68 (1):98-100. [QxMD MEDLINE Link].
Kumaran SS, Palanivelu C, Kavalakat AJ, Parthasarathi R, Neelayathatchi M. Laparoscopic repair of high rectovaginal fistula: is it technically feasible?. BMC Surg. 2005 Oct 12. 5:20. [QxMD MEDLINE Link]. [Full Text].
Mukwege D, Mukanire N, Himpens J, Cadière GB. Minimally invasive treatment of traumatic high rectovaginal fistulas. Surg Endosc. 2016 Jan. 30 (1):379-87. [QxMD MEDLINE Link].
Lamazza A, Fiori E, Schillaci A, Sterpetti AV, Lezoche E. Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results. Colorectal Dis. 2015 Apr. 17 (4):356-60. [QxMD MEDLINE Link].
Yuan X, Chen H, Chen C, Yang M, Li Q, Gao R, et al. Minimally invasive treatment of mid-low rectovaginal fistula: a transanal endoscopic surgery study. Surg Endosc. 2020 Sep. 34 (9):3971-3977. [QxMD MEDLINE Link].
Casadesus D, Villasana L, Sanchez IM, Diaz H, Chavez M, Diaz A. Treatment of rectovaginal fistula: a 5-year review. Aust N Z J Obstet Gynaecol. 2006 Feb. 46 (1):49-51. [QxMD MEDLINE Link].
Khanduja KS, Yamashita HJ, Wise WE Jr, Aguilar PS, Hartmann RF. Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach. Dis Colon Rectum. 1994 Apr. 37 (4):344-9. [QxMD MEDLINE Link].
Jasonni VM, La Marca A, Manenti A. Rectovaginal fistula repair using fascia graft of autologous abdominal muscles. Int J Gynaecol Obstet. 2006 Jan. 92 (1):85-6. [QxMD MEDLINE Link].
Tong Y, Trilling B, Sage PY, Girard E, Faucheron JL. Short-term outcomes of the over-the-scope clip proctology system for rectovaginal fistula repair: a prospective study. Tech Coloproctol. 2019 Mar. 23 (3):245-249. [QxMD MEDLINE Link].
Löffler T, Welsch T, Mühl S, Hinz U, Schmidt J, Kienle P. Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn's disease. Int J Colorectal Dis. 2009 May. 24 (5):521-6. [QxMD MEDLINE Link].
El-Gazzaz G, Hull T, Mignanelli E, Hammel J, Gurland B, Zutshi M. Analysis of function and predictors of failure in women undergoing repair of Crohn's related rectovaginal fistula. J Gastrointest Surg. 2010 May. 14 (5):824-9. [QxMD MEDLINE Link].

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Author

Dana Taylor, MD, FACS Assistant Professor of Surgery, University of Tennessee Health Science Center College of Medicine; 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, Southeastern Surgical Congress, Eastern Association for the Surgery of Trauma, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jan Rakinic, MD Chief, Section of Colorectal Surgery, Program Director, SIU Residency in Colorectal Surgery, Southern Illinois University School of Medicine

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, Illinois State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Lewis J Kaplan, MD, FACS, FCCM, FCCP Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania; Section Chief, Surgical Critical Care, Philadelphia Veterans Affairs Medical Center

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, Surgical Infection Society

Disclosure: Nothing to disclose.

Acknowledgements

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

Rectovaginal Fistula Clinical Presentation

History

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