Edit concept Create issue ticket

Rectovaginal Fistula

Recto Vaginal Fistula

Rectovaginal fistula is defined as an abnormal epithelial-lined connection between the rectum and vagina. It is frequently seen as a bothersome condition for both patients and surgeons, because of the distressing and annoying signs as well as its high repair failure rate.


Presentation

The presentation shows no major variation from case to case. A little group of patients appear to be asymptomatic, while the majority frequently report the distressing symptom of the passage of flatus and stools through the vagina, especially when patients are affected by diarrhea. The condition is further worsened by fecal incontinence as a consequence of sphincter damage. This clinical situation is usually followed by the appearance of inflammation in the form of vaginitis or cystitis. Fecal incontinence is particularly frequent in patients who have experienced an obstetrical trauma, with a frequency of up to 50%.

Abnormalities observed in the rectal mucosa or a previous and coexisting fistula-in-ano usually indicates the presence of Crohn disease. The prompt diagnosis of this condition is paramount, as it might lead to an inappropriate surgical intervention which further worsens the patient's situation.

Aspiration
  • Postoperative complications included 1 superficial wound infection that was treated conservatively and 1 rectovaginal hematoma, which required CT-guided aspiration.[ncbi.nlm.nih.gov]
Disability
  • This devastating and disabling complication has a significant impact on patients' quality of life and presents unique management challenges.[ncbi.nlm.nih.gov]
  • This article offers a disease-based review of traditional management strategies and highlights the variety of technical approaches that are currently effective for the eradication of this socially disabling condition.[scholars.northwestern.edu]
  • It is a disabling condition that negatively impacts a woman's quality of life. Current treatment algorithms range from observation to medical management to the need for surgical intervention.[ncbi.nlm.nih.gov]
Congestive Heart Failure
  • A 77-year-old woman, with a medical history of 2 myocardial infarctions, congestive heart failure, 2 cardiac stents, multiple urinary-tract infections, and diverticulitis, presented to the hospital with a fever of 38.3 degrees C (101 degrees F) for 2[ncbi.nlm.nih.gov]
Hyperthermia
  • Twenty-three patients (77%) had curative radiotherapy with or without chemotherapy and/or hyperthermia. Seven patients (23%) received only palliative therapy or no treatment at all.[ncbi.nlm.nih.gov]
Heart Failure
  • A 77-year-old woman, with a medical history of 2 myocardial infarctions, congestive heart failure, 2 cardiac stents, multiple urinary-tract infections, and diverticulitis, presented to the hospital with a fever of 38.3 degrees C (101 degrees F) for 2[ncbi.nlm.nih.gov]
Suggestibility
  • Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.[ncbi.nlm.nih.gov]
  • Histopathology confirmed the presence of multiple shallow ulcers throughout the colon with features suggestive of Beçhet's colitis.[ncbi.nlm.nih.gov]
  • Neither the initial clinical examination nor the pathologic examination suggested the correct diagnosis.[ncbi.nlm.nih.gov]
  • We suggest that this approach can be used on selected patients with high rectovaginal fistula or other rectal pathology who are otherwise not candidates for a transanal approach.[ncbi.nlm.nih.gov]
  • Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.[ncbi.nlm.nih.gov]
Neglect
  • The clinician must stress proper pessary maintenance in order to avoid the serious consequences of a neglected pessary.[ncbi.nlm.nih.gov]
Vaginal Discharge
  • An 82-year-old woman was admitted with feculent vaginal discharge and bleeding per vagina. Investigations revealed the presence of a rectovaginal fistula with no obvious etiology.[ncbi.nlm.nih.gov]
  • The patient was admitted in our department 4 years after the onset of the disease, with an altered general state, diarrhea, malnutrition, fever and fecaloid vaginal discharge.[ncbi.nlm.nih.gov]
  • Success was defined by the absence of a diverting stoma and/or any vaginal discharge of faeces, flatus or mucous discharge. Ten women [median age 39 (24.5-65) years] were included.[ncbi.nlm.nih.gov]
  • Rectovaginal Fistula 59 year-old woman who had presented with frequent episodes of vaginitis, vaginal discharge and a history of passing air per vagina.[endoatlas.com]
  • Symptoms The following are the major symptoms of the rectovaginal fistula: Vaginal discharge: Faecal material and gas are discharged through the vaginal route. In severe case, pus is also passed away from vaginal route.[healthsurgical.com]
Dyspareunia
  • Dyspareunia was higher in unhealed women.[ncbi.nlm.nih.gov]
  • Advanced Procedure Modified Martius flap for rectovaginal fistula Indications Repair of rectovaginal fistula after multiple failed attempts Contraindications Pre-existing dyspareunia (relative) Preoperative Workup CT scan, digital rectal exam, vaginal[csurgeries.com]
  • Patients may also present with dyspareunia secondary to inflammed or irritated vaginal tissue at the site of the fistula.[gynecologicsurgery.com]
  • .  Preoperative discussion  anticipated results  abnormally high patient expectations need to be adjusted  Quality of life and assessment of dyspareunia and sexual dysfunction after rectovaginal fistula surgery have not been rigorously evaluated in[slideshare.net]
  • During intercourse, she had severe dyspareunia which was followed by bleeding; otherwise she didn’t have leakage of feces or flatus the first three days after the event.[omicsonline.org]
Foul Smelling Urine
  • Presenting symptoms included passage of feces per vaginam, signs of intestinal subocclusion without perianal inflammation, left leg paresis and foul-smelling urine. An anterior sacral meningocele was repaired at the age of three months.[ncbi.nlm.nih.gov]

Workup

The presence of a sepsis is usually confirmed by laboratory studies which include:

  • Complete blood count
  • Blood culture
  • Blood urea nitrogen
  • Creatinine

RVF appears elusive on physical examination [11], and this is the reason why its presence has to be confirmed with other tests such as:

  • Barium enema
  • Computed tomography: Particularly useful especially when a perifistular inflammation is involved.
  • Endorectal and transvaginal ultrasound: Frequently used to identify low fistula tracts [12] [13].
  • Vaginography: Used to diagnose proximal fistulas.
  • Endoscopy: Especially when physicians suspect the involvement of inflammatory bowel disease.
  • Endoanal ultrasound: Very accurate when physicians need to identify a sphincter defect [12].
  • Magnetic resonance imaging (MRI): As for endoanal ultrasound, MRI too is very accurate when there is the need of identifying sphincter defects [12].
  • Manometry: Used to localize sphincter defects when there is no apparent anatomic problem.

The physical examination serves to assess the physical integrity of the tissues surrounding the fistula, as well as localizing its position, and it can be very valuable to assess anal sphincter before planning surgical procedures. When the fistula is small in size, the physician may notice the presence of a palpable depression and pit-like defect in the anterior midline of the rectum. The mucosa of the fistula track is generally darker than the vagina's, which might be affected by vaginitis.

The physical examination of suspected RVF cases should include a careful inspection of the rectum, vagina, and perineal body. Digital examination is particularly advised, as it allows to locate low or anovaginal fistulas when small dimples are present, which in turn can be easily confirmed by anoscopic and speculum examination. The physical examination is carried out by inserting a finger in the anus and another in the vagina. Obviously, the higher the position of the fistula, the more difficult the diagnosis will be.

Treatment

Of note, many fistulas following obstetric or operative trauma heal spontaneously and require no further treatment. However, the presence of the fistulas might be persistent and cause the appearance of local cases of inflammation. When this condition occurs, the patient needs to be treated with the due approach and set of techniques.
Experts suggest to perform a biopsy on the area under examination, to rule out the possibility of neoplasm. If the fistula is the result of a particular trauma, the therapy consists in draining the abscesses and treating infections with antibiotics. The tissues affected should heal within 6-12 weeks, while the related symptoms and signs can be greatly diminished if the due dietary modifications are applied.

In case of inflammatory bowel disease, repair is possible while the patient is on steroids, even though with a very high risk of failure. The surgical operation consists of a local or transabdominal approach with a minimum level of invasivity [14], especially in the cases of high RVF originated from neoplasms, radiation therapy, or inflammatory bowel disease. The approach should be accompanied by treatments aimed at restoring bowel function and controlling diarrhea, as well as a course of antibiotics and immunosuppressive medications to prepare the patient for the surgical operation. If the tissues surrounding the fistula appear to be healthy and in good conditions, surgical repair can be performed immediately, otherwise a period of preparation ranging from 3 to 6 months is recommended. The most common surgical operation is advancement flap [15] and its many variations, all based on the approach of excising and closing the fistula rectal portion, then covering everything on the fistula high pressure side with a vascularized musical flap.

In addition to advancement flaps, another approach has recently been adopted, which was developed for the treatment of intersphincteric anorectal fistulas. The surgical procedure concerned is called LIFT (ligation of intersphincteric fistula tract), and consists of dissecting the bloodless portion after the fistula lying between the external and internal anal sphincters.

Prognosis

RVF has always been an agonizing disorder for the patients and a troublesome condition for physicians, which requires an individualized and systematic approach based on size, etiology, location, as well as the right techniques to get the most out of the treatment. The worst cases are represented by the patients affected by recurrent RVF, who have the poorest prognosis for final repairs [9]. In this case, experts recommend the use of rectal sleeve advancement, which is reported to have a healing rate of around 75% [10]. However, recurrence seems to be influenced by the etiology and complexity of RVF, and therefore fistulas with obstetric origin and more generally those considered “simple” have a far better prognosis.

Etiology

The most common etiological factor of RVF is obstetric injury [1] [2]. The other possible etiologies are described as follows:

RVF might occur following childbirth, something which especially common in underdeveloped countries. The condition may result as the consequence of prolonged labor with necrosis of the rectovaginal septum or an obstetric injury associated with a third- or fourth-degree perineal tear or episiotomy. Other causes for the development of a fistula may be inadequate or interrupted repair or an infection.

Fistula development is particularly frequent with infectious processes inside the rectovaginal septum. For instance, cryptoglandular anorectal abscesses and Bartholin gland infections might drain spontaneously, leading to RVF. The most common infectious causes of fistulas include diverticular disease in the setting of previous hysterectomy, but cases associated with tuberculosis and lymphogranuloma venereum have also been observed. Moreover, malignancies have been reported as cause of RVF, usually seen with large extent in the uterine, rectal, vaginal, and cervical areas, and frequently treated with radiological methodologies. After radiological treatment, proctitis appears which is then followed by anterior rectal wall ulceration that finally results in fistula formation within 6 to 24 months after the initial radiological therapy.

Fistulas might also develop from operative trauma, especially in the context of anorectal and vaginal surgical procedures. For example, during low stapled colorectal anastomoses, the vaginal walls end up being incorporated in staplers or anastomotic leaks during formation of abscesses, which in turn result in the development of a fistula. Other surgical risks include pelvic procedures, which might cause the formation of a high RVF, hysterectomy after radiation therapy, or unrecognized intraoperative rectal injury.

Inflammatory bowel diseases are frequently associated with RVF formation, especially Crohn disease as it might cause transmural inflammation of the rectal wall [5]. In this case, RVF usually develops before the appearance of intestinal symptoms [6]. RVF is also often associated with ulcerative colitis, especially in the context of ileo-anal pouch anastomoses characterized by anastomotic leak or pelvic abscess. Complications of radiation therapy or surgical operations such as rectocele repair and restorative proctocolectomy may also lead to RVF.

Rarer etiologies include vaginal dilatation (especially after radiation at the level of the vaginal cuff), fecal impaction, sexual assault, and infections of bacterial or viral origin in subjects affected by HIV immunodeficiency.

Epidemiology

The frequency of RVF varies greatly on the basis of the particular etiology. RVF classification is based on its location, size, and etiology, and affects profoundly the treatment options and the possible prognosis for the patient. According to its location, RVF can be divided in two main groups:

  1. Low RVF: In this case, the fistula is positioned between the lower half of the vagina and the lower third of the rectum. Because of this particular location, RVF is very close to the anus and treatment requires a perineal approach. 
  2. High RVF: Here, the fistula is located between the posterior vaginal fornix and the middle third of the rectum. High RVF is located in greater distance to the anus compared to low RVF, and treatment requires a transabdominal approach.

RVF is particularly frequent in patients affected by inflammatory bowel disease, especially in those who also present with Crohn disease rather than in those with ulcerative colitis. In this last case, the incident rate of RVF has been found to range between 0.5 and 2.2% [7].

Sex distribution
Age distribution

Pathophysiology

There are several mechanisms connected with RVF development. The first one is perineal laceration during childbirth, above all in the cases occurring after episioproctotomy, a factor which highly increases the predisposition to develop fistulas. Perineal laceration is particularly frequent in primigravidae, especially when pregnancy becomes precipitous, and with the use of forceps or vacuum extraction. The probability of developing RVF further increases if perineal laceration is not promptly diagnosed and duly treated, or in case of secondary infections.

Another factor which might cause the development of RVF is a vaginal or rectal surgical procedure that is not properly performed. This frequently happens when surgical procedures are carried out near the dentate line, and complications can become very likely especially in the context of stapled hemorrhoidopexy, STARR (stapled transanal rectal resection), and TRANSTAR (transanal stapled resection) [8]. The list of surgical procedures should also include pelvic operations, which can cause the development of high RVF. It should be noted that the mechanical trauma responsible for the appearance of the fistula can also derive from a traumatic injury, be it penetrating or blunt, or from a forceful coitus which has created a heavy mechanical stress.

RVF has also been seen associated with Crohn disease [3] and ulcerative colitis. In this case, the fistula can appear as either a primary event or as a secondary symptom following the appearance of a perirectal abscess after the development of perianal sepsis.

Radiation is regarded the mainstay of treatment for pelvic malignancies and can be included in the list of pathophysiological mechanisms responsible for the development of RVF [4]. Fistulas, in fact, may frequently arise after this type of therapy, and they only become apparent months after the completion of the treatment. In general, it takes from 6 to 24 months on average for physicians to be able to observe the development of a fistula following radiation therapy. In this context, the risk of fistula formation is further increased by other factors such as smoking, previous abdominal or pelvic operations, diabetes mellitus, or hypertension. Since any type of neoplasm, primary, recurrent, or metastatic, can trigger the development of RVF, it is very important to use biopsy in order to differentiate any radiation-related change in the fistula from a recurrent tumor.

Lastly, infection is also another pathophysiological mechanism which might cause RVF. The types of infection which are mostly correlated with cases of RVF include perirectal abscess and diverticulitis, to which should be added the less frequent types such as Bartholin gland abscess, lymphogranuloma venereum, and tuberculosis.

Prevention

There is no known method to prevent the development of RVF.

Summary

Rectovaginal fistula (RVF) is a tract which connects the rectum with the vagina. It appears as a devastating condition for the patients and a serious technical challenge for surgeons due to the difficulty of the related surgical procedure. RFV has a number of etiologies which include obstetric injury, inflammatory bowel disease, trauma, malignant processes, and possible complications of radiological and surgical procedures. Treatment depends on many factors such as etiology, size, location of the fistula itself, and includes different repair options like local repairs, abdominal operations, and transfer techniques.

Patient Information

A rectovaginal fistula (RVF) is a connection that develops in the lower part of the large intestine and vagina. Because of this defect, the gases and stools present in the bowels can leak out through the vagina, causing a distressful and shocking situation for the patient affected. RVF appears when one of the following conditions occurs:

  • Injury during childbirth
  • Inflammatory bowel disease
  • Crohn disease
  • Radiation therapy (as clinical complication)
  • Cancer in the pelvic area (as clinical complication)
  • Surgery of the pelvic area (as clinical complication)

Symptoms depend on the size and location of the fistula, and range from minor signs to significant conditions such as incontinence. These can be summed up as follows:

  • Recurrent infections in the vaginal and urinary area
  • Passage of gases and stools normally contained in the bowels through the vagina
  • Foul-smelling discharge from the vagina as a consequence of the passage of bowel contents through it
  • Irritations of the areas inside vulva, vagina, and perineum (the region between vagina and anus)
  • Intense pain felt while engaging in sexual intercourse

In some cases fistulas might heal spontaneously. However, the majority of the patients need surgical procedures that are aimed at removing the fistula and closing the opening with portions of the surrounding healthy tissues.

References

Article

  1. Bangser M. Obstetric fistula and stigma. Lancet. 2006 Feb 11. 367(9509):535-6.
  2. 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.
  3. Bricker EM, Johnston WD. Repair of postirradiation rectovaginal fistula and stricture. Surg Gynecol Obstet. 1979 Apr. 148(4):499-506.
  4. Cohen JL, Stricker JW, Schoetz DJ, et al. Rectovaginal fistula in Crohn''s disease. Dis Colon Rectum. 1989 Oct. 32(10):825-8.
  5. Radcliffe AG, Ritchie JK, Hawley PR, Lennard-Jones JE, Northover JM. Anovaginal and rectovaginal fistulas in Crohn's disease. Dis Colon Rectum. 1988 Feb;31(2):94-9.
  6. Greenwald JC, Hoexter B. Repair of rectovaginal fistulas. Surg Gynecol Obstet. 1978 Mar;146(3):443-5.
  7. Zinicola R, Nicholls RJ. Restorative proctocolectomy in patients with ulcerative colitis having a recto-vaginal fistula. Colorectal Dis. 2004 Jul;6(4):261-4.
  8. 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.
  9. 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. 2009 Jan 20.
  10. Schouten WR, Oom DM. Rectal sleeve advancement for the treatment of persistent rectovaginal fistulas. Tech Coloproctol. 2009 Dec. 13(4):289-94.
  11. Shobeiri SA, Quiroz L, Nihira M. Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jan 22.
  12. Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol. 2002 Mar;178(3):737-41.
  13. Alexander AA, Liu JB, Merton DA, Nagle DA. Fecal incontinence: transvaginal US evaluation of anatomic causes. Radiology. 1996 May;199(2):529-32.
  14. Kumaran SS, Palanivelu C, Kavalakat AJ, et al. Laparoscopic repair of high rectovaginal fistula: is it technically feasible?. BMC Surg. 2005. 5:20.
  15. Casadesus D, Villasana L, Sanchez IM, et al. Treatment of rectovaginal fistula: a 5-year review. Aust N Z J Obstet Gynaecol. 2006 Feb. 46(1):49-51.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 03:19