Rectovaginal Fistul1

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Rectovaginal Fistula

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.

Epidemiology

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 disease [5]), 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. Perineallacerations 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. The stapled hemorrhoidopexy and STARR (stapled transanal rectal resection

and TRANSTAR (transanal stapled resection) have had increasing complications of

RVFs.[6] Pelvic operations can be complicated by the development of a high RVF.

Traumatic injury (penetrating or blunt) and forceful coitus also have produced RVFs.


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Crohn disease[5] 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 mostcases. 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 andthe 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.

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 isextremely 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.[7]

Barium enema can demonstrate RVF or the more common sigmoid-vaginal cuff fistulaobserved in diverticulitis.

Computed tomography (CT) scanning often shows perifistular inflammation, identifyingthe responsible digestive organ.

Other Tests

Physical examination is essential. This usually confirms the diagnosis of rectovaginalfistula (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 andoccasionally can be gently probed for confirmation.

The suspicion of Crohn disease should be high if there is any other abnormality of therectal 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 thetampon 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.Diagnostic Procedures

Flexible endoscopy (sigmoidoscopy orcolonoscopy) is used to fully evaluate the possibility

of treatment varies according to the diagnosis, endoscopy with biopsies must precede any

operative approach to the fistula, when IBD is in the differential diagnosis.

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.

Medical Therapy

Use local care, drainage of abscesses, and directed antibiotic therapy to treat acute

rectovaginal fistulas (RVFs) of traumatic origin (including those caused by obstetric [2, 3] and

operative trauma), RVFs complicated by secondary infection, and fistulas of infectious

origin. Allow tissues to heal for 6-12 weeks. Dietary modification and supplemental fiber can

greatly diminish symptoms during this period. Many fistulas resulting from obstetric or

operative trauma heal completely, requiring no further therapy. When the fistula persists after

this period of treatment and the tissues become uninflamed and supple, repair may beconsidered.
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Perform a biopsy on any area suggestive of neoplasm. Treat neoplasms as appropriate. In this

setting, very symptomatic fistulas may prompt the physician and patient to consider a

diverting colostomy for patient comfort. Otherwise, fecal diversion is rarely used with

RVFs.[1]

If the evaluation is consistent with the diagnosis of IBD, institute appropriate medical

therapy. Repair of an RVF can be performed while the patient is on steroids, with the

understanding that the risk of failure is increased. Even after initial failed repair attempts,

some patients with Crohn disease can maintain RVF repair while on antimetabolites, such as

6-mercaptopurine or azathioprine (Imuran). Clinical use of infliximab (Remicade)[8] suggests

that few fistulas heal completely, but most patients are dramatically improved

symptomatically. Predictors of failure requiring fecal diversion have been identified and

include significant colonic involvement and the presence of anal stricture.[1] The development

of carcinoma has been described in Crohn fistulas.[9]

RVFs originating from radiation therapy are very difficult to treat surgically,[4] and medical

therapy is often initially recommended in this setting. Diet and fiber are the mainstays of

therapy.

Surgical Therapy

See Intraoperative Details.

Preoperative Details

Complete mechanical bowel preparation is essential for the transabdominal repair of

rectovaginal fistula (RVF) and is also recommended for local repairs. The practice of

including poorly absorbed oral antibiotics in the bowel preparation is under scrutiny. New

data suggest that intravenous antibiotics administered in a manner that provides appropriate

tissue levels at the beginning of the operative procedure are sufficient for prophylaxis. The

author recommends that prophylactic intravenous antibiotics be administered preoperatively

for all patients undergoing RVF repairs, transabdominal or local.

Although diverting colostomy was used in the past, the overwhelming majority of RVFs are

now repaired without this procedure being performed beforehand.

Cleanse the vaginal lumen with an antiseptic solution, such as Betadine. Insert a catheter into

the urinary bladder.

If a transabdominal procedure is planned, perform standard preoperative cardiopulmonary

evaluation as appropriate. Prophylaxis against venous thromboembolism is essential and may

include the use of fractionated or unfractionated heparin, as well as the employment of

sequential compression devices. If the pelvis has been irradiated or previously operated upon,the use of ureteral catheters may aid in dissection. A laparoscopic approach has been

described.[10]

Intraoperative Details

Local repair methods

Transanal advancement flap repair[11]

The best results have been reported with this type of repair. General, regional, or local

anesthesia may be used. The patient is placed in the prone, flexed position with a hip roll in

place; the buttocks are taped apart for exposure. The fistula is identified using the operating

anoscope. A flap is outlined, extending at least 4 cm cephalad to the fistula, with the base ofthe flap twice the width of the apex to allow adequate blood supply to the flap tip. Local


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anesthetic with epinephrine is injected submucosally to facilitate raising the flap and to

diminish bleeding.

The flap, consisting of mucosa and submucosa, is raised; some surgeons include circular

muscle as well. Meticulous hemostasis is imperative. The fistula tract is curetted gently.

Circular muscle is closed over the fistula. The tip of the flap, which includes the fistula

opening, is excised. The flap is sutured in place with simple interrupted, absorbable sutures,

effectively closing the rectal opening of the fistula. The vaginal side of the fistula is left open

for drainage. This approach separates the suture line from the fistula site and interposes

healthy muscle between the rectal and vaginal walls. Proponents point out that the relatively

high pressure within the rectum serves to buttress the repair, in contrast to a transvaginal

repair, in which the intrarectal pressure is more prone to disrupt the repair. If indicated,

sphincteroplasty can be performed concomitantly.[12]

Transvaginal inversion repair

The vaginal mucosa is circumferentially elevated, exposing the fistula. Two or 3 concentric

pursestring sutures are used to invert the fistula into the rectal lumen. The vaginal mucosa is

reapproximated. This approach is suitable only for small, low fistulas in otherwise healthytissues with an intact perineal body. It is rarely performed today.

Bioprosthetic repair

Bioprosthetic interposition graft is placed by making a transverse incision over the

midportion of the perineal body with dissection through the subcutaneous tissue. The fistula

tract is transected. The dissection is continued 2 cm proximal to the transected fistula tract

and laterally. The fistula openings are closed with 3/0 interrupted, absorbable sutures. The

graft needs an overlap of 2 cm on all sides of the rectal and vaginal mucosal closures. A

bioprosthetic plug is placed through the rectal opening and out the vaginal opening. The

excess plug is trimmed and secured on the rectal side with 2/0 absorbable suture.Conversion to complete perineal laceration with layer closure

[11]

The fistulous tract is laid open in the midline, essentially creating a cloaca. Closure in layers

follows, identical to the classic obstetric repair of a fourth-degree perineal laceration. This

method is described in the gynecologic literature; it is rarely employed by colorectal surgeons

because of concerns of juxtaposed suture lines.

Simple fistulotomy

This procedure works well for true anovaginal fistulas, in which no sphincter is involved in

the tract. If the technique is used to treat an RVF, however, partial or total fecal incontinence

results.

Transabdominal approaches

Transabdominal approaches are generally used for high RVFs when the fistula originates

from a neoplasm, from radiation, or, occasionally, from IBD. They are also used if

concomitant disease (eg, diverticulitis) warrants an abdominal approach.

Fistula division and closure without bowel resection

This is the simplest abdominal approach. The rectovaginal septum is dissected, the fistula is

divided, and the rectum and vagina are closed primarily without bowel resection.

Interposition of healthy tissue, such as omentum, may be used to buttress the repair andseparate the suture lines. Good results have been reported when the fistula is not large and thetissues available for closure are healthy.


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Bowel resection

When tissues are abnormal because of irradiation, inflammation, or neoplasm, the repair is

doomed to failure unless the abnormal tissues are resected. Preserve functional anal

sphincters whenever possible by use of a low anterior resection, a coloanal anastomosis

technique, or a pull-through; the last alternative has the poorest results with respect to

continence. Rarely, abdominoperineal resection may be necessary for symptom control in the

setting of radiation damage or neoplasm. An alternative, particularly in cases of poor

operative risks or with patients whose survival is limited, is simple fecal diversion with a loop

ileostomy or colostomy.

Ancillary procedures

A host of supplementary procedures have been described to augment bowel resection in the

difficult pelvis. These include local flaps, such as the bulbocavernosus flap, and a variety of

muscle, fascial, and musculocutaneous flaps for repair of large pelvic defects. A variety of

graft procedures also have been described.[13] All of these procedures have the goal of

interposing healthy tissue between vaginal and rectal repairs. These are well described in the

plastic surgery literature.

Postoperative Details

Local repairs

Pay attention to the patient's bowel habits. Constipation or diarrhea can disrupt a repair. The

goal is a soft, formed, deformable stool. The patient is carefully counseled regarding diet,

copious fluid intake, and the use of stool softeners. The use of bulking agents immediately

after repair is at the discretion of the surgeon and is a matter of individual preference rather

than of scientifically proven practice. The use of oral antibiotics also varies. The author

prefers that patients use an oral broad-spectrum antibiotic for 3-5 days postoperatively, take 1

tablespoon of mineral oil orally twice daily for 2 weeks postoperatively, and avoid bulkingagents for 2 weeks postoperatively. The patients need to refrain from sexual activity or any

physical activity more strenuous than a slow walk for 3 weeks.

Abdominal repairs

Postoperative care is identical to the care administered to all patients who have undergone

major laparotomy with bowel resection and anastomosis. Postoperative gastric

decompression is performed selectively, expecting that 15-20% of patients require cessation

of oral intake or gastric decompression for symptomatic postoperative ileus. Most patients

can be offered sips of clear liquids on the first postoperative day. Early ambulation is

beneficial in many ways. Continue perioperative prophylaxis for thromboembolic events until

the patient is ambulating well.

Follow-up

Patients are seen 2 weeks after discharge for evaluation of wounds and bowel habits. In the

absence of recurrent fistula symptoms or other specific indications, no follow-up

investigation, aside from physical examination, is required. Specific signs and symptoms are

investigated appropriately. For example, fever, diarrhea, and low abdominal pain indicating

an abscess are evaluated by a CT scan of the abdomen and pelvis. In this setting, physical

examination may be difficult because of patient discomfort.

Complications


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Complications of local repairs

Bleeding is rarely encountered postoperatively, probably because of careful intraoperative

hemostasis. If bleeding occurs beneath the flap, fistula recurrence is common. Infection is a

feared complication, because it almost invariably results in a failed repair. However, good

data on the incidence of infection after local repair are few. Of course, repairs may fail in the

absence of infection as well (see Outcome and Prognosis). Rarely, postoperative pain

precipitates urinary retention.

Complications of transabdominal repairs

These may include the usual complications of any laparotomy with bowel resection,

including fistula recurrence. The most common complications are bleeding and wound

infection, each with an incidence of less than 2-5% in reasonable-risk candidates. Pelvic

abscess occurs in 5-7% of patients. Data from the United States and Europe suggest that

anastomotic leaks occur more often than is clinically recognized. However, because

intervention is indicated only in clinically evident leaks, routine postoperative anastomotic

evaluation is not warranted.

Outcome and Prognosis

Local repair methods

Transanal advancement flap repair

This approach to rectovaginal fistula (RVF) repair is very safe. Results are good to excellent,

with success reported in 77-100% of patients in various series. Reports have noted the

importance of preoperative assessment of anal sphincter integrity. Sphincter repair is easily

performed simultaneously and increases the success rate of RVF repair. Vaginal childbirth

after RVF repair is not associated with increased risk of RVF recurrence. However, if a

sphincter repair is performed along with the RVF repair, many surgeons recommend cesarean

delivery for subsequent pregnancies in order to avoid disruption of the sphincteroplasty.

Transvaginal inversion repair and conversion to complete perineal laceration with layer

closure

Results from these approaches can be acceptable in selected cases, as noted above (see

Intraoperative Details).

Bioprosthetic repair

This is a new technique for RVF repair. Early experience indicates that it produces results

that are equal or superior to those of advancement flap repair.[14] The new button fistula plug

has been successful in 58% of rectovaginal and ileal pouch-vaginal fistulas.[15]

Simple fistulotomy

As noted, this is suitable for true anovaginal fistulas only, which incorporate no sphincter

muscle whatsoever. Application of this approach to RVF results in incontinence.

Transabdominal approaches

With approximation of healthy tissue in the absence of inflammation, infection, or tension,

transabdominal repairs yield good long-term results. Always consider the morbidities of

major abdominal surgery and any coexistent morbidities related to the patient's history.

Patients with fistulas due to radiation may have added morbidities associated with other

irradiated tissues. These morbidities include (1) cystitis; (2) ureteral complications, including


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stricture and obstruction; (3) vascular injury, including stenosis and occlusion; (4) small

bowel injury, including stricture, malabsorption, and obstruction; (5) neurologic

complications; and (6) bony complications, including necrosis and fractures.

Prognosis of recurrent RVFs

Recurrence of an RVF confers a poorer prognosis for future repair attempts.[16]Rectal sleeve

advancement had an overall healing rate of 75% for persistent rectovaginalfistulas.[17] Recurrence is influenced by the etiology of the fistula and by its complexity.

Fistulas of obstetric origin and fistulas that are considered simple (rather than complex) fare

better after repeated repair attempts.

Future and Controversies

Crohn disease

Rectovaginal fistulas (RVFs) associated with Crohn disease are difficult to manage.[5,

18] When symptoms are few, operative intervention may not be indicated. Conversely,

severely symptomatic patients may require proctectomy. Patients with relatively normal

rectal mucosa and an RVF are good candidates for an endorectal advancement flap. In thisspecific setting, outcome is good, although it is not as good as in patients without Crohn

disease. An endorectal advancement flap is considered the preferred technique for local RVF

repair in patients with Crohn disease and a relatively normal rectum. A multivariable logistic

regression model identified immunomodulators as being associated with successful healing

and smoking and steroid usage as being associated with failure.[19]

Bricker patch

The on-lay Bricker patch also has been used to repair RVFs, chiefly those produced by

radiation. Briefly summarized, the rectosigmoid colon is mobilized transabdominally, and the

RVF is exposed. The rectosigmoid is divided above the fistula. The proximal end is brought

out as an end sigmoid colostomy. The distal rectosigmoid is turned down, and the open end is

anastomosed to the debrided edge of the rectal opening of the fistula, essentially creating an

internal loop with drainage through the anus. When healing of the inferior-patched rectum

can be demonstrated radiologically several months later, continuity of the colon is

reestablished by anastomosis of the colostomy to the apex of the patch loop in an end-to-side

fashion.

Advantages to this procedure may include less difficulty than with resection approaches;

therefore, less morbidity of hemorrhage and organ injury occurs. Disadvantages include the

radiation-damaged rectum being left in place and in use, with the possibility of further

morbidity, including bleeding and stricture.

Although situations exist in which this approach may be preferable to a resection approach,

the author believes that resection of the radiation-damaged bowel provides the best long-term

results in patients who are reasonable operative candidates.

References

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

2. Bangser M. Obstetric fistula and stigma.Lancet. Feb 11 2006;367(9509):535-6.3. Browning A, Menber B. Women with obstetric fistula in Ethiopia: a 6-month follow upafter surgical treatment.BJOG. Nov 2008;115(12):1564-9.


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

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

6. Giordano P, Gravante G, Sorge R, Ovens L, Nastro P. Long-term outcomes of stapledhemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomizedcontrolled trials.Arch Surg. Mar 2009;144(3):266-72.

7. Shobeiri SA, Quiroz L, Nihira M. Rectovaginal fistulography: a technique for theidentification of recurrent elusive fistulas.Int Urogynecol J Pelvic Floor Dysfunct. Jan

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12. Khanduja KS, Yamashita HJ, Wise WE Jr. Delayed repair of obstetric injuries of theanorectum and vagina. A stratified surgical approach.Dis Colon Rectum. Apr

1994;37(4):344-9.

13. Jasonni VM, La Marca A, Manenti A. Rectovaginal fistula repair using fascia graft ofautologous abdominal muscles.Int J Gynaecol Obstet. Jan 2006;92(1):85-6.

14. Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics.Dis ColonRectum. Jul 2008;51(7):1084-8.

15. Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the efficacy ofthe rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and

rectovaginal fistulas.Dis Colon Rectum. Nov 2009;52(11):1877-81.

16. 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

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20. Burke C. Rectovaginal fistulas. Clin J Oncol Nurs. Jun 2005;9(3):295-7.21. Fry RD, Kodner IJ. Rectovaginal fistula. Surg Annu. 1995;27:113-31.


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Rectovaginal Fistul1