Rectovaginal and anovaginal fistulas
- Marc R Toglia, MD
Marc R Toglia, MD
- Director, Urogynecology Associates of Philadelphia
- Chief, Division of Urogynecology - Mainline Hospitals
- Associate Professor of Obstetrics and Gynecology
- Thomas Jefferson School of Medicine
- Philadelphia, PA
Anovaginal and rectovaginal fistulas are abnormal tracts that connect the lower gastrointestinal tract with the vagina. Other types of urogenital or anorectal fistulas are discussed elsewhere. (See "Urogenital tract fistulas in women" and "Anorectal fistula: Clinical manifestations, diagnosis, and management principles".)
Anovaginal fistulas (AVFs) and rectovaginal fistulas (RVFs) most frequently result from obstetric trauma, especially in undeveloped countries where prolonged obstructed labor can lead to pressure necrosis of the rectovaginal septum. These fistulas can also occur following a failed repair of a third- or fourth-degree laceration of the perineum, from unrecognized injury at the time of vaginal delivery, and from episiotomy infection. Radiation damage and Crohn disease are two other important causes of RVFs [1,2].
RVFs may also occur following difficult hysterectomies, especially those performed for severe endometriosis with involvement or obliteration of the posterior cul-de-sac (pouch of Douglas); from extension or rupture of perirectal, perianal, and, rarely, Bartholin's abscesses; and from any surgical procedures involving the posterior vaginal wall, perineum, anus, or rectum.
In older women, RVFs can occur as a result of diverticulitis, colon cancer, or fecal impaction. In addition, treatment options for pelvic organ prolapse such as pessaries  and various mesh repair procedures have been associated with RVFs .
CLASSIFICATION OF FISTULAS
Although the term "rectovaginal fistula" is sometimes used loosely in clinical practice to refer to all fistulas that involve the bowel and vagina, it is preferable to subclassify female genital fistulas according to anatomic landmarks:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CLASSIFICATION OF FISTULAS
- CLINICAL MANIFESTATIONS
- EVALUATION AND DIAGNOSIS
- DIFFERENTIAL DIAGNOSIS
- Distinguishing AVFs and RVFs from fistula-in-ano
- INDICATIONS FOR SURGERY
- PREOPERATIVE PREPARATION
- Mechanical bowel cleansing
- Antibiotic prophylaxis
- SURGICAL PRINCIPLES
- Basic principles
- Timing of repair
- Choice of sutures
- SURGICAL APPROACH
- Fistulas due to obstetric injury
- - Fistulas with intact sphincter: Simple fistulectomy
- - Fistulas with injured sphincter: Transsphincteric approach
- - Fistulas above the sphincter: Transverse transperineal approach
- Fistulas due to radiation
- - Low fistulas: Local repair with Martius graft interposition
- - High fistulas: Transabdominal repair with tissue interposition
- Fistulas due to inflammatory bowel disease
- Other complex fistulas
- Adjuvant techniques
- - Modified Martius graft
- - Diverting colostomy
- POSTOPERATIVE CARE
- In-hospital care
- Bowel regimen
- General care
- MORBIDITY AND MORTALITY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS