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:
- Andreani SM, Dang HH, Grondona P, et al. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 2007; 50:2215.
- Saclarides TJ. Rectovaginal fistula. Surg Clin North Am 2002; 82:1261.
- Torbey MJ. Large rectovaginal fistula due to a cube pessary despite routine follow-up; but what is 'routine'? J Obstet Gynaecol Res 2014; 40:2162.
- Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requiring reoperation following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol 2008; 199:678.e1.
- Rosenshein NB, Genadry RR, Woodruff JD. An anatomic classification of rectovaginal septal defects. Am J Obstet Gynecol 1980; 137:439.
- Thompson JD. Relaxed vaginal outlet, rectocele, fecal incontinence, and rectovaginal fistula. In: TeLinde's Operative Gynecology, 7th ed, Thompson JD, Rock JA (Eds), JB Lippincott, Philadelphia 1992. p.941.
- Baden, WF, Walker, T (eds). Fundamentals, symptoms, and classification. p. 9. In Surgical Repair of Vaginal Defects. JB Lippincott, Philadelphia, 1992.
- Whiteford MH, Kilkenny J 3rd, Hyman N, et al. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005; 48:1337.
- Corman ML. Anal incontinence following obstetrical injury. Dis Colon Rectum 1985; 28:86.
- Shieh CJ, Gennaro AR. Rectovaginal fistula: a review of 11 years experience. Int Surg 1984; 69:69.
- Göttgens KW, Smeets RR, Stassen LP, et al. The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study. Dis Colon Rectum 2014; 57:888.
- Wiskind AK, Thompson JD. Transverse transperineal repair of rectovaginal fistulas in the lower vagina. Am J Obstet Gynecol 1992; 167:694.
- Boronow RC. Repair of the radiation-induced vaginal fistula utilizing the Martius technique. World J Surg 1986; 10:237.
- Aartsen EJ, Sindram IS. Repair of the radiation induced rectovaginal fistulas without or with interposition of the bulbocavernosus muscle (Martius procedure). Eur J Surg Oncol 1988; 14:171.
- Schloericke E, Hoffmann M, Zimmermann M, et al. Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas. Colorectal Dis 2012; 14:604.
- Bricker EM, Johnston WD, Patwardhan RV. Repair of postirradiation damage to colorectum: a progress report. Ann Surg 1981; 193:555.
- van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis 2011; 26:1463.
- Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727.
- Bauer JJ, Sher ME, Jaffin H, et al. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease. Ann Surg 1991; 213:151.
- Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn's disease. Am J Surg 1997; 173:95.
- 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