Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Rectovaginal, anovaginal, and colovesical fistulas

ETIOLOGY

Rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) frequently result from obstetric trauma. These fistulas are frequently found in undeveloped countries where prolonged obstructed labor leading to pressure necrosis is more common. They also occur following an unsuccessful primary repair of a third or fourth degree laceration, from unrecognized injury at the time of vaginal delivery, and from episiotomy infection with formation of a fistulous tract.

RVFs may also result from difficult hysterectomies, especially those performed for severe endometriosis with involvement or obliteration of the posterior cul-de-sac (pouch of Douglas), and from surgical procedures involving the posterior vaginal wall, perineum, anus, and rectum. Inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, is another important cause of RVFs in women [1]. In elderly women, RVFs can occur as the result of diverticulitis, colon cancer, or fecal impaction. Vaginal trauma, induced by a retained foreign body such as a Pessary can also result in RVFs [2]. In addition, operative procedures that incorporate the use of transvaginal and perineal mesh placement to repair pelvic organ prolapse have resulted in rectovaginal fistula [3].

Fistula-in-ano describes a communication between the anal canal and the perianal skin or perineum. These fistulas are typically initiated by an infection such as an anal abscess, trauma, anal fissure, or Crohn's disease, or as a complication of episiotomy [4]. Anatomically, the fistula may originate anywhere below the dentate line internally and exists externally along the perianal skin or perineum. Histologically, fistula-in-ano differs from AVFs in that the fistulous tract is typically lined with chronically inflamed granulation tissue, rather than the epithelialized tract typical of anovaginal and RVFs.

CLINICAL MANIFESTATIONS

Women suffering from anovaginal (AVFs) or rectovaginal fistulas (RVFs) present with complaints of uncontrollable passage of gas or feces from the vagina. A malodorous vaginal discharge and fecal soiling of the undergarments are also common complaints. Symptoms may be more pronounced when bowel movements are loose. Occasionally, a small fistula may be asymptomatic. It is important to inquire about fecal urgency and fecal incontinence associated with urgency as this often suggests that the external anal sphincter is also disrupted. (See "Delayed surgical management of the disrupted anal sphincter".)

Clinically, fistula-in-ano differs from AVF and RVF in that rectal and/or vaginal pain is a prominent symptom with fistula-in-ano, and may reflect its chronic inflammatory etiology. It is characterized by chronic purulent drainage or cyclical pain. Palpation of the fistula tract is very uncomfortable for the patient with a fistula-in-ano, in contrast to the relatively painless tract of a rectovaginal or anovaginal fistula. The course of a fistula-in-ano can be complex and circuitous with one or more blind sinus tracts. Their location is usually lateral from the midline, whereas most AVFs and RVFs are located close to the midline (related to their obstetric origin).

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2014. | This topic last updated: Aug 26, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Andreani SM, Dang HH, Grondona P, et al. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 2007; 50:2215.
  2. Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1173.
  3. 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.
  4. 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.
  5. Corman ML. Anal incontinence following obstetrical injury. Dis Colon Rectum 1985; 28:86.
  6. Shieh CJ, Gennaro AR. Rectovaginal fistula: a review of 11 years experience. Int Surg 1984; 69:69.
  7. Rosenshein NB, Genadry RR, Woodruff JD. An anatomic classification of rectovaginal septal defects. Am J Obstet Gynecol 1980; 137:439.
  8. 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.
  9. Baden, WF, Walker, T (eds). Fundamentals, symptoms, and classification. p. 9. In Surgical Repair of Vaginal Defects. JB Lippincott, Philadelphia, 1992.
  10. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg 1976; 63:1.
  11. Casadesus D, Villasana L, Sanchez IM, et al. Treatment of rectovaginal fistula: a 5-year review. Aust N Z J Obstet Gynaecol 2006; 46:49.
  12. Wiskind AK, Thompson JD. Transverse transperineal repair of rectovaginal fistulas in the lower vagina. Am J Obstet Gynecol 1992; 167:694.
  13. Boronow RC. Repair of the radiation-induced vaginal fistula utilizing the Martius technique. World J Surg 1986; 10:237.
  14. 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.
  15. Bricker EM, Johnston WD, Patwardhan RV. Repair of postirradiation damage to colorectum: a progress report. Ann Surg 1981; 193:555.
  16. 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.
  17. Bauer JJ, Sher ME, Jaffin H, et al. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease. Ann Surg 1991; 213:151.
  18. Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn's disease. Am J Surg 1997; 173:95.