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直肠阴道瘘、肛门阴道瘘和结肠膀胱瘘

Author
Marc R Toglia, MD
Section Editor
Linda Brubaker, MD, FACOG
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Translators
江从庆, 主任医师，副教授

病因

直肠阴道瘘(rectovaginal fistula, RVF)和肛门阴道瘘(anovaginal fistula, AVF)常由产伤导致。这些瘘常见于不发达国家，在这些国家中长时的梗阻性分娩导致压迫性坏死是比较常见的。也可发生在三度或四度撕裂伤一期修复失败之后，由阴道分娩时未发现的损伤所致，以及由会阴切开术伤口感染伴瘘道形成所致。

RVF也可由难度较大的子宫切除术导致，尤其是那些因严重子宫内膜异位症累及直肠子宫陷凹(Douglas陷凹)或使其闭塞而进行的子宫切除术，也可由涉及阴道后壁、会阴、肛门和直肠的外科手术操作所致。在女性中，炎症性肠病，如克罗恩病和溃疡性结肠炎，是RVF的另一个重要病因[1]。对于老年女性，RVF可由憩室炎、结肠癌或粪便嵌塞所致。由存留异物(如子宫托)导致的阴道损伤也可导致RVF[2]。此外，经阴道和会阴置入网片来修复盆腔器官脱垂的手术操作也会导致RVF[3]。

肛瘘是指在肛管和肛周皮肤或会阴之间的交通。这些瘘通常由感染(如肛周脓肿)、创伤、肛裂或克罗恩病引发，或并发于会阴切开术[4]。从解剖学上来讲，内瘘口可始于齿状线以下的任何地方，外瘘口则可沿肛周皮肤或会阴发生。从组织学上讲，肛瘘与AVF的不同之处在于，肛瘘的瘘道通常内衬有慢性炎性肉芽组织，而AVF和RVF的典型瘘道是上皮化管道。

临床表现

AVF或RVF女性患者会诉有无法控制的阴道排气或排便。内裤被恶臭的阴道分泌物和粪便弄脏也是常见的主诉。腹泻时上述症状可能更加显著。偶尔，比较小的瘘可能没有症状。询问患者关于便急及其相关的大便失禁的情况是很重要的，因为这通常提示肛门外括约肌也被破坏。 (参见“肛门括约肌破坏的延迟手术治疗”)

临床上，肛瘘与AVF和RVF的不同之处在于直肠和/或阴道疼痛是肛瘘的突出症状，反映其慢性炎症性病因。肛瘘的特征为慢性化脓性排出物或周期性疼痛。触诊瘘道对肛瘘患者来说十分不适，而RVF或AVF患者的瘘道则相对无痛。肛瘘病程是复杂和迁延的，可有一个或多个有盲端的窦道。肛瘘通常位于正中线的外侧，而多数AVF和RVF接近正中线(与其产科起源有关)。

                               

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Literature review current through: 2017-06 . | This topic last updated: 2016-08-25.
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