You are in: eMedicine Specialties > General Surgery > Colorectal Rectovaginal FistulaArticle Last Updated: Aug 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Carol E H Scott-Conner, MD, PhD, Professor, Department of Surgery, University of Iowa College of Medicine Carol E H Scott-Conner is a member of the following medical societies: American Association for Cancer Research, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Gastroenterology, American College of Surgeons, American Medical Association, American Society for Gastrointestinal Endoscopy, Association for Academic Surgery, Association for Surgical Education, Association of VA Surgeons, Iowa Medical Society, Sigma Xi, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Society of Surgical Oncology, Society of University Surgeons, and Southeastern Surgical Congress Coauthor(s): Jan Rakinic, MD, Chief, Section of Colorectal Surgery, Southern Illinois University Editors: Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: RVF, RVFs, anovaginal fistulas, obstetric injury, radiation injury, inflammatory bowel disease, IBD, Crohn disease, operative trauma, perineal lacerations, forceful coitus, ulcerative colitis, perirectal abscess, diverticulitis, tuberculosis, lymphogranuloma venereum, Bartholin gland abscess, vaginitis, cystitis, sigmoid-vaginal cuff fistulas, proctosigmoidoscopy, sigmoidoscopy, colonoscopy, colostomy INTRODUCTIONSection 2 of 11
  History of the ProcedureFor 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 cannot be corrected because of patient comorbidity or disease-related factors; these unfortunate patients can be helped only by fecal diversion. ProblemRVFs are epithelial-lined tracts 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; these are anovaginal fistulas, and they are treated differently. FrequencyFrequency varies among reported series 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 are closest to the anus and can be corrected with a perineal approach. High fistulas require a transabdominal approach for repair. A more precise definition is that a low RVF is between the lower third of the rectum and the lower half of the vagina, and a high fistula is between the middle third of the rectum and the posterior vaginal fornix. 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. EtiologyThe most common etiology is obstetric injury, followed by radiation injury, inflammatory bowel disease ([IBD], most often Crohn disease), operative trauma, infectious etiologies, and neoplasm. PathophysiologySeveral traumatic causes of RVF exist. Perineal lacerations during childbirth, especially those due to episioproctotomy, predispose patients to RVFs. Perineal lacerations 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. Pelvic operations can be complicated by the development of a high RVF. Traumatic injury (penetrating or blunt) and forceful coitus have produced RVFs. Both Crohn disease 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. Fistulas that occur during therapy are usually due to tumor regression. Most other fistulas become apparent 6 months to 2 years after completion of therapy. Diabetes, hypertension, smoking, and previous abdominal or pelvic surgery increase the risk of fistula formation. Differentiating radiation change at the fistula from a recurrent tumor by biopsy 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 common conditions are tuberculosis, lymphogranuloma venereum, and Bartholin gland abscess. ClinicalThe clinical presentation of RVFs varies little. A few patients are asymptomatic. Most patients report 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, mucous-rich diarrhea caused by the underlying clinical etiology. INDICATIONSSection 3 of 11
Because the symptoms of RVFs 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 most cases. Some patients are better served by a diverting stoma than an ill-advised repair attempt. RELEVANT ANATOMYSection 4 of 11
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 RVF repair. The dentate line is the grossly visible demarcation between the squamous anal epithelium and the 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, posterior to the cervix uteri, or both. Occupation of this space by the small bowel is termed an enterocele. Occupation of this space by the sigmoid colon is termed a sigmoidocele. CONTRAINDICATIONSSection 5 of 11
See Medical therapy and Intraoperative details. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic FindingsHistology is most important in the evaluation of possible IBD. Neither a diagnosis of ulcerative colitis nor a diagnosis of Crohn disease completely excludes operative repair of 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. TREATMENTSection 7 of 11
Medical therapyTreat acute fistulas of traumatic origin (including those caused by obstetric and operative trauma) and fistulas complicated by secondary infection or of infectious origin with local care, drainage of abscesses, and directed antibiotic therapy. 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 be considered. 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. If 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) 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. The development of carcinoma has been described in Crohn fistulas. RVFs of radiation origin are very difficult to treat surgically, and medical therapy is often initially recommended in this setting. Diet and fiber are the mainstays of therapy. Surgical therapyPreoperative detailsComplete mechanical bowel preparation is essential for transabdominal repairs of RVFs 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 to provide 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 used in the past, the overwhelming majority of RVFs are now repaired without first performing a diverting colostomy. 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 fractionated or unfractionated heparin as well as sequential compression devices. If the pelvis has been radiated or previously operated upon, the use of ureteral catheters may aid in dissection. A laparoscopic approach has been described. Intraoperative detailsLocal repair methods
Transabdominal approaches Transabdominal approaches are generally used for high RVFs when the fistula originates from a neoplasm, radiation, or, occasionally, IBD. They are also used if concomitant disease (eg, diverticulitis) warrants an abdominal approach.
Postoperative details
Follow-upPatients 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. COMPLICATIONSSection 8 of 11
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. Anastomotic leaks probably occur more often than is clinically recognized based on recent data from the United States and Europe. However, because intervention is indicated only in clinically evident leaks, routine postoperative anastomotic evaluation is not warranted. OUTCOME AND PROGNOSISSection 9 of 11
Local repair methods
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 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 confers a poorer prognosis for future repair attempts. Recurrence is influenced by the etiology of the fistula as well as its complexity. Fistulas of obstetric origin and fistulas that are considered simple (rather than complex) fare better after repeated repair attempts. FUTURE AND CONTROVERSIESSection 10 of 11
Crohn disease RVFs associated with Crohn disease are difficult to manage. 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 this specific setting, outcome is good, though 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. The author has had experience treating patients with Crohn disease, an RVF, and a relatively normal rectum with 6-mercaptopurine for several months and then performing an endorectal advancement flap repair with good results in a small series. Bricker patch The on-lay Bricker patch has been used for repair of RVFs that are chiefly due to 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 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 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 in which this approach may be preferable to a resection approach exist, the author believes that resection of the radiation-damaged bowel provides the best long-term results in patients who are reasonable operative candidates. REFERENCESSection 11 of 11
Article Last Updated: Aug 3, 2006 |
