What is a rectovaginal fistula?
A rectovaginal fistula is a condition best described as a tunnel that communicates between the rectum and the vagina [Figure 1]. The fistula can connect with any part of the vagina, but it is often in its lower portion. Another type of fistula is anovaginal fistula which is a tunnel from inside the anus to the vagina or to the skin between the vagina and the anus. Rectovaginal fistula is different from colovaginal fistula, which is typically a communication between the colon and the top aspect of the vagina.
Figure 1 – The pelvic organs with the vagina and the rectum
What causes a rectovaginal fistula?
Most women with rectovaginal fistula are young. Several conditions can lead to a vaginal fistula including:
- Childbirth trauma (episiotomy, forceps delivery, tear)
- Crohn’s disease
- Infection of an anal gland
- Prior anal, rectal, or vaginal surgery
- Radiation therapy
- Tuberculosis or other atypical infections
What are the symptoms of a rectovaginal fistula?
Most women with rectovaginal fistula have symptoms. The severity and frequency of the symptoms vary depending on the location and size of the fistula, as well as the underlying condition. Patients have 1 or more of the following symptoms:
- Abscess or cavity
- Bloody secretion from the vagina
- Pain and swelling in the vagina, anus, or perineum (the skin area between these 2 organs)
- Pain during sexual intercourse
- Passage of gas, liquid, or feces into the vagina
- Pus drainage from the vagina (creamy whitish or yellowish fluid)
- Skin opening or nodule in the vagina or the perineum
- Urinary tract infection (bladder infection)
- Yeast infection
How is a rectovaginal fistula diagnosed?
The history and physical examination are often sufficient to make the diagnosis. An office-based examination includes visual inspection, probing of any vaginal or skin opening with a thin metal probe, a finger examination, and Anoscopy or Proctoscopy to look inside the anus and the rectum. Dr. Maher Abbas personalizes the care of every patient. One or more of the following tests may be recommended to complete the evaluation:
- Endoscopic examination: Colonoscopy to assess the large bowel (colon and rectum). Colonoscopy is a very important test especially if the patient has any abdominal symptoms, rectal bleeding, or fistula features suggestive of the possibility of inflammatory bowel disease such as Crohn’s disease. Vaginoscopy is an examination where the inside of the vagina is inspected using special instruments to document the presence and location of the fistula
- Imaging studies: an endoanal ultrasound or magnetic resonance scan (MRI) is ordered to assess the fistula and the anal sphincter muscles
- Physiologic testing: women with a childbirth history, trauma, or prior proctologic surgery, and/or symptoms of anal incontinence require testing of the anal function with Anorectal Manometry and rectal compliance measurements
Some rectovaginal fistulas are very narrow and difficult to find during the office visit or additional testing. Under such circumstance, it may be necessary to perform an examination under anesthesia in the operating room in order to employ various maneuvers to identify the fistula.
How is a rectovaginal fistula treated?
Surgical intervention is the main treatment modality for women with rectovaginal fistula. Temporary medical measures to help control the symptoms of the fistula include antibiotics, high fiber diet, the judicious use of anti-diarrheal pills if diarrhea is present, the insertion of a vaginal tampon or pad, daily vaginal irrigation, and the use of skin protecting ointments.
The following are some of the various types of surgery performed in patients with rectovaginal fistula:
Abscess drainage. If a patient presents with acute abscess, incision and drainage of the abscess is the first step
Abdominal surgery. Women with a high fistula deep in the vagina and those with a colovaginal or enterovaginal fistula (communication from the colon or small bowel to the vagina) require an abdominal operation to remove the involved segment of small or large bowel. Laparoscopic camera surgery (keyhole surgery) is Dr. Maher Abbas’ preferred method for patients with this type of fistulas. The advantages of keyhole surgery include less risk, less pain, and faster recovery
Fistula removal (fistulotomy). Fistula with minimal tissue involvement such as a low anovaginal fistula can be treated with fistula removal
Transanal fistula repair. Repair of the fistula with the use of an endorectal advancement flap (using the rectal lining) is the preferred method of repair in most young patients. Reinforcement of the repair with the use of biologic mesh is helpful in some cases in order to increase the success rate
Transperineal fistula repair. Various techniques are available to correct the fistula by going through the perineum (the skin area between the vagina and the rectum). A multilayer repair using different layers of tissue, an episioproctomy (division of the fistula with vaginal, rectal, and anal muscle reconstruction), or a muscle interposition repair (use of the gracilis muscle from the leg) are some of the options
Transvaginal fistula repair. Repair of the fistula coming through vagina is another technique that is recommended in some patients such as the elderly
Seton drainage. Many patients require control of the fistula drainage with a seton drain [Figure 2]. Following a minimum period of 6 to 8 weeks, a definitive fistula procedure is performed to eradicate the fistula
Figure 2 – Seton drain
What happens if a fistula is left untreated?
Rectovaginal fistula is a nuisance that negatively impacts a woman’s quality of life. It is usually not dangerous but untreated it can become more complicated by forming additional tracts. Furthermore, if a fistula is not drained properly it can form more serious infections including a deeper abscess infection.
Why seek the care of Dr. Maher Abbas?
Dr. Maher Abbas is an American Board Certified Colon and Rectal Surgeon with special interest in simple and complex pelvic and colorectal fistulas. He provides the entire spectrum of operations for rectovaginal and colovaginal fistulas including flap operations. Rectovaginal fistulas are very complex and require extensive surgical expertise for best outcome.
If you would like to schedule a consultation with Dr. Maher Abbas to discuss and evaluate your condition, click here. If you have previously undergone any operation or tests related to your condition, kindly bring all outside reports for Dr. Maher Abbas to review the day of your consultation.