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Rectovaginal and anovaginal fistulas

Rectovaginal and anovaginal fistulas
Literature review current through: May 2024.
This topic last updated: Jun 23, 2023.

INTRODUCTION — 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 females" and "Anorectal fistula: Clinical manifestations and diagnosis".)

ETIOLOGY — Anovaginal fistulas (AVFs) and rectovaginal fistulas (RVFs) most frequently result from obstetric trauma, especially in resource-limited 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 [3] and various mesh repair procedures have been associated with RVFs [4].

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:

Fistulas that occur below the dentate line are called anovaginal fistulas (AVFs) or low fistulas. AVFs are usually found within the first 3 cm from the anal verge. Fistulas that open on the perineal body are called anoperineal fistulas.

Fistulas cephalad to the dentate line are true rectovaginal fistulas (RVFs) and are classified by some experts as high fistulas. The distinction between AVFs and RVFs is important as the anal sphincter complex is often involved with the former.

Fistulas of the colon above the rectum are referred to as colovaginal fistulas.

Although a variety of classification systems exist for these fistulas by size, location, or etiology, none is correlated with patient outcomes [5-7].

CLINICAL MANIFESTATIONS — Women suffering from anovaginal fistulas (AVFs) or rectovaginal fistulas (RVFs) present with uncontrollable passage of gas or feces from the vagina. A malodorous vaginal discharge and fecal soiling of the undergarments are also common complaints. These symptoms may be more pronounced when patient bowel movements are loose. Occasionally, a small fistula may be asymptomatic.

Patients suspected of having AVFs should also be questioned about symptoms of fecal urgency as well as fecal incontinence associated with urgency. These additional symptoms often suggest disruption of the external anal sphincter. (See "Delayed surgical management of the disrupted anal sphincter".)

EVALUATION AND DIAGNOSIS — All patients suspected of having anovaginal fistulas (AVFs) or rectovaginal fistulas (RVFs) should undergo a vaginal examination. The diagnosis is made on vaginal examination.

In addition, patients diagnosed with fistulas should have a complete evaluation of their anal sphincter complex to rule out concomitant sphincter injury. If a surgeon is unclear as to whether the anal sphincter is intact, endoanal ultrasound can detect defects in both the internal and external anal sphincter complexes [8].

It is critical that the clinician evaluate the entire sphincteric mechanism in women with RVFs to exclude coexisting causes for incontinence, such as a disrupted anal sphincter. Although concomitant sphincter injury has been reported to exist in up to one-third of women presenting with RVFs [9,10], concomitant internal or external sphincter injuries (or both) are probably more frequent when the location of the fistula is within the distal 3 cm of the anal canal. Anatomic and physiologic studies have shown that this is the normal length of the sphincter complex. Failure to recognize and repair such a sphincter injury may result in continued incontinence following a successful fistulectomy.

Pinpoint fistulas can be difficult to locate on vaginal examination. The use of a Sims speculum and magnification, such as a colposcope, may be helpful. Lacrimal duct or silver wire probes can also be used to assist in identifying the fistula tract. A few drops of methylene blue dye can be mixed with lubricating gel and massaged into the anterior rectal wall. Alternatively, an enema consisting of warmed saline and a few drops of methylene blue dye can be instilled into the rectum using a genitourinary syringe. Using a peroxide solution will avoid staining the tissues [11]. If a tract cannot be found easily, the patient's hips can be elevated, water placed in the posterior vagina, then air (50 to 100 cc) placed in the rectum with a catheter-tip syringe connected to a Robertson catheter. Air will generally pass anteriorly through a small tract and bubble through the vaginal water. Proctoscopy or an anorectal speculum may also be useful in visualizing the fistulous tract from the rectal side. The role of imaging tests, such as endoanal ultrasound and magnetic resonance imaging, in the diagnosis of fistulas is discussed separately. (See "The role of imaging tests in the evaluation of anal abscesses and fistulas".)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of anovaginal and rectovaginal fistulas (AVFs and RVFs) includes conditions that cause fecal soiling, such as fistula-in-ano, perianal abscess, and anal incontinence, and conditions that cause malodorous vaginal discharge, such as vaginal infection. AVFs and RVFs can be distinguished from these entities based upon the patient's symptoms and the physical examination. Among the conditions in the differential diagnosis, fistula-in-ano is most commonly confused with AVF.

Distinguishing AVFs and RVFs from fistula-in-ano — Another type of perineal fistula, fistula-in-ano, is an abnormal connection between the anal canal and the perianal or perineal skin. Fistula-in-ano can occur as a complication of episiotomy [9] but is caused far more often by perianal abscesses or trauma. A detailed discussion of fistula-in-ano can be found elsewhere. (See "Anorectal fistula: Clinical manifestations and diagnosis".)

Clinically, fistula-in-ano is characterized by chronic purulent drainage or cyclical pain. Palpation of the fistula tract is painful for the patient with a fistula-in-ano, in contrast to the relatively painless tract of an AVF or RVF. The location of a fistula-in-ano is usually lateral to the midline, whereas most AVFs and RVFs are located close to the midline (related to their obstetric origin). Morphologically, an anal fistula tract is lined with chronically inflamed granulation tissue, instead of the epithelialized tract typical of AVFs and RVFs.

INDICATIONS FOR SURGERY — For women with small fistulas and minimal symptoms, nonsurgical management is appropriate [9]. Optimizing the patient's bowel function, particularly controlling diarrhea, is beneficial. However, for the majority of patients with anovaginal or rectovaginal fistulas, the symptoms are intolerable. Thus, surgical repair is indicated.

The surgical approaches to fistula repair vary by the etiology of the fistula, its location and size, the quality of the surrounding tissue, the patient's underlying comorbidities, and any previous attempts at repair. Most published studies are small case series, which makes comparison of techniques and outcomes difficult [12].

PREOPERATIVE PREPARATION — There is no consensus regarding the best preoperative regimens for women undergoing repair of anorectal fistula (AVF) or rectovaginal fistula (RVF). In our practice, we prescribe a liquid diet for 24 to 48 hours prior to surgery, followed by a mechanical bowel cleansing; we give a single dose of preoperative antibiotic 30 minutes before surgery.

Diet — Dietary manipulation is required in all women undergoing AVF or RVF repair. The ultimate goal is to avoid fecal seeding of the wound during the procedure and to decrease the amount of stool that will pass over the repaired area in the first few weeks of healing. In most cases, a liquid diet should be followed for 24 to 48 hours prior to surgery.

Mechanical bowel cleansing — Mechanical bowel cleansing is routinely recommended. The author prefers to give oral agents (32 ounces of magnesium citrate or 4 to 6 liters of Golytely) 48 hours preoperatively. Administering these agents within 24 hours of the procedures can result in a thin fecal effluent being present at the time of the repair.

In addition, a tap water enema or a Fleet enema can be given the night before surgery to complete the emptying of the lower colon and rectum. Alternatively, a Fleet enema can be given an hour prior to surgery.

Antibiotic prophylaxis — We administer a single dose of a broad-spectrum antibiotic, such as cefoxitin or cefotetan, intravenously 30 minutes before the procedure. Alternatively, a combination of cefazolin and metronidazole also provides adequate coverage. For patients with a beta-lactam allergy, clindamycin plus gentamicin can be used as an alternative regimen; gentamicin should be dosed based upon actual patient weight [13]. Additional antibiotic therapy is typically not indicated, unless there is fecal soiling during the procedure. In most patients, prophylactic antibiotics should be discontinued within 24 hours after the surgical procedure.

SURGICAL PRINCIPLES

Basic principles — The basic principles essential to all successful fistula repairs include:

Wide mobilization of the adjacent tissue planes

Complete excision of the fistula tract

Multilayered closure, which reapproximates broad tissue surfaces without tension and avoids "dead space"

Proper timing of the repair

Timing of repair — Most rectovaginal and anovaginal fistulas are amenable to early repair, provided there is no infection, induration, or inflammation present in the tissues involved.

When active wound infection or tissue induration is present, patients should be provided with aggressive wound care (eg, sitz baths, debridement) and a 10 to 14 day course of broad-spectrum oral antibiotics. In addition, a low residue diet helps to decrease the frequency of bowel movements, prevent continuous seeding of the wound with liquid stool, and restore some degree of fecal continence. In these patients, surgery is deferred until all signs of infection, induration, and inflammation have subsided.

Choice of sutures — The choice of suture materials is determined by individual surgeon preference. We prefer to use delayed absorbable sutures, such as polyglactin or polyglycolic acid, instead of chromic catgut in the repair of these fistulas. The tensile strength of delayed absorbable sutures is maintained for longer, and the knot is more secure and smaller in size when compared with catgut sutures. Tissue reaction is also less with these suture types. There may also be a role for small-diameter monofilament delayed absorbable and permanent nonbraided sutures in selected patients.

SURGICAL APPROACH — Surgical approaches to anovaginal or rectovaginal fistula repair are dictated by fistula etiologies. Given that most rectovaginal fistulas result from obstetric trauma, the discussion below will focus on obstetric fistulas.

Fistulas due to obstetric injury — For women with anovaginal or rectovaginal fistulas from childbirth, we suggest a simple local repair with or without sphincteroplasty.

Fistulas with intact sphincter: Simple fistulectomy — Small rectovaginal fistulas that do not involve the anal sphincter complex can often be repaired by simple fistulectomy via a transvaginal or transrectal approach.

An incision is first made around the fistula opening (figure 1). The surgeon's nondominant index finger can be inserted into the rectum during the procedure to assist the repair (figure 2). Sharp mobilization of the vagina and rectum in a circumferential fashion should be accomplished next by providing traction and countertraction on the edges of the fistula (figure 3).

After the tissue planes are widely mobilized, the entire fistulous tract and any adjacent scar tissue are excised (figure 4). The edges of the surgical wound should only contain fresh, viable tissue. The edges of the anterior rectal wall are then inverted, either by placing interrupted submucosal stitches of 3-0 or 4-0 delayed absorbable sutures (figure 5) or by placing a pursestring suture. The most cephalad and most caudal sutures should be placed at least 5 mm above and below the fistula. A second layer of sutures of 2-0 delayed absorbable type is then placed in the muscularis of the anterior rectal wall to invert and take tension off of the first suture line (figure 6). This layer should begin and end approximately 5 mm above and below the first suture line.

An additional layer of adjacent rectovaginal tissue is then approximated to provide a third layer of closure and take tension off of the underlying layers of repair (figure 7). If necessary, a modified Martius graft can be interposed between the rectum and vagina before this step (see 'Modified Martius graft' below). Finally, the vaginal mucosa is approximated with a continuous 3-0 suture (figure 8).

Complete hemostasis and closure of all potential dead space must be ascertained. Depending upon the extent of repair, we frequently will place a small vaginal pack soaked in a very dilute Betadine solution or use a petroleum-impregnated gauze to promote hemostasis and provide gentle pressure against the incision line. If placed, the vaginal pack is typically removed within the first 12 to 24 hours postoperatively.

Fistulas with injured sphincter: Transsphincteric approach — In patients with concomitant sphincter injury and absent perineal body or a small bridge of perineal skin, fistula repair may be performed in conjunction with repair of the external and internal sphincters and reconstruction of the perineal body and rectovaginal septum. The preferred approach in these patients is a midline perineal incision (transsphincteric or perineoproctomy) with wide mobilization of the posterior vaginal wall, followed by a multilayered closure as described for a chronic third- or fourth-degree laceration (see "Delayed surgical management of the disrupted anal sphincter"). In all cases, it is important that the fistula tract be excised in its entirety, as discussed above.

Fistulas above the sphincter: Transverse transperineal approach — Rectovaginal fistulas located above the sphincter complex should be approached with a transverse transperineal incision. This approach allows the surgeon to preserve the intact internal and external anal sphincter and allows wide mobilization of the rectal and vaginal tissue [14]. A transverse incision is made across the perineal body above the sphincter complex. Dissection is then carried out in the true rectovaginal space between the anterior rectal wall and the posterior vaginal wall to mobilize the tissues widely laterally and cephalad to the fistula tract (figure 9 and figure 10). Dissection above the fistula tract is usually easy because the vagina and rectum are only loosely connected above this point.

The fistula tract and any adjacent scar tissue are then excised with Metzenbaum or Cooley scissors (figure 11). The rectal wall defect can be closed either longitudinally or transversely with interrupted 3-0 or 4-0 delayed absorbable sutures to invert the rectal mucosa without tension. We prefer to close the other layers longitudinally in all but the smallest fistulas (figure 12). By closing the rectal mucosal and perirectal fascial layers longitudinally, the anal canal is lengthened, which may help to reestablish the high-pressure zone of the anal canal. Closing the vaginal mucosa and perineal body longitudinally helps to avoid narrowing the vaginal introitus and also lengthens the perineal body.

Alternatively, the rectal and vaginal defects may be closed in perpendicular directions to each other to avoid overlapping suture lines. With this approach, the rectal defect should be closed transversely and the vaginal mucosa closed longitudinally to minimize narrowing of the vaginal introitus and avoid creation of a transverse ridge across the posterior vaginal wall, which can cause dyspareunia.

The second layer of closure is placed into the muscularis of the rectum in the same direction as the first layer, thus imbricating the first layer and reinforcing the closure (figure 13). The puborectalis muscles are approximated in the midline, providing an additional reinforcing layer between the anterior rectal and posterior vaginal walls (figure 14).

The subcutaneous tissues and skin of the perineal body can be approximated with a running nonlocking suture. The skin is closed with interrupted mattress sutures or a running closure of 4-0 delayed absorbable suture (figure 15).

Following this procedure, patients are generally hospitalized overnight for pelvic rest (no vaginal insertions), pain control, observation for bleeding, and vaginal pack removal.

Fistulas due to radiation — Fistula formation following radiotherapy is believed to be the result of progressive endarteritis obliterans and tissue hypoxia. These fistulas can occur years after the completion of radiotherapy, can be large, and can appear high in the posterior vaginal wall. They are often associated with rectal stricture due to perirectal fibrosis. Refinements in modern radiotherapy have led to a decline in radiation-induced fistulas.

Radiation-induced fistulas can be either low fistulas or high fistulas. Low fistulas can be repaired locally with interposition of a fat graft, usually of a modified Martius type. High fistulas need to be approached transabdominally with interposition of an omental flap, a muscle flap, or a bowel onlay patch (Bricker-Johnson procedure). Permanent diverting colostomy should be performed when radiation necrosis is extensive, and temporary colostomy or ileostomy should be considered for all radiation-related fistulas.

Low fistulas: Local repair with Martius graft interposition — Successful local repair of radiation-induced fistulas needs to follow the basic surgical principles of other fistula repairs (see 'Basic principles' above). Repair should be delayed until the radiation-induced necrosis process has resolved. A preoperative diverting colostomy diverts fecal stream away from the fistula area to allow for healing. At the beginning of the repair, margins of the fistula should be biopsied to exclude residual or recurrent malignancy. At the end of the repair, a Martius graft should be interposed between the vagina and the rectum to bring in new blood supply, especially in patients with extensive tissue excision. Before the temporary diverting ostomy is taken down, the closure of the defect should be tested by placing water in the vagina and air in the rectum as described above. The success of radiation-induced fistula repair varies widely between series [15,16]. (See 'Modified Martius graft' below.)

High fistulas: Transabdominal repair with tissue interposition — High rectovaginal fistulas caused by radiation damage often need to be approached transabdominally. The transabdominal approach is facilitated by use of long instruments and retractors, such as those used in thoracic or deep pelvic surgery. A preoperative diverting colostomy diverts fecal stream away from the fistula area to allow for healing.

First, the rectum and vaginal apex are widely mobilized from the fistulous communication. All of the scarred, fibrous, and nonviable tissues are then resected from the fistulous site. This is then followed by multilayered closures of the rectum and vagina.

Serosal dissection on the rectal side can be extensive, especially when the fistula opening is large. Excessive dissection can disrupt a significant portion of the blood supply to the bowel, thereby interfering with successful closure and healing of the fistula. If extensive bowel ischemia is present, a segmental resection and primary anastomosis of compromised bowel may be necessary. Extensive radiation-induced bowel ischemia may necessitate the use of a permanent diverting colostomy as the definitive procedure to control a rectovaginal fistula.

In repairing high fistulas due to radiation, it is also essential to interpose well-vascularized tissue between the rectum and the vagina to bring in new blood supply, fill in dead space, and therefore prevent recurrence. Such well-vascularized tissues include omentum, muscle, or healthy bowel, as long as they can be mobilized to the deep pelvis [17].

An omental J-flap is created by detaching the omentum from the transverse colon while leaving it attached to the stomach. A J-shaped incision is then made approximately 4 cm inside the lateral border of the omentum adjacent to the edge of the stomach, down past the most distal and lateral termination of the mesenteric vessels within the omental apron. This flap is then rotated down to the fistula site and sutured in place between the rectum and the vagina.

A segment of the rectus abdominis muscle can be interposed between the rectum and vagina. This also provides excellent neovascularity and tissue support to the fistula repair site.

Because patients will have undergone a diverting colostomy, it is possible to use the proximal end of the bypassed colon as an onlay patch for the fistula repair (figure 16). The proximal colon is nonradiated and brings its own blood supply. The procedure requires minimal dissection of the rectal ampulla, and the presacral space is never entered. After fistula healing is confirmed, the colostomy can be reversed by suturing to the loop of colon used in the fistula repair [18].

Fistulas due to inflammatory bowel disease — Rectovaginal fistulas have been associated with inflammatory bowel disease, particularly Crohn disease. Successful local repair is predicated upon controlling the disease process itself and timing the repair during periods of remission. (See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults".)

Fistulas associated with Crohn disease may be single or multiple, and a single vaginal opening may be connected with multiple tracts leading to the anus with microabscesses developing along the way.

Local repair of Crohn fistula should not be attempted until the patient's Crohn symptoms are fully controlled and there is no longer any evidence of active proctitis on proctoscopy examination. The timing of such a repair procedure is usually decided jointly by a gynecologist, a colorectal surgeon, and a gastroenterologist treating the patient.

A transverse, transperineal approach is often ideal in these women as the sphincter complex tends to be uninvolved (see 'Fistulas above the sphincter: Transverse transperineal approach' above). All branches of the fistulous tract should be resected. A modified Martius graft can bring in additional tissue and blood supply to cover large tissue defects resulting from complete excision of the affected area (see 'Modified Martius graft' below). A colostomy is often performed in these patients to promote healing by diverting fecal stream. Despite all these efforts, recurrence rates remain high in this group of patients. Thus, they need to be appropriately counseled.

Other complex fistulas — Rectovaginal fistulas can also develop from pelvic malignancies or as complications following pelvic surgeries done for endometriosis or diverticular disease. These fistulas are usually high fistulas, and therefore a transabdominal procedure should be used for their repair. Minimally invasive, including robotic, techniques have been employed successfully, using the same surgical principles described above to achieve adequate visualization and bowel mobilization [19]. (See 'High fistulas: Transabdominal repair with tissue interposition' above.)

Adjuvant techniques

Modified Martius graft — A modified Martius graft is a bulbocavernosus muscle or labial fat pad graft used in closing large or difficult rectovaginal or vesicovaginal fistulas. A Martius graft does not provide any significant structural support to the repair, but it provides neovascularity, fills in dead space, and enhances granulation tissue formation at the site of repair.

A modified Martius graft can be used in patients with complex fistulas caused by inflammatory bowel disease or radiation injury, as well as in patients with recurrent fistulas. It is most useful in the repair of rectovaginal fistulas located in the middle to upper third of the vaginal vault, where there may not be sufficient tissue to transpose between the vagina and the rectum.

The procedure involves transposing a vascularized graft made of healthy tissue to the repair site [20]. First, a vertical incision is made over the labia majora to expose the labial fat pad (figure 17). The labial fat pad is then sharply mobilized with care taken to preserve the blood supply either superiorly or inferiorly (figure 18). For most repairs, the base of the pedicle should be on the inferior border of the graft, thus allowing the graft to be rotated medially without significant tension. The graft is tunneled subcutaneously beneath the vaginal mucosa and labia minora to overlay the repaired fistula site (figure 19) and secured at its edges with interrupted sutures of 3-0 chromic or delayed absorbable sutures (figure 20). The labial incision is closed in two layers (figure 21). A typical Martius graft repair of a rectovaginal fistula is depicted in a video clip (movie 1).

Diverting colostomy — Diversion of the fecal stream is not required in the management of most anovaginal or rectovaginal fistulas. However, a colostomy is a useful adjunct to the care of complex fistulas associated with a lower healing rate. Examples of such complex fistulas include radiation-induced fistulas, large rectovaginal fistulas with diameter greater than 4 cm, and some fistulas secondary to inflammatory bowel disease. Retrospective series reported improved outcomes with fecal diversion in the management of rectovaginal fistulas associated with Crohn disease [21,22].

In patients with preexisting stoma, surgical repair of the fistula should be delayed until all evidence of inflammation and cellulitis has resolved, typically 8 to 12 weeks after the start of fecal diversion. Takedown of the colostomy is usually performed three to four months after the fistula repair.

The construction and maintenance of a diverting colostomy is discussed elsewhere. (See "Overview of surgical ostomy for fecal diversion".)

POSTOPERATIVE CARE — Following an anovaginal or rectovaginal fistula repair, patients are observed overnight in the hospital, then discharged home with specific instructions on diet, bowel regimen, and general care.

In-hospital care — Most patients can be discharged home on the first postoperative day, as long as they can be seen within one week for a wound check. It is unnecessary to keep women in the hospital until their first bowel movement. While the patient is on a low-residue diet, it is common to have a bowel movement as infrequently as twice weekly.

Urinary retention is a common problem following fistula repair. It is reasonable to place a Foley catheter and a vaginal pack at the end of the surgical procedure and remove them both on the evening of the surgery or, alternatively, the morning of the first postoperative day. Antibiotics in the postoperative period are probably unnecessary in the absence of clinical infection.

Diet — Dietary manipulation should be considered to decrease the amount of stool that will pass over the repair in the first few weeks of healing. A clear liquid diet is prescribed for the first 24 to 72 postoperative hours. A low-residue diet should then be instituted for at least three to four weeks. The low-residue diet should be discontinued if constipation develops.

Bowel regimen — A stool softener should be given for one month to lubricate the stool. If the patient complains of constipation, milk of magnesia or other laxatives can be given to ease bowel movements. Enemas should be avoided.

General care — Ambulation is allowed. Women should be instructed in wound care and taught how to perform Sitz baths starting two to three days following the procedure. A heat lamp or a blow dryer on a cool setting can also be used to keep the area dry.

MORBIDITY AND MORTALITY — Perioperative deaths are rare following anovaginal (AVF) and rectovaginal (RVF) fistula repair.

The major morbidities associated with AVF or RVF repair include recurrent fistula; wound infection; urinary tract infection; bowel obstruction or perforation; vaginal, anal, or rectal stenosis; fecal incontinence; and sexual dysfunction. The rates vary depending upon the etiologies that cause the fistulas.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Rectovaginal fistula".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Rectovaginal fistula (The Basics)")

SUMMARY AND RECOMMENDATIONS

Definitions – Rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) frequently result from obstetric trauma. Patients present with uncontrollable passage of gas or feces from the vagina. (See 'Clinical manifestations' above.)

Diagnosis – RVFs and AVFs are diagnosed on vaginal examination. Patients diagnosed with a fistula should be evaluated for concomitant anal sphincter injury before undergoing surgical repair. (See 'Evaluation and diagnosis' above.)

Management – For women with small fistulas and minimal symptoms, nonsurgical management is appropriate. Otherwise, surgical approaches to anovaginal or rectovaginal fistula repair are dictated by fistula etiologies:

Fistulas due to obstetric injury – Patients with childbirth-related fistulas should undergo local repair via transvaginal, transanal, transsphincteric, or transverse transperineal approach, depending upon their sphincter status and the location of the fistula. (See 'Fistulas due to obstetric injury' above.)

Fistulas due to radiation – Patients with radiation-induced fistulas should undergo repair with tissue interposition. The approach (local versus transabdominal) is dictated by fistula location (low versus high). (See 'Fistulas due to radiation' above.)

Fistulas due to inflammatory bowel disease – Patients with Crohn fistulas should not undergo repair until adequate medical control of their disease has been achieved. Surgically, we use a transverse, transperineal approach to the repair with a Martius graft interposition. (See 'Fistulas due to inflammatory bowel disease' above.)

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  21. Bauer JJ, Sher ME, Jaffin H, et al. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease. Ann Surg 1991; 213:151.
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Topic 1385 Version 22.0

References

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