• Passing stool and flatus through the vagina
• Communication between the anterior wall of the rectum and posterior wall of the vagina
• Tract generally visible or palpable
• Etiologies include:
-Undrained cryptoglandular disease
-Foreign body trauma
-Surgical extirpation of anterior rectal tumors
-Malignancies of the rectum, cervix, or vagina
• Classified as low, middle, or high
• Considered low if can be repaired from a perineal approach
• Considered high if must be repaired transabdominally
• Passing stool and flatus through the vagina is characteristic
• There may be varying degrees of incontinence
• With low or small fistula, passage of flatus through vagina most common complaint
• Large fistula
• An opening in the vagina or rectum may be seen or felt on physical exam
• Anoscopy may detect opening in anal canal
• A vaginogram or barium enema may identify the fistula
• If the fistula is not demonstrated on radiographic or physical exam, a dilute methylene blue enema may be administered with a tampon in the vagina
• Proctoscopy may be required to visualize opening in mid to high fistula
• Complete history and physical exam
• History of obstetric trauma, foreign body, inflammatory bowel disease, radiation injury
• Bimanual exam
• Methylene blue enema
• Anoscopy or proctoscopy
• The cause and location of the fistula determine the treatment
• Inciting event (injury, inflammation, radiation injury) should be allowed to heal or subside prior to undertaking repair
• About 50% of small rectovaginal fistulae secondary to obstetric trauma heal spontaneously
• Fistulas secondary to cryptoglandular disease may close spontaneously once the primary process is drained
• Fistulas secondary to Crohn disease rarely heal spontaneously
-Require aggressive medical therapy
-Once in remission, local advancement flap procedures may be performed
• Temporary diverting colostomy may be necessary in patients with severe disease or complex rectovaginal fistulae that do not respond to local measures
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