Skip to Main Content

+

  • • 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:

    • -Obstetric injury

      -Crohn disease

      -Diverticulitis

      -Radiation

      -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

++

Epidemiology

+

  • • Obstetric injury accounts for the majority of rectovaginal fistulae

++

Symptoms and Signs

+

  • • 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

    • -Vaginal discharge with fecal odor

      -Passage of flatus and stool per vagina

      -Vaginitis

    • An opening in the vagina or rectum may be seen or felt on physical exam

    • Anoscopy may detect opening in anal canal

++

Laboratory Findings

+

  • • No specific findings

++

Imaging Findings

+

  • • 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

    • -If a fistula is present, it should be confirmed by methylene blue staining of the tampon

    • Proctoscopy may be required to visualize opening in mid to high fistula

+

  • • The signs and symptoms of a rectovaginal fistula are fairly unmistakable

    • -The important differential is the cause of the fistula, as this affects management

+

  • • Complete history and physical exam

    • History of obstetric trauma, foreign body, inflammatory bowel disease, radiation injury

    • Bimanual exam

    • Methylene blue enema

    • Anoscopy or proctoscopy

++

When to Admit

+

  • • Signs of perineal sepsis

+

  • • The cause and location of the fistula determine the treatment

    • -Involvement of surrounding tissue by the disease process that leads to the fistula may limit the surgical options

    • 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

++

Surgery

++

Indications

+

  • • Fistulas secondary to radiation injury are not amenable to local procedures

    • -Transabdominal resection and coloanal anastomosis is preferred

    • High rectovaginal fistulas are best ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.