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  • • 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



      -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




  • • 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


    • 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






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

    • -Transabdominal resection and coloanal anastomosis is preferred

    • High rectovaginal fistulas are best ...

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