RECTOVAGINAL FISTULA (RVF)

Rectovaginal fistula (RVF) is defined as an epithelium lined abnormal communication between rectum and vagina. It is reported to represent approximately 5% of all anorectal fistulas. For affected women, the passing of air and secretions or stool from the rectum through the vagina represents a psychosocial burden.

RVF can result in recurrent infections of the vagina or lower urinary tract. In terms of etiology, various types of RVF are distinguished. Principal causes are obstetric trauma or iatrogenic trauma following procedures in the perineal and pelvic region. RVF can also arise as a result of local inflammations or due to cancer.

The majority of rectovaginal fistulas, >80%, are caused by obstetric trauma (postpartum rectovaginal fistula]. Rectovaginal fistula occurs in 0.2–2.1% of patients with chronic inflammatory bowel disease (particularly Crohn’s disease). Following low anterior rectal resection, the frequency is as high as 10%.

In recent years, rectovaginal fistula has been an increasingly common complication following hemorrhoid or pelvic floor surgery, particularly in cases where staplers or foreign materials were used.

Classification

No generally accepted classification of rectovaginal fistulas exists. Most classifications are based on size, localization, and etiology. In view of the surgical procedure, it makes sense to distinguish between low and high rectovaginal fistulas. Low fistulas are those that can be reconstructed via an anal, perineal, or vaginal access, while high fistulas require an abdominal approach. The assessment of any perineal defects is also important for treatment planning.

The diagnosis of rectovaginal fistula is primarily based on the patient history and the clinical examination.

Patients typically report air, mucus, and possibly stool discharge through the vagina. Most commonly, rectovaginal fistulas are located at the height of the dentate line and communicate with the posterior vaginal fornix. Especially in case of unclear findings, additional examinations should be considered before surgical intervention;

These examinations particularly include colonoscopy and tomography of the lesser pelvis (computed tomography (CT) or magnetic resonance imaging (MRI)) to rule out accompanying pathologies (especially malignancies). Endosonography is a recognized, good alternative, particularly in the confirmation of sphincter lesions.

Treatment procedures

  1. Endorectal closure
  2. Transvaginal closure
  3. Transperineal closure
  4. Martius procedure
  5. Gracilis interposition
  6. Miscellaneous procedures
  7. Interposition of biomaterials
  8. Abdominal techniques

    Perioperative management

    • Wound management and perioperative complications
    • Postoperative return to normal diet
    • Ostomy
    • Continence

      Conclusions

      • The majority of rectovaginal fistulas are of traumatic origin. The most common causes are obstetric trauma,local infection, and rectal surgery.
      • Persistent rectovaginal fistulas generally require surgical treatment.
      • Rectovaginal fistula is diagnosed based on the patient history and the clinical examination. Other pathologies should be ruled out through additional examinations (endoscopy, endosonography, tomography). Various surgical procedures have been described, but evidence levels are low. The most common procedure is transrectal surgery with endorectal suture. The transperineal approach is primarily used in case of simultaneous anal sphincter reconstruction. Closure can also be achieved through the interposition of autologous tissue (Martius flap, gracilis muscle) or biomaterials. Autologous tissue is predominantly used in recurrent fistulas. In higher fistulas, abdominal approaches are also used. No specific procedure can be recommended on the basis of the literature. Ostomy is more frequently required in rectovaginal fistulas than in anal fistulas.

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