Rectovaginal Fistula

What is a rectovaginal fistula?
A rectovaginal fistula is a medical condition where there is a fistula or abnormal connection between the rectum and the vagina. Although generally uncommon, rectovaginal fistulas may be extremely debilitating. If the fistula is wide it will allow both gas and stool to escape from the rectum into the vagina, leading to fecal incontinence. Patients can experience recurrent urinary and vaginal infections due to this leakage. The severity of symptoms will depend on the size of fistula.

What causes a rectovaginal fistula?
Rectovaginal fistulas are often the result of trauma during childbirth, such as tearing, episiotomy or forceps/vacuum extraction. Rectovaginal fistulas are also seen where there is inadequate health care, such as in some developing countries. The rectovaginal fistula can become evident within 1 week of delivery.

Rectovaginal fistula can also be a symptom of various diseases, including Crohn’s disease or less commonly rectal cancer.  Or, they can be an unintended result of surgery, such as vaginal hysterectomy, hemorrhoidectomy, abscess drainage or sexual reassignment surgery. They are seen rarely after radiotherapy treatment for cervical cancer.

How is a rectovaginal fistula diagnosed? 
Patients should undergo a thorough history and physical exam. History taking will focus on obstetrical history, previous adbominal and anorectal surgeries, history of radiation treatment, and signs and symptoms of Crohn’s disease.  Physical exam includes a thorough inspection of both the anus and the vagina, including anoscopy of the distal rectum and anal canal. Endoanal ultrasound and/or MRI may be performed to help in identifying the fistula.

How is a rectovaginal fistula treated?
After diagnosing a new rectovaginal fistula, it is best to wait for 3-6 months to allow the inflammation to subside. Surgical treatment of a rectovaginal fistula can greatly improve a paitent’s quality of life. However, these can be challenging to repair successfully, and many patients require multiple attempts at repiar. Several differrent operations have been described to fix rectovaginal fistulas.  The most common surgical options are a sliding endorectal advancement flap or an overlapping sphincter repair. 

While most rectovaginal fistulas will require surgical repair, patients with Crohn’s disease may be treated with medications, which can sometimes help in closing the fistula.