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Rectovaginal Fistula

  • Elizabeth R. RaskinEmail author
Chapter

Abstract

Rectovaginal fistula is an abnormal communication between the rectum and vagina that results after traumatic, infectious, neoplastic, and inflammatory insult to the rectovaginal septum. This distressing condition afflicts millions of women worldwide, causing the passage of gas and/or feces through the vagina. This chapter reviews the etiology, classification, and diagnosis of rectovaginal fistula. Medical and surgical treatment should be tailored to each particular patient since there is great heterogeneity in the cohort of women suffering from the condition.

Keywords

Rectovaginal fistula Advancement flap Overlapping sphincteroplasty Perineoproctotomy Crohn’s disease Martius flap Gracilis muscle transposition 

Notes

Acknowledgements

Proctor and lecturer for Intuitive Surgical, Inc.

References

  1. 1.
    Champagne B, McGee M. Rectovaginal fistula. Surg Clin N Am. 2010;90:69–82.CrossRefGoogle Scholar
  2. 2.
    Browning A, Whiteside S. Characteristics, management, and outcomes of repair of rectovaginal fistula among 1100 consecutive cases of female genital tract fistula in Ethiopia. Int J Gynecol Obstet. 2015;131:70–3.CrossRefGoogle Scholar
  3. 3.
    Brown H, Wang L, Bunker C, Lowder J. Lower reproductive tract fistula repairs in inpatient US women, 1979-2006. Int Urogynecol J. 2012;23:403–10.CrossRefGoogle Scholar
  4. 4.
    Reisenauer C. Presentation and management of rectovaginal fistulas after delivery. Int Urogynecol J. 2016;27:859–64.CrossRefGoogle Scholar
  5. 5.
    Ommer A, Herold A, Berg E, Furst A, Schiedeck T, Sailer M. German S3-Guideline: rectovaginal fistula. Ger Med Sci. 2012;10:Doc15.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Goldaber K, Wendel P, McIntire D, Wendel G. Postpartum morbidity after fourth-degree perineal repair. Am J Obstet Gynecol. 1993;168:489–93.CrossRefGoogle Scholar
  7. 7.
    Miller D, Lucente V, Babin E, Beach P, Jones P, Robinson D. Prospective clinical assessment of the transvaginal mesh technique for treatment of pelvic organ prolapse: 5-year results. Female Pelvic Med Reconstr Surg. 2011;17:139–43.CrossRefGoogle Scholar
  8. 8.
    Caquant F, et al. Safety of transvaginal mesh procedure: retrospective study of 684 patients. J Obstet Gynaecol Res. 2008;34:449–56.CrossRefGoogle Scholar
  9. 9.
    Watanabe J, et al. Incidence and risk factors for rectovaginal fistula after low anterior resection for rectal cancer. Int J Color Dis. 2015;30:1659–66.CrossRefGoogle Scholar
  10. 10.
    Matthiessen P, Hansson L, Sjodahl R, Rutegard J. Anastomotic-vaginal fistula after anterior resection of the rectum for cancer—occurrence and risk factors. Color Dis. 2010;12:351–7.CrossRefGoogle Scholar
  11. 11.
    Radcliffe A, Ritchie J, Hawley P, Lennard-Jones J, Northover J. Anovaginal and rectovaginal fistulas in Crohn’s disease. Dis Colon Rectum. 1988;31:94–9.CrossRefGoogle Scholar
  12. 12.
    Richard C, Cohen Z, Stern H, McLeod R. Outcome of the pelvic pouch procedure in patients with prior perianal disease. Dis Colon Rectum. 1997;40:647–52.CrossRefGoogle Scholar
  13. 13.
    Belliveau P, Trudel J, Vasilevsky C, Stein B, Gordon P. Ileoanal anastomosis with reservoirs: complications and long-term results. Can J Surg. 1999;42:345–52.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Seidel S, Peach S, Newman M, Sharp K. Ileoanal pouch procedures: clinical outcomes and quality of life assessment. Am Surg. 1999;65:40–6.PubMedGoogle Scholar
  15. 15.
    Corte H, Maggiori L, Treton X, Lefevre J, Ferron M, Panis Y. Rectovaginal fistula: what is the optimal strategy? Ann Surg. 2015;262:855–61.CrossRefGoogle Scholar
  16. 16.
    Jakubowicz J, Blecharz P, Skotnicki P, Reinfuss M, Walasek T, Luczynska E. Toxicity of concurrent chemoradiotherapy for locally advanced cervical cancer. Eur J Gynaecol Oncol. 2014;35:393–9.PubMedGoogle Scholar
  17. 17.
    De Beche-Adams T, Bohl J. Rectovaginal fistulas. Clin Colon Rectal Surg. 2010;23:99–103.CrossRefGoogle Scholar
  18. 18.
    Ugurel V, Ozer D, Varol F. A rare case of rectovaginal fistula after consensual vaginal intercourse. J Sex Med. 2014;11:1345–8.CrossRefGoogle Scholar
  19. 19.
    Schwartz J, Rabinowitz H, Rozenfeld V, Leibovitz A, Stelian J, Habot B. Rectovaginal fistulas associated with fecal impaction. J Am Geriatr Soc. 1992;40:641.CrossRefGoogle Scholar
  20. 20.
    Ozuner G, Elagili F, Aytac E. Rectovaginal fistula secondary to an erosive pessary. Tech Coloproctol. 2015;19:491–2.CrossRefGoogle Scholar
  21. 21.
    Ampt A, Patterson J, Roberts C, Ford J. Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery. Int J Gynaecol Obstet. 2015;131:260–4.CrossRefGoogle Scholar
  22. 22.
    Yee L, Birnbaum E, Read T, Kodner I, Fleshman J. Use of endoanal ultrasound in patients with rectovaginal fistulas. Dis Colon Rectum. 1999;42:1057–64.CrossRefGoogle Scholar
  23. 23.
    Stoker J, Rociu E, Wiersma T, Lameris J. Imaging of anorectal disease. Br J Surg. 2000;87:10–27.CrossRefGoogle Scholar
  24. 24.
    Tsang C, et al. Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum. 1998;41:1141–6.CrossRefGoogle Scholar
  25. 25.
    Stoker J, Rociu E, Schouten W, Lameris J. Anorectal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol. 2002;178:737–41.CrossRefGoogle Scholar
  26. 26.
    Denson L, Shobeiri S. Peroxide-enhanced 3-dimensional endovaginal ultrasound imaging for diagnosis of rectovaginal fistula. Female Pelvic Med Reconstr Surg. 2014;20:240–2.CrossRefGoogle Scholar
  27. 27.
    Rahman M, Al-Suleiman S, El-Yahia A, Rahman J. Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years’ experience in a teaching hospital. J Obstet Gynaecol. 2003;23:607–10.CrossRefGoogle Scholar
  28. 28.
    Hannaway C, Hull T. Current considerations in the management of rectovaginal fistula from Crohn’s disease. Color Dis. 2008;10:747–56.CrossRefGoogle Scholar
  29. 29.
    Zhu Y, Tao G, Zhou N, Xiang C. Current treatment of rectovaginal fistula in Crohn’s disease. World J Gastroenterol. 2011;28:963–7.CrossRefGoogle Scholar
  30. 30.
    Present D, Lichtinger S. Efficacy of cyclosporine in the treatment of fistula of Crohn’s disease. Dig Dis Sci. 1994;39:374–80.CrossRefGoogle Scholar
  31. 31.
    Present D, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med. 1999;340:1398–405.CrossRefGoogle Scholar
  32. 32.
    Parsi M, Lashner B, Achkar J, Connor J, Brzezinski A. Type of fistula determines response to infliximab in patients with Crohn’s disease. Am J Gastroenterol. 2004;99:445–9.CrossRefGoogle Scholar
  33. 33.
    Sands B, Blank M, Patel K, van Deventer S. Long-term treatment of rectovaginal fistulas in Crohn’s disease: response to infliximab in the ACCENT II study. Clin Gastroenterol Hepatol. 2004;10:912–20.CrossRefGoogle Scholar
  34. 34.
    Lichtenstein G, et al. Clinical trial: benefits and risks of immunomodulators and maintenance infliximab for IBD-subgroup analyses across 4 random trials. Aliment Pharmacol Ther. 2009;30:210–26.CrossRefGoogle Scholar
  35. 35.
    Kodner I, Mazor A, Shemesh E, Fry R, Fleshman J, Birnbaum E. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery. 1993;114:682–90.PubMedGoogle Scholar
  36. 36.
    Ozuner G, Hullt T, Cartmill J, Fazio V. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum. 1996;39:10–4.CrossRefGoogle Scholar
  37. 37.
    Sonoda T, Hull T, Piedmonte M, Fazio V. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum. 2002;45:1622–8.CrossRefGoogle Scholar
  38. 38.
    Lowry A, Thorson A, Rothenberger D, Goldberg S. Repair of simple rectovaginal fistulas: influence of previous repairs. Dis Colon Rectum. 1988;31:676–8.CrossRefGoogle Scholar
  39. 39.
    Buchanan G, et al. Efficacy of fibrin sealant in the management of complex anal fistulas: a prospective trial. Dis Colon Rectum. 2003;46:1167–74.CrossRefGoogle Scholar
  40. 40.
    Loungnarath R, Dietz D, Mutch M, Birnbaum E, Kodner I, Fleshman J. Fibrin glue treatment of complex anal fistulas has low success rates. Dis Colon Rectum. 2004;47:432–6.CrossRefGoogle Scholar
  41. 41.
    Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum. 2009;52:1877–81.CrossRefGoogle Scholar
  42. 42.
    Thekkinkattil D, Botterill I, Ambrose N, Lundby L, Sagar P, Buntzen S, Finan P. Efficacy of the anal fistula plug in complex anorectal fistulae. Color Dis. 2009;11:584–7.CrossRefGoogle Scholar
  43. 43.
    Gajsek U, McArthur D, Sagar P. Long-term efficacy of the button fistula plug in the treatment of ileal pouch-vaginal and Crohn’s-related rectovaginal fistulas. Dis Colon Rectum. 2011;54:999–1002.CrossRefGoogle Scholar
  44. 44.
    Chew S, Rieger N. Transperineal repair of obstetric-related anovaginal fistula. Aust N Z J Obstet Gynaecol. 2004;44:68–71.CrossRefGoogle Scholar
  45. 45.
    El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping sphincter repair: does age matter? Dis Colon Rectum. 2012;55:256–61.CrossRefGoogle Scholar
  46. 46.
    Maslekar S, Gardiner A, Duthie G. Anterior anal sphincter repair for fecal incontinence: good long-term results are possible. J Am Coll Surg. 2007;204:40–6.CrossRefGoogle Scholar
  47. 47.
    Barisic G, Krivokapic Z, Markovic V, Saranovic D, Kalezic V, Sekulic A. Endorectal ultrasound (ERUS) in pelvic disorders. Acta Chir Iugosl. 2006;53:117–20.CrossRefGoogle Scholar
  48. 48.
    Goetz L, Lowry A. Overlapping sphincteroplasty: is it the standard of care? Clin Colon Rectal Surg. 2005;18:22–30.CrossRefGoogle Scholar
  49. 49.
    Bravo-Gutierrez A, Madoff R, Lowry A, Parker S, Buie W, Baxter N. Long-term results of anterior sphincteroplasty. Dis Colon Rectum. 2004;47:727–31.CrossRefGoogle Scholar
  50. 50.
    Malouf A, et al. A prospective audit of fistula-in-ano at St. Mark’s Hospital. Color Dis. 2002;4:13–9.CrossRefGoogle Scholar
  51. 51.
    Hull T, El-Gazzaz G, Gurland B, Church J, Zutshi M. Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum. 2011;54:54–9.CrossRefGoogle Scholar
  52. 52.
    Mazier W, Senagore A, Schiesel E. Operative repair of anovaginal and rectovaginal fistulas. Dis Colon Rectum. 1995;38:148–52.CrossRefGoogle Scholar
  53. 53.
    Tancer M, Lasser D, Rosenblum N. Rectovaginal fistula or perineal and anal sphincter disruption, or both, after vaginal delivery. Surg Gynecol Obstet. 1990;171:43–6.PubMedGoogle Scholar
  54. 54.
    Reichert M, Schwandner T, Hecker A, Behnk A, Baumgart-Vogt E, Wagenlehner F, Padberg W. Surgical approach for repair of rectovaginal fistula by modified Martius flap. Geburtshilfe Frauenheilkd. 2014;74:923–7.CrossRefGoogle Scholar
  55. 55.
    Kniery K, Johnson E, Steele S. How I do it: Martius flap for rectovaginal fistulas. J Gastrointest Surg. 2015;19:570–4.CrossRefGoogle Scholar
  56. 56.
    Pitel S, Lefevre J, Parc Y, Chafai N, Shields C, Tiret E. Martius advancement flap for low rectovaginal fistula: short and long-term results. Color Dis. 2011;13:112–5.CrossRefGoogle Scholar
  57. 57.
    Takano S, Boutros M, Wexner SD. Gracilis muscle transposition for complex perineal fistulas and sinuses: a systematic literature review of surgical outcomes. J Am Coll Surg. 2014;219(2):313–23.  https://doi.org/10.1016/j.jamcollsurg.2014.04.006.CrossRefGoogle Scholar
  58. 58.
    Abu Gazala M, Wexner SD. Management of rectovaginal fistulas and patient outcome. Expert Rev Gastroenterol Hepatol. 2017;11(5):461–71.  https://doi.org/10.1080/17474124.2017.1296355.CrossRefGoogle Scholar
  59. 59.
    Takano S, Boutros M, Wexner SD. Gracilis transposition for complex perineal fistulas: rectovaginal fistula and rectourethral fistula. Dis Colon Rectum. 2014;57(4):538.  https://doi.org/10.1097/DCR.0000000000000093.CrossRefGoogle Scholar
  60. 60.
    Lefevre J, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y. Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum. 2009;52:1290–5.CrossRefGoogle Scholar
  61. 61.
    Wexner S, Ruiz D, Genua J, Nogueras J, Weiss E, Zmora O. Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg. 2008;248:39–43.CrossRefGoogle Scholar
  62. 62.
    Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwander O, Agha A. Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Color Dis. 2008;23:349–53.CrossRefGoogle Scholar
  63. 63.
    Schloericke E, Hoffmann M, Zimmermann M, Kraus M, Bouchard R, Roblick U, Hildebrand P, Nolde J, Bruch H, Limmer S. Transperineal omentum flap for the anastomotic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas. Color Dis. 2011;14:604–10.CrossRefGoogle Scholar
  64. 64.
    van der Hagen S, Soeters P, Baeten C, van Gemert W. Laparoscopic fistula excision and omenoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis. 2011;26:1463–7.CrossRefGoogle Scholar
  65. 65.
    Mukwege D, Mukanire N, Himpens J, Cadiere G. Minimally invasive treatment of traumatic high rectovaginal fistulas. Surg Endosc. 2016;30:379–87.CrossRefGoogle Scholar
  66. 66.
    Maggiori L, Blanche J, Harnoy Y, Ferron M, Panis Y. Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula. Int J Color Dis. 2015;30:543–8.CrossRefGoogle Scholar
  67. 67.
    Hallet J, Bouchard A, Drolet S, Milot H, Desrosiers E, Lebrun A, Gregoire R. Anastomotic salvage after rectal cancer resection using Turnbull-Cutait delayed anastomosis. Can J Surg. 2014;57:405–11.CrossRefGoogle Scholar
  68. 68.
    Rivadeneira D, Ruffo B, Amrani S, Salinas C. Rectovaginal fistulas: current surgical management. Clin Colon Rectal Surg. 2007;20:96–101.CrossRefGoogle Scholar
  69. 69.
    Lamazza A, Fiori E, Schillaci A, Sterpetti A, Lezoche E. Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results. Color Dis. 2014;17:356–60.CrossRefGoogle Scholar
  70. 70.
    El-Gazzaz G, Hull T, Mignanelli E, Hammel J, Gurland B, Zutshi M. Analysis of function and predictors of failure in women undergoing repair of Crohn’s related rectovaginal fistula. J Gastrointest Surg. 2010;14:824–9.CrossRefGoogle Scholar
  71. 71.
    Loffler T, Welsch T, Muhl S, Hinz U, Schmidt J, Kienle P. Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn’s disease. Int J Color Dis. 2009;24:521–6.CrossRefGoogle Scholar
  72. 72.
    Hull T, Fazio V. Surgical approaches to low anovaginal fistula in Crohn’s disease. Am J Surg. 1997;173:95–8.CrossRefGoogle Scholar
  73. 73.
    Ruffalo C, et al. Outcome of surgery for rectovaginal fistula due to Crohn’s disease. Br J Surg. 2009;96:1190–5.CrossRefGoogle Scholar
  74. 74.
    Shah N, Remzi F, Massmann A, Baixauli J, Fazio V. Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy. Dis Colon Rectum. 2003;46:911–7.CrossRefGoogle Scholar
  75. 75.
    Lambertz A, Luken B, Ulmer T, Bohm G, Neumann U, Klink C. Influence of diversion stoma on surgical outcome and recurrence rates in patients with rectovaginal fistula—a retrospective cohort study. Int J Surg. 2016;25:114–7.CrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Surgical Oncology, Department of SurgeryLoma Linda University HealthLoma LindaUSA

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