Rectovaginal fistulas (RVFs) are an abnormal communication between the anorectum and vagina that can be disabling for patients and challenging to treating surgeons. Addressed in this chapter are RVFs resulting from obstetric trauma, cryptoglandular disease, and Crohn’s disease. A number of different surgical approaches have been described in the treatment of rectovaginal fistulas. A single “best” approach has not been identified, and surgeons must be familiar with a variety of techniques in order to determine which approach is best suited for their patient. This chapter will review the most commonly described techniques and propose an algorithm for managing these complex patients.