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Rectovaginal Fistula

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Urinary Fistula

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Abstract

Rectovaginal fistulas are congenital or acquired abnormal, epithelium-lined connections between the rectum and the vagina. Etiologies include obstetrical injury, infectious or inflammatory causes, malignancy, radiation-related, or traumatic (including iatrogenic) injury. Most RVFs are apparent on physical exam, but ultrasound, MRI, and endoscopy may be useful diagnostic tools. Medical management may ameliorate symptoms to some degree, but really plays only a limited role in treatment. Therefore, surgical intervention is the mainstay of therapy and includes local repair with adjacent tissue or muscle flaps, which may be rotated into the field. Transabdominal repair and fecal diversion are considered on a case-by-case basis. The variety of etiologies, anatomic considerations, and therapeutic options result in a spectrum of possible outcomes. Therefore, an individualized approach tailored to each patient remains the most appropriate treatment philosophy.

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Abbreviations

CT:

Computed tomography

EUS:

Endoanal ultrasound

IBD:

Inflammatory bowel disease

LIFT:

Ligation of intersphincteric fistula tract

MRI:

Magnetic resonance imaging

RVF:

Rectovaginal fistula

References

  1. Bashah DT, Worku AG, Yitayal M, Azale T. The loss of dignity: social experience and coping of women with obstetric fistula, in Northwest Ethiopia. BMC Womens Health. 2019;19(1):84.

    Article  Google Scholar 

  2. Hauch A, McKee RM, Li WY, Crowley JS, Ramamoorthy S, Dobke M. Rectovaginal fistula repair 1 year later: lessons learned. Ann Plast Surg. 2021;87(2):187–93.

    Article  CAS  Google Scholar 

  3. Gazala MA, Wexner SD. Management of rectovaginal fistulas and patient outcome. Expert Rev Gastroenterol Hepatol. 2017;11(5):461–71.

    Article  Google Scholar 

  4. Tozer PJ, Balmforth D, Kayani B, Rahbour G, Hart AL, Phillips RKS. Surgical management of rectovaginal fistula in a tertiary referral centre: many techniques are needed. Colorectal Dis. 2013;15(7):871–7.

    Article  CAS  Google Scholar 

  5. Venkatesh KS, Ramanujam PS, Larson DM, Haywood MA. Anorectal complications of vaginal delivery. Dis Colon Rectum. 1989;32:1039–41.

    Article  CAS  Google Scholar 

  6. Champagne BJ, McGee MF. Rectovaginal fistula. Surg Clin North Am. 2010;90(1):69–82.

    Article  Google Scholar 

  7. Dawes AJ, Jensen CC. Rectovaginal fistulas secondary to obstetrical injury. Clin Colon Rectal Surg. 2021;34:28–39.

    Article  Google Scholar 

  8. Reisenauer C. Presentation and management of rectovaginal fistulas after delivery. Int Urogynecol J. 2016;27(6):859–64.

    Article  Google Scholar 

  9. Rahman MS, Al-Suleiman SA, El-Yahia AR, 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(6):607–10.

    Article  CAS  Google Scholar 

  10. Lo TS, Huang YH, Dass AK, Karim N, Uy-Patrimonio MC. Rectovaginal fistula: twenty years of rectovaginal repair. J Obstet Gynaecol Res. 2016;42(10):1361–8.

    Article  Google Scholar 

  11. Halverson AL, Hull TL, Fazio VW, Church J, Hammel J, Floruta C. Repair of recurrent rectovaginal fistulas. Surgery. 2001;130(4):753–7.

    Article  CAS  Google Scholar 

  12. Karp NE, Kobernik EK, Berger MB, Low CM, Fenner DE. Do the surgical outcomes of rectovaginal fistula repairs differ for obstetric and nonobstetric fistulas? A retrospective cohort study. Female Pelvic Med Reconstr Surg. 2019;25(1):36–40.

    Article  Google Scholar 

  13. Radcliffe AG, Ritchie JK, Hawley PR, et al. Anovaginal and rectovaginal fistulas in Crohn’s disease. Dis Colon Rectum. 1988;31:94–9.

    Article  CAS  Google Scholar 

  14. Schwartz DA, Loftus EV Jr, Tremaine WJ, et al. The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology. 2002;122:875–80.

    Article  Google Scholar 

  15. Sands BE, Anderson FH, Bernstein CN, Chey WY, Feagan BG, Fedorak RN, Kamm MA, Korzenik JR, Lashner BA, Onken JE, Rachmilewitz D, Rutgeerts P, Wild G, Wolf DC, Marsters PA, Travers SB, Blank MA, van Deventer SJ. Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med. 2004;350(09):876–85.

    Article  CAS  Google Scholar 

  16. Sands BE, Blank MA, Patel K, van Deventer SJ, ACCENT II Study. Long-term treatment of rectovaginal fistulas in Crohn’s disease: response to infliximab in the ACCENT II Study. Clin Gastroenterol Hepatol. 2004;2(10):912–20.

    Article  CAS  Google Scholar 

  17. Kaimakliotis P, Simillis C, Harbord M, Kontovounisios C, Rasheed S, Tekkis PP. A systematic review assessing medical treatment for rectovaginal and enterovesical fistulae in Crohn’s disease. J Clin Gastroenterol. 2016;50(09):714–21.

    Article  Google Scholar 

  18. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, Podolsky DK, Sands BE, Braakman T, DeWoody KL, Schaible TF, van Deventer SJ. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med. 1999;340(18):1398–405.

    Article  CAS  Google Scholar 

  19. González-Lama Y, Abreu L, Vera MI, Pastrana M, Tabernero S, Revilla J, Durán JG, Escartin P. Long-term oral tacrolimus therapy in refractory to infliximab fistulizing Crohn’s disease: a pilot study. Inflamm Bowel Dis. 2005;11(01):8–15.

    Article  Google Scholar 

  20. Hannaway CD, Hull TL. Current considerations in the management of rectovaginal fistula from Crohn’s disease. Colorectal Dis. 2008;10:747–55; discussion 755-6.

    Article  CAS  Google Scholar 

  21. Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in Crohn’s disease. World J Gastrointest Pathophysiol. 2014;5(04):487–95.

    Article  Google Scholar 

  22. Buchmann P, Allan RN, Thompson H, Alexander-Williams J. Carcinoma in a rectovaginal fistula in a patient with Crohn’s disease. Am J Surg. 1980;140:462–3.

    Article  CAS  Google Scholar 

  23. Moore-Maxwell CA, Robboy SJ. Mucinous adenocarcinoma arising in rectovaginal fistulae associated with Crohn’s disease. Gynecol Oncol. 2004;93:266–8.

    Article  Google Scholar 

  24. de Bruijn H, Maeda Y, Murphy J, Warusavitarne J, Vaizey CJ. Combined laparoscopic and perineal approach to omental interposition repair of complex rectovaginal fistula. Dis Colon Rectum. 2018;61(1):140–3.

    Article  Google Scholar 

  25. Ohta H, Hashimoto K, Mizukuro T, An B, Zen Y, Nishina Y, Terada Y, Kitamura N, Akabori H, Fujino M, Mekata E. Successful laparoscopy-assisted repair of a rectovaginal fistula after low anterior resection for rectal cancer: a report of two cases. Surg Case Rep. 2021;7(1):68.

    Article  Google Scholar 

  26. Hotouras A, Ribas Y, Zakeri S, Murphy J, Bhan C, Chan CL. Gracilis muscle interposition for rectovaginal and anovaginal fistula repair: a systematic literature review. Colorectal Dis. 2015;17(2):104–10.

    Article  CAS  Google Scholar 

  27. Kimose HH, Fischer L, Spjeldnaes N, Wara P. Late radiation injury of the colon and rectum. Surgical management and outcome. Dis Colon Rectum. 1989;32(8):684–9.

    Article  CAS  Google Scholar 

  28. Piekarski JH, Jereczek-Fossa BA, Nejc D, Pluta P, Szymczak W, Sek P, Bilski A, Gottwald L, Jeziorski A. Does fecal diversion offer any chance for spontaneous closure of the radiation-induced rectovaginal fistula? Int J Gynecol Cancer. 2008;18(1):66–70.

    Article  CAS  Google Scholar 

  29. Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A. Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies—new patients, old problem? Langenbecks Arch Surg. 2017;402(7):1079–88.

    Article  Google Scholar 

  30. Rex JC Jr, Khubchandani IT. Rectovaginal fistula: complication of low anterior resection. Dis Colon Rectum. 1992;35(4):354–6.

    Article  Google Scholar 

  31. Watanabe J, Ota M, Kawaguchi D, Shima H, Kaida S, Osada S, Kamimukai N, Kamiya N, Ishibe A, Watanabe K, Matsuyama R, Akiyama H, Ichikawa Y, Oba M, Endo I. Incidence and risk factors for rectovaginal fistula after low anterior resection for rectal cancer. Int J Colorectal Dis. 2015;30(12):1659–66.

    Article  Google Scholar 

  32. Pata G, Pasini M, Roncali S, Tognali D, Ragni F. Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition. Int J Surg Case Rep. 2014;5(8):527–31.

    Article  Google Scholar 

  33. Liekens E, van Sprundel F, Thiessen F, Pirenne Y. Martius flap reconstruction for rectovaginal fistula after stapled hemorrhoidopexy (Longo operation): a case report. Int J Colorectal Dis. 2019;34(9):1619–23.

    Article  Google Scholar 

  34. 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 Colorectal Dis. 2015;30(4):543–8.

    Article  Google Scholar 

  35. Gallo G, Luc AR, Tutino R, Clerico G, Trompetto M. Delayed coloanal anastomosis for rectovaginal fistula after colorectal resection for deep endometriosis. Ann Ital Chir. 2016;87:S2239253X16026074.

    Google Scholar 

  36. Debeche-Adams TH, Bohl JL. Rectovaginal fistulas. Clin Colon Rectal Surg. 2010;23(2):99–103.

    Article  Google Scholar 

  37. Baig MK, Zhao RH, Yuen CH, Nogueras JJ, Singh JJ, Weiss EG, Wexner SD. Simple rectovaginal fistulas. Int J Colorectal Dis. 2000;15:323–7.

    Article  CAS  Google Scholar 

  38. Yin HQ, Wang C, Peng X, Xu F, Ren YJ, Chao YQ, Lu JG, Wang S, Xiao HS. Clinical value of endoluminal ultrasonography in the diagnosis of rectovaginal fistula. BMC Med Imaging. 2016;16:29.

    Article  Google Scholar 

  39. Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol. 2002;178(3):737–41.

    Article  Google Scholar 

  40. Yee LF, Birnbaum EH, Read TE, Kodner IJ, Fleshman JW. Use of endoanal ultrasound in patients with rectovaginal fistulas. Dis Colon Rectum. 1999;42(8):1057–64.

    Article  CAS  Google Scholar 

  41. Van Buren WM, Lightner AL, Kim ST, Sheedy SP, Woolever MC, Menias CO, Fletcher JG. Imaging and surgical management of anorectal vaginal fistulas. Radiographics. 2018;38(5):1385–401.

    Article  Google Scholar 

  42. Tonolini M. Elucidating vaginal fistulas on CT and MRI. Insights Imaging. 2019;10(1):123.

    Article  Google Scholar 

  43. Giordano P, Drew PJ, Taylor D, Duthie G, Lee PW, Monson JR. Vaginography—investigation of choice for clinically suspected vaginal fistulas. Dis Colon Rectum. 1996;39(5):568–72.

    Article  CAS  Google Scholar 

  44. Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum. 2008;51(7):1084–8.

    Article  Google Scholar 

  45. Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas. Influence of previous repair. Dis Colon Rectum. 1988;31:676–8.

    Article  CAS  Google Scholar 

  46. Rothenberger DA, Christenson CE, Balcos EG, Schottler JL, Nemer FD, Nivatvongs S, Goldberg S. Endorectal advancement flap for treatment of simple rectovaginal fistula. Dis Colon Rectum. 1982;25:297–300.

    Article  CAS  Google Scholar 

  47. Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum. 2002;45:1622–8.

    Article  Google Scholar 

  48. Hull TL, 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.

    Article  Google Scholar 

  49. Jones IT, Fazio VW, Jagelman DG. The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum. Dis Colon Rectum. 1987;30:919–23.

    Article  CAS  Google Scholar 

  50. Watson SJ, Philips RKS. Non-inflammatory rectovaginal fistula. Br J Surg. 1995;82:1641–3.

    Article  CAS  Google Scholar 

  51. Kniery KR, Johnson EK, Steele SR. Operative considerations for rectovaginal fistulas. World J Gastrointest Surg. 2015;7(8):133–7.

    Article  Google Scholar 

  52. Bauer JJ, Sher ME, Jaffin H, Present D, Gelerent I. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn’s disease. Ann Surg. 1991;213(2):151–8.

    Article  CAS  Google Scholar 

  53. Ruffolo C, Scarpa M, Bassi N, Angriman I. A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach. Colorectal Dis. 2010;12(12):1183–91.

    Article  CAS  Google Scholar 

  54. Athanasiadis S, Yazigi R, Kohler A, Helmes C. Recovery rates and functional results after repair for rectovaginal fistula in Crohn’s disease: a comparison of different techniques. Int J Colorectal Dis. 2007;22:1051–60.

    Article  Google Scholar 

  55. Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn’s disease. Am J Surg. 1997;173(2):95–8.

    Article  CAS  Google Scholar 

  56. Marchesa P, Hull TL, Fazio VW. Advancement sleeve flaps for treatment of severe perianal Crohn’s disease. Br J Surg. 1998;85:1695–8.

    Article  CAS  Google Scholar 

  57. Parks AG, Allen CL, Frank JD, McPartlin JF. A method of treating post-irradiation rectovaginal fistulas. Br J Surg. 1978;65:417–21.

    Article  CAS  Google Scholar 

  58. Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO. The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study. Dis Colon Rectum. 2014;57(7):888–98.

    Article  Google Scholar 

  59. Kaiser AM. Cloaca-like deformity with faecal incontinence after severe obstetric injury—technique and functional outcome of ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty. Colorectal Dis. 2008;10(8):827–32.

    Article  CAS  Google Scholar 

  60. Göttgens KW, Heemskerk J, van Gemert W, Smeets R, Stassen LP, Beets G, Baeten CG, Breukink SO. Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh. Tech Coloproctol. 2014;18(9):817–23.

    Google Scholar 

  61. Schwandner O, Fuerst A, Kunstreich K, Scherer R. Innovative technique for the closure of rectovaginal fistula using Surgisis mesh. Tech Coloproctol. 2009;13(2):135–40.

    Article  CAS  Google Scholar 

  62. McNevin MS, Lee PY, Bax TW. Martius flap: an adjunct for repair of complex, low rectovaginal fistula. Am J Surg. 2007;193(5):597–9.

    Article  Google Scholar 

  63. Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD. Are there predictors of outcome following rectovaginal fistula repair? Dis Colon Rectum. 2010;53:1240–7.

    Article  Google Scholar 

  64. Lefèvre JH, 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(7):1290–5.

    Article  Google Scholar 

  65. Papadopoulos O, Konofaos P, Georgiou P, Chrisostomidis C, Tsantoulas Z, Karypidis D, Kostakis A. Gracilis myocutaneous flap: evaluation of potential risk factors and long-term donor-site morbidity. Microsurgery. 2011;31(6):448–53.

    Article  Google Scholar 

  66. Van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis. 2011;26:1463–7.

    Article  Google Scholar 

  67. Chu L, Wang J, Li L, Tong XW, Fan BZ, Guo Y, Li HF. Laparoscopic repair of iatrogenic vesicovaginal and rectovaginal fistula. Int J Clin Exp Med. 2015;8(2):2364–70.

    Google Scholar 

  68. Mukwege D, Mukanire N, Himpens J, Cadière GB. Minimally invasive treatment of traumatic high rectovaginal fistulas. Surg Endosc. 2016;30(1):379–87.

    Article  Google Scholar 

  69. Saidy MN, Adewole AD, Ambroze WL, Schertzer ME, Armstrong DN. Case discussion of Turnbull-Cutait procedure for complex Ano-vaginal fistula: revival of the delayed coloanal pull-through procedure and its application for the modern surgeon. Am Surg. 2016;82(7):e150–2.

    Article  Google Scholar 

  70. Karakayali FY, Tezcaner T, Ozcelik U, Moray G. The outcomes of ultralow anterior resection or an abdominoperineal pull-through resection and coloanal anastomosis for radiation-induced recto-vaginal fistula patients. J Gastrointest Surg. 2016;20(5):994–1001.

    Article  Google Scholar 

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Authors and Affiliations

  1. Division of Colon and Rectal Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA

    Carey Wickham

  2. Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Christine Hsieh

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  1. Carey Wickham
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  2. Christine Hsieh
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Correspondence to Christine Hsieh .

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Editors and Affiliations

  1. Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA

    René Sotelo

  2. Capital Health – Urology Specialists, Capital Health Medical Center, Pennington, NJ, USA

    Charles F. Polotti

  3. School of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, Mexico

    Juan Arriaga

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Wickham, C., Hsieh, C. (2022). Rectovaginal Fistula. In: Sotelo, R., Polotti, C.F., Arriaga, J. (eds) Urinary Fistula. Springer, Cham. https://doi.org/10.1007/978-3-031-15317-4_15

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