Abstract
PURPOSE: The purpose of our study was to define the role of endoanal ultrasound in the evaluation and management of patients with rectovaginal fistula. METHODS: A retrospective review was performed of all patients with rectovaginal fistula who were evaluated by endoanal ultrasound at Barnes-Jewish Hospital at Washington University from 1992 to 1997. RESULTS: Twenty-five females underwent endoanal ultrasound before rectovaginal fistula repair. Mean age was 34 years. Rectovaginal fistulas were caused by obstetric trauma (19 patients; 76 percent), cryptoglandular disease (5 patients; 20 percent), and Crohn's disease (1 patient; 4 percent). Previous rectovaginal fistula repair had been performed in ten patients (40 percent). A history of anal incontinence was present in ten patients (40 percent). Rectovaginal fistula location was above (15 patients), at (7 patients), or below (3 patients) the dentate line. Rectovaginal fistula size was <5 mm (19 patients; 76 percent) or >5 mm (6 patients; 24 percent). Anal manometry revealed decreased sphincter pressures (resting or squeeze) in 12 patients (48 percent). Pudendal nerve latency was abnormal in three patients (9 percent). Endoanal ultrasound identified the rectovaginal fistula in 7 patients (28 percent) and an anterior sphincter defect in 23 patients (92 percent). At surgery sphincter injuries were identified in 23 patients (92 percent). Treatment was either sliding flap repair with anal sphincter reconstruction (22 patients; 88 percent) or sliding flap repair alone (3 patients; 12 percent). Repair of the rectovaginal fistula was successful in 23 patients (92 percent). Complications occurred in 11 patients (44 percent): two recurrent rectovaginal fistulas, five infections, two skin separations, one ectropion, and one hematoma. The two patients with recurrent rectovaginal fistula had prior repairs, and both were subsequently repaired successfully. Of the 11 patients with preoperative anal incontinence, 6 patients (54 percent) were continent and 2 (18 percent) improved after surgery. Cause, size, location, and previous repair of fistula had no effect on final outcome. CONCLUSIONS: Noncontrast endoanal ultrasound was not useful in imaging rectovaginal fistulas and cannot be recommended as a diagnostic or screening tool for the identification of a rectovaginal fistula. However, we recommend that endoanal ultrasound be performed preoperatively in all patients with known rectovaginal fistulas to identify and map occult sphincter defects. Concomitant anal sphincter reconstruction should be considered strongly in patients with rectovaginal fistula and an endoanal ultrasound-documented sphincter defect.
Similar content being viewed by others
References
Fry R, Kodner I. Anorectal disease. In: Levine BA, Copeland EM, Howard RJ, Sugerman HJ, Warshaw AL, eds. Current practice of surgery. Vol 3. New York: Churchill-Livingston, 1993:3–22.
Kodner IJ, Fry RD, Fleshman JW, Birnbaum EH. Colon, rectum and anus. In: Schwartz S, ed. Principles of surgery. 6th ed. New York: McGraw-Hill, 1993:1191–306.
Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993;114:682–90.
Wexner S, Rosen L, Roberts P,et al., The Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for treatment of fistula-in-ano—supporting documentation. Dis Colon Rectum 1996;39:1363–72.
Fry R, Kodner I. Rectovaginal fistula. Surg Ann 1995;10:113–31.
Tsang CB, Madoff RD, Wong WD,et al. Anal sphincter integrity and function influences outcome in rectovaginal repair. Dis Colon Rectum 1998;41:1141–6.
Dragsted J, Gammegaard J. Ultrasonic scanning in the evaluation of rectal cancer: a preliminary report of 13 cases. Gastrointest Radiol 1983;8:367–9.
Rifkin M, McGlynn E. Endorectal sonographic prospective staging of rectal cancer. Scand J Gastroenterol 1986;21(Suppl 123):99–103.
Beynon J, Mortensen N, Foy D, Channer J, Virjee J, Goddard P. Pre-operative assessment of local invasion in rectal cancer: digital examination, endoluminal ultrasonography, or computed tomography? Br J Surg 1986;73:1015–7.
Senagore A, Milsom J, Talbot T,et al. Intrarectal ultrasonography in the staging and management of rectal tumors. Am Surg 1988;54:352–5.
Orrom WJ, Wong WD, Rothenberger DA, Jensen LL, Goldberg SM. Endorectal ultrasound in the preoperative staging of rectal tumors: a learning experience. Dis Colon Rectum 1990;33:654–9.
Hildebrandt U, Klein G, Feifel G, Schwarz H-P, Koch B, Schmitt RM. Endosonography of pararectal lymph nodes:in vitro andin vivo evaluation. Dis Colon Rectum 1990;33:863–8.
Felt-Bersma R, Cuesta M. Anorectal endosonography in benign anorectal disorders. Scand J Gastroenterol 1993;Suppl 200:70–3.
Law PJ, Kamm MA, Bartram CI. A comparison between electromyography and anal endosonography in mapping external anal defects. Dis Colon Rectum 1990;33:370–3.
Law P, Talbot R, Bartram C, Northover J. Anal endosonography in the evaluation of perianal sepsis and fistula in ano. Br J Surg 1989;76:752–5.
Choen S, Burnett S, Bartram C, Nicholls R. Comparison between anal endosonography and digital examination in the evaluation of anal fistulae. Br J Surg 1991;78:445–7.
Cheong DM, Nogueuras JJ, Wexner SD, Jagelman DG. Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide. Dis Colon Rectum 1993;36:1158–60.
Deen K, Williams J, Hutchinson R,et al. Fistulas in ano: endoanal ultrasonographic assessment assists decision-making for surgery. Gut 1994;35:1158–60.
Burnett S, Speakman C, Kamm M, Bartram C. Confirmation of endosonographic detection of external anal sphincter defects by simultaneous electromyographic mapping. Br J Surg 1991;78:448–50.
Law P, Kamm M, Bartram C. Anal endosonography in the investigation of faecal incontinence. Br J Surg 1991;78:312–4.
Felt-Bersma RJ, Cuesta MA, Koorevaar M,et al. Anal endosonography: relationship with anal manometry and neurophysiologic tests. Dis Colon Rectum 1992;35:944–9.
Deen K, Kumar D, Williams J, Ollif J, Keighley M. The prevalence of anal sphincter defects in faecal incontinence: a prospective endosonic study. Gut 1993;34:685–8.
Tjandra JJ, Milsom JW, Schroeder T, Fazio VW. Endoluminal ultrasound is preferable to electromyography in mapping anal sphincteric defects. Dis Colon Rectum 1993;36:689–92.
Deen K, Kumar D, Williams J, Olliff J, Keighley M. Anal sphincter defects: correlation between endoanal ultrasound and surgery. Ann Sur 1993;218:201–5.
Farouk R, Bartolo D. The use of endoluminal ultrasound in the assessment of patients with faecal incontinence. J R Coll Surg Edinb 1994;39:312–8.
Falk PM, Blatchford GJ, Cali RL, Christensen MA, Thorsen AG. Transanal ultrasound and manometry in the evaluation of fecal incontinence. Dis Colon Rectum 1994;37:468–72.
Bartram C, Sultan A. Anal endosonography in faecal incontinence. Gut 1995;37:4–6.
Felt-Bersma RJ, van Baren R, Koorevaar M, Strijers RL, Cuesta MA. Unsuspected sphincter defects shown by anal endosonography after anorectal surgery: a prospective study. Dis Colon Rectum 1995;38:249–53.
Sultan A, Kamm M, Hudson C, Thomas J, Bartram C. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
Fleshman JW, Dreznik Z, Fry RD, Kodner IJ. Anal sphincter repair for obstetric injury: manometric evaluation of functional results. Dis Colon Rectum 1991;34:1061–7.
Sentovich SM, Blatchford GJ, Rivela LJ, Lin K, Thorson AG, Christensen MA. Diagnosing anal sphincter injury with transanal ultrasound and manometry. Dis Colon Rectum 1997;40:1430–4.
Rieger NA, Sweeney JL, Hoffmann DC, Young JF, Hunter A. Investigation of fecal incontinence with endoanal ultrasound. Dis Colon Rectum 1996;39:860–4.
Laurberg S, Swash M. Effects of aging on the anorectal sphincters and their innervation. Dis Colon Rectum 1989;32:737–42.
Snooks S, Swash M, Mathers S, Henry M. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 1990;77:1358–60.
Russell T, Gallagher D. Low rectovaginal fistulas: approach and treatment. Am J Surg 1977;134:13–8.
Rothenberger DA, Christenson CE, Balcos EG,et al. Endorectal advancement flap for treatment of simple rectovaginal fistula. Dis Colon Rectum 1982;25:297–300.
Lowry AC, Thorsen AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas: influence of previous repairs. Dis Colon Rectum 1988;31:676–8.
Schafer R, Heyer T, Gantke B,et al. Anal endosonography and manometry: comparison in patients with defecation problems. Dis Colon Rectum 1997;40:293–7.
Keating JP, Stewart PJ, Eyers AA, Warner D, Bokey EL. Are special investigations of value in the management of patients with fecal incontinence? Dis Colon Rectum 1997;40:896–901.
Author information
Authors and Affiliations
Additional information
Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.
About this article
Cite this article
Yee, L.F., Birnbaum, E.H., Read, T.E. et al. Use of endoanal ultrasound in patients with rectovaginal fistulas. Dis Colon Rectum 42, 1057–1064 (1999). https://doi.org/10.1007/BF02236703
Issue Date:
DOI: https://doi.org/10.1007/BF02236703