Abstract
Purpose
Crohn’s disease is characterized by transmural bowel inflammation and a tendency to form fistulas with adjacent structures. Several different fistulas have been described: enterocutaneous, enteroenteric, enterovesical, enterovaginal, and perineal. Rectovaginal fistulas are difficult to treat despite multimodal therapy. This study was designed to review the current strategic options to best manage this condition.
Methods
We reviewed the English-language literature from 1966 to 2006, using PUBMED, targeting Crohn’s disease involving vagina using key words “rectovaginal fistula and CD,” “anovaginal fistula and CD,” “anovaginal fistula,” and “rectovaginal fistula.” We excluded the involvement of the vagina from a pouch after a proctectomy. A total of 776 articles were found; 206 articles were identified and judged as being relevant on the basis of title-related articles and links were reviewed. Fifty-three articles were selected after reading the abstract or full manuscript.
Results
The management of rectovaginal fistula, representing 9 percent of all fistulas, remains a challenge in the setting of Crohn’s disease. Medical treatments are not favorable with low rates of long-term symptomatic control and unacceptable high rates of recurrence. Several novel and new surgical techniques have been described, and rectal advancement flap, in selected patients, seems to have the most successful results.
Conclusions
The management of rectovaginal fistula of Crohn’s origin should involve both gastroenterologists and coloproctologists, with the best surgical results being achieved in patients receiving optimum medical therapy. More focused studies targeting these patients with the use of combined medical and surgical therapy are necessary.
Similar content being viewed by others
References
Adams F. The genuine works of Hippocrates. Baltimore: Williams and Wilkins, 1939:308.
Gabriel WB. Results of an experimental and histological investigation of seventy-five cases of rectal fistulae. Proc R Soc Med 1921;14:156-61.
Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis: a pathological and clinical entity. JAMA 1932;99:1323-8.
Saclarides TJ. Rectovaginal fistula. Surg Clin North Am 2002;82:1261-72.
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.
Radcliffe AG, Ritchie JK, Hawley PR, Lennard-Jones JE, Northover JM. Anovaginal and rectovaginal fistulas in Crohn’s disease. Dis Colon Rectum 1988;31:94-9.
Sher ME, Bauer JJ, Gelernt I. Surgical repair of rectovaginal fistulas in patients with Crohn’s disease: transvaginal approach. Dis Colon Rectum 1991;34:641-8.
Tuxen PA, Castro AF. Rectovaginal fistula in Crohn’s disease. Dis Colon Rectum 1979;22:58-62.
Heyen F, Winslet MC, Andrews H, Alexander-Williams J, Keighley MR. Vaginal fistulas in Crohn’s disease. Dis Colon Rectum 1989;32:379-83.
Rankin GB, Watts HD, Melnyk CS, Kelley ML. National Cooperative Crohn’s Disease Study: extraintestinal manifestations and perianal complications. Gastroenterology 1979;77:914-20.
Hesterberg R, Schmidt WU, Muller F, Roher HD. Treatment of anovaginal fistulas with an anocutaneous flap in patients with Crohn’s disease. Int J Colorectal Dis 1993;8:51-4.
Fry RD, Shemesh EI, Kodner IJ, Timmcke A. Techniques and results in the management of anal and perianal Crohn’s disease. Surg Gynecol Obstet 1989;168:42-8.
Van Patter WN, Bargen JA, Dockerty MB, et al. Regional enteritis. Gastroenterology 1954;26:347-450.
Ritchie JK, Lennard-Jones JE. Crohn’s disease of the distal large bowel. Scand J Gastroenterol 1976;11:433-6.
Morrison JG, Gathright JB, Ray JE, Ferrari BT, Hicks TC, Timmcke AE. Results of operation for rectovaginal fistula in Crohn’s disease. Dis Colon Rectum 1989;32:497-9.
Nicholls RJ, Dozois RR. Surgery of the colon and rectum. London: Churchill Livingstone, 1997:632-3.
Abel ME, Chiu YS, Russell TR, Volpe PA. Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum 1993;36:447-9.
Brandt LJ, Bernstein LH, Boley SJ, Frank MS. Metronidazole therapy for perirectal Crohn’s disease: a follow-up study. Gastroenterology 1982;83:383-7.
Bernstein LH, Frank MS, Brandt LJ, Boley SJ. Healing of perineal Crohn’s disease with metronidazole. Gastroenterology 1980;79:357-65.
Dejaco C, Harrer M, Waldhoer T, Miehsler W, Vogelsang H, Reinisch W. Antibiotics and azathioprine for the treatment of perianal fistulas in Crohn’s disease. Aliment Pharmacol Ther 2003;18:1113-20.
Turunen U, Farkkila M, Seppala K. Long-term treatment of perianal or fistulous Crohn’s disease with ciprofloxacin. Scan J Gastroenterol 1989;24:144.
Wolf JL. Ciprofloxacin may be useful in Crohn’s disease. Gastroenterology 1990;98:A212.
Solomon MJ, McLeod RS, O’Connor BI, Steinhart A, Greenberg G, Cohen Z. Combination ciprofloxacin and metronidazole in severe perianal Crohn’s disease. Can J Gastroenterol 1993;7:571-3.
Korelitz B, Present D. Favorable effect of 6-mercaptopurine on fistulae of Crohn’s Disease. Dig Dis Sci 1985;30:58-64.
Present DH, Korelitz BI, Wisch N, Glass JL, Sachar DB, Pastermack BS. Treatment of Crohn’s disease with 6-mercaptopurine. A long-term randomized, double-blind study. N Engl J Med 1980:302:981-7.
Brynskov J, Freund L, Rasmussen SN, et al. A placebo-controlled double blind randomized trial of cyclosporine therapy in active chronic Crohn’s disease. N Engl J Med 1989;321:845-50.
Present DH, Lichtiger S. Efficacy of cyclosporine in treatment of fistula of Crohn’s disease. Dig Dis Sci 1994;39:374-80.
Hanauer SB, Smith MB. Rapid closure of Crohn’s disease fistulas with continuous intravenous cyclosporine A. Am J Gatroenterol 1993;88:646-9.
Amati L, Caradonna L, Jirillo E, Caccavo D. Immunological disorders in inflammatory bowel disease and immunotherapeutic implications. Ital J Gastroenterol Hepatol 1999;31:313-25.
Hanauer SB, Feagan BG, Lichtenstein GR, et al. ACCENT I Study Group. Maintenance of infliximab for Crohn’s disease: the ACCENT 1 randomised trial. Lancet 2002;359:1541-9.
D’haens G, Van Deventer S, Van Hogezand R, et al. Endoscopic and histological healing with infliximab anti-tumor nerosis factor antibodies in Crohn’s disease: a European multicenter trial. Gastroenterology 1999;116:1029-34.
Topstad D, Panaccione R, Heine JA, Johnson DR, MacLean AR, Buie WD. Combined seton placement, infliximab infusion and maintenance immunosuppressives improve healing rate in fistulizing anorectal Crohn’s Disease. A single-center experience. Dis Colon Rectum 2003;46:577-83.
Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999;340:1398-405.
Parsi M, Lashner B, Achkar JP, Connor JT, Brzezinski A. Type of fistula determines response to infliximab in patients with fistulous Crohn’s Disease. Am J Gastroenterol 2004;99:445-9.
Van Bodegraven AA, Sloots CE, Felt-Bersma RJ, Meuwissen SG. Endosonographic evidence of persistence of Crohn’s disease associated fistulas after inflixmab treatment, irrespective of clinical response. Dis Colon Rectum 2002;45:39-45.
Ricart E, Panaccione R, Loftus EV, Tremaine WJ, Sandborn WJ. Infliximab for Crohn’s disease in clinical practice at the Mayo Clinic: the first 100 patients. Am J Gastroenterol 2001;96:722-9.
Farrell RJ, Shah SA, Lodhavia PJ, et al. Clinical experience with infliximab therapy in 100 patients with Crohn’s Disease. Am J Gastroenterol 2000;95:3490-7.
Sands BE, Blank MA, Patel K, van Deventer SJ. Long-term treatment of rectovaginal fistulas in Crohn’s Disease: Response to infliximab in the ACCENT II study. Clin Gastroenterol Hepatol 2004;2:912-20.
Ochsenkuhn T, Goke B, Sackmann M. Combining infliximab with 6-mercaptopurine/azathioprine for fistula therapy in Crohn’s disease. Am J Gastroenterol 2002;97:2022-5.
Rasul I, Wilson SR, MacRae H, Irwin S, Greenberg GR. Clinical and radiologial responses after infliximab treatment for perianal fistulizing Crohn’s disease. Am J Gastroenterol 2004;99:82-8.
Ardizzone S, Maconi G, Colombo E, Manzionna G, Bollani S, Bianchi Porro G. Perianal fistula following infliximab treatment:clinical and endosonographic outcome. Inflamm Bowel Dis 2004;10:91-6.
Bell SJ, Halligan S, Windsor AC, Williams AB, Wiesel P, Kamm MA. Response of fistulating Crohn’s disease to infliximab treatment assessed by MRI. Aliment Pharmacol Ther 2003;17:387-93.
Scott NA, Nair A, Hughes LE. Anovaginal and rectovaginal fistula in patients with Crohn’s disease. Br J Surg 1992;79:1379-80.
Levy C, Tremaine WJ. Management of internal fistulas in Crohn’s disease. Inflamm Bowel Dis 2002;8:106-11.
Lichtenstein GR. Treatment of fistulizing Crohn’s disease. Gastroenterology 2000;119:1132-47.
Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fistulas in Crohn’s disease. Dis Colon Rectum 2005;48:459-63.
Solomon MJ, McLeod RS, Cohen EK, Cohen Z. Anal wall thickness under normal and inflammatory conditions of the anorectum as determined by endoluminal ultrasonography. Am J Gastroenterol 1995;90:574-8.
Noble GH. A new operation for complete laceration of the perineum designed for the purpose of eliminating danger of infection from the rectum. Trans Am Gynecol Soc 1902;27:357-63.
Laird DR. Procedures used in the treatment of complicated fistulas. Am J Surg 1948;76:701-8.
Farkas AM, Gingold BS. Repair of rectovaginal fistula in Crohn’s disease by rectal mucosal advancement flap. Mt Sinai J Med 1983;50:420-3.
Penninckx F, d’Hoore A, Filez L. Advancement flap plasty for the closure of anal and recto-vaginal fistulas in Crohn’s disease. Acta Gastroenterol Belg 2001;64:223-6.
Greenwald JC, Hoexter B. Repair of rectovaginal fistulas. Surg Gynecol Obstet 1978;146:443-5.
Cohen JL, Stricker JW, Schoetz DJ, Coller JA, Veidenheimer MC. Rectovaginal fistula in Crohn’s disease. Dis Colon Rectum 1989;32:825-8.
Crim RW, Fazio VW, Laveri IC. Rectal advancement flap repair in Crohn’s disease. Factors predictive of failure. Dis Colon Rectum 1990;33:P3.
Makowiec F, Jehle EC, Becker HD, Starlinger M. Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn’s disease. Br J Surg 1999;82:603-6.
Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn’s disease. Am J Surg 1997;173:95-8.
Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Bimbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993;114:682-90.
Berman IR. Sleeve advancement anorectoplasty for complicated anorectal/vaginal fistula. Dis Colon Rectum 1991;34:1032-7.
Marchesa P, Hull TL, Fazio VW. Advancement sleeve flaps for treatment of severe perianal Crohn’s disease. Br J Surg 1998;85:1695-8.
Simmang CL, Lacey SW, Huber PJ. Rectal sleeve advancement: repair of rectovaginal fistula associated with anorectal stricture in Crohn’s disease. Dis Colon Rectum 1998;41:787-9.
Joo JS, Weiss EG, Nogueras JJ, Wexner SD. Endorectal advancement flap in perianal Crohn’s disease. Am Surg 1998;64:147-50.
MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R. Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum 1995;38:921-5.
O’Leary DP, Milroy CE, Durdey P. Definitive repair of anovaginal fistula in Crohn’s disease. Ann R Coll Surg Engl 1998;80:250-2.
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.
Grant DR, Cohen Z, McLeod R. Loop ileostomy for anorectal Crohn’s disease. Can J Surg 1986;29:32-5.
Author information
Authors and Affiliations
Corresponding author
Additional information
Reprints are not available.
About this article
Cite this article
Andreani, S.M., Dang, H.H., Grondona, P. et al. Rectovaginal Fistula in Crohn’s Disease. Dis Colon Rectum 50, 2215–2222 (2007). https://doi.org/10.1007/s10350-007-9057-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10350-007-9057-7