Anorectal: Rectovaginal Fistula

Rectovaginal Fistula

General Enteric Fistulas

Definitions/Classification

  • Definitions:
    • Rectovaginal Fistula (High Rectovaginal Fistula) – A Fistula from the Rectum to the Vagina
    • Anovaginal Fistula (Low Rectovaginal Fistula) – A Fistula from the Anus to the Vagina
  • Classification:
    • Simple: Low-Mid Rectovaginal Septum, Diameter < 2.5 cm & Caused by Trauma/Infection
    • Complex: Upper Rectovaginal Septum, Diameter > 2.5 cm or Caused by Malignancy, Diverticulitis, Radiation or Crohn’s Disease

Causes

  • Obstetric Trauma – Most Common
  • Surgery
  • Diverticulitis
  • Crohn’s Disease
  • Malignancy
  • Radiation
  • Fecal Impaction

Symptoms

  • Gas from the Vagina
  • Feces from the Vagina
  • Abdominal Pain
  • Recurrent UTI
  • Dyspareunia

Diagnosis

  • Dx: Vaginal Exam
    • Methylene Blue Tampon Test (Best Sensitivity)
      • Tampon Placed in Vagina & Dilute Methylene Blue Enema Given
      • After Ambulation Tampon is Evaluated for Dye
    • CT with Rectal Contrast
    • Exam Under Anesthesia

Treatment

  • Tx: Surgical Repair
    • First Treat Any Underlying Pathology
    • May Consider Conservative Management if Minimal Symptoms
    • Drain Any Abscess & Resolve Sepsis Before Definitive Repair
  • Surgical Approach:
    • Simple/Low: Fistulectomy vs Endorectal Advancement Flap
      • If Sphincter Defect: Add Sphincteroplasty
      • Other Options:
        • Episioproctotomy
        • Interposition Flaps
          • Gracilis Muscle Flap
          • Bulbocavernosus (Martius) Flap
        • Vaginal Advancement Flap
    • Complex/High: Transabdominal Approach
      • Options:
        • Primary Repair & Omental Interposition
        • Rectal Resection & Sleeve Advancement
      • *Primarily Repair Vaginal Defect

Rectovaginal Fistula 1

Rectovaginal Fistula 2

Rectovaginal Fistula on CT with Rectal Contrast 3

References

  1. Kobayashi H, Sugihara K. Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review. Springerplus. 2015 Jan 15;4:21. (License: CC BY-4.0)
  2. Galanopoulos M, Ladias S, Tzannetakou X, Tsigaridas A, Sarafis A, Liatsos C, Kalafatis E. A rectovaginal fistula after treatment with bevacizumab. A dangerous side effect needing emergency treatment. Clin Case Rep. 2016 Feb 26;4(4):449-50. (License: CC BY-4.0)

References

  1. Galanopoulos M, Ladias S, Tzannetakou X, Tsigaridas A, Sarafis A, Liatsos C, Kalafatis E. A rectovaginal fistula after treatment with bevacizumab. A dangerous side effect needing emergency treatment. Clin Case Rep. 2016 Feb 26;4(4):449-50. (License: CC BY-4.0)
  2. Kobayashi H, Sugihara K. Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review. Springerplus. 2015 Jan 15;4:21. (License: CC BY-4.0)
  3. Rahalkar MD, Rahalkar AM, Phadke DM. Pictorial essay: Distal colostography. Indian J Radiol Imaging. 2010 May;20(2):122-5. (License: CC BY-2.0)