Definition and Overview

A fistula is an abnormal tract that forms a tunnel between two organs in the body. If it connects the rectum and the vagina, it is referred to as rectovaginal fistula. Other fistulas that involve the vagina include vesicovaginal fistula (opens into the urinary tract), colovaginal fistula (opens into the colon), and enterovaginal fistula (opens into the small bowel).

Rectovaginal fistulas, just like other vaginal fistulas, are usually painless and do not represent a life-threatening emergency. However, they can cause significant discomfort and emotional distress as they allow the bowel content and gas to pass through the vagina. This leads to incontinence and hygiene problems, which can impact intimacy and self-esteem.

Causes of the Condition

Rectovaginal fistulas commonly develop as a result of trauma during childbirth. They are often observed in developing countries where health care is inadequate. In these countries, rectovaginal fistulas are one of the leading causes of maternal death.

The condition, which is extremely rare in Western culture, can also be the result of episiotomy, a surgical cut between the vagina and the anus made by a midwife or obstetricians during childbirth to enlarge the vaginal opening. This is often necessary if there’s a risk of serious foetal distress due to prolonged labour.

Other less common rectovaginal fistula causes include:

  • Complications of vaginal surgery, such as hysterectomy

  • Crohn’s disease and other inflammatory bowel diseases

  • Diverticular disease

  • Fecal impaction

  • Infections in the rectum or anus

  • Physical trauma to the anus or vagina (such as in the case of some rape victims)

  • Radiotherapy treatment for cervical cancer

  • Rectal carcinoma

  • Gender or sex reassignment surgery

Key Symptoms

Rectovaginal fistula symptoms, which cause physical discomfort and emotional distress, include:

  • Passages of pus, stool or gas from the vagina

  • Foul-smelling vaginal discharge

  • Recurrent urinary tract or vaginal infections

  • Pain or irritation in the area between the vagina and anus

  • Pain during sexual activity

Who to See and Types of Treatments Available

Doctors often diagnose the condition during physical examination and assessment of symptoms of rectovaginal fistula. However, additional diagnostic tests are performed to accurately assess its extent. These tests include:

  • Anorectal ultrasound to determine whether there are other problems caused by the fistula and to assess the anal sphincter

  • Blood and urine tests to check for infection

  • Imaging tests to locate the fistula and determine if other pelvic organs are also affected

Although rectovaginal fistulas are easy to diagnose, they are often difficult to cure and patience is required during the evaluation process to fully assess the extent of the condition.

After diagnosing a patient with rectovaginal fistula, it is a common practice for patients to undergo antibiotic therapy for up to three months for the treatment of any inflammation or infection. In some cases, this is enough for some fistulas to close on their own. However, most require a surgical procedure, which involves incising the fistula so it can heal. This can be done through the vagina or rectum (for low fistulas) or via an incision in the abdomen (for high fistulas located at the posterior fornix).

During a rectovaginal fistula repair, a sharp circumferential dissection is made to separate the vagina from the rectum. The entire fistulous tract and the small rim of the mucosa are then incised before the rectal wall is closed with incisions.

Rectovaginal fistula treatment also involves harvesting a tissue graft from other parts of the body or folding a flap of healthy tissue near the fistula to cover the opening. Surgeons also repair the anal sphincter muscles if they have been damaged.

Colostomy, a surgical procedure in which feces is diverted to a bag outside of the body to allow the rectum to heal, is also performed in recurrent or complex cases. This is done when there’s scarring caused by previous radiation treatment or surgery, tissue damage, cancerous tumours, significant fecal contamination, or abscess. If a colostomy is performed, treatment of rectovaginal fistula will take place as soon as the rectum has healed, which can take between eight and twelve weeks. After rectovaginal fistula surgery, the colostomy is reversed to restore normal bowel function.

While waiting for the repair of a rectovaginal fistula, patients are advised to practice good hygiene to prevent infection. They are also given antibiotics and medications to treat inflammation.

References:

  • Tintinalli JE, et al. Anorectal disorders. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: The McGraw-Hill Companies; 2011.

  • Browning A, et al. Characteristics, management, and outcomes of repair of rectovaginal fistula among 1100 consecutive cases of genital tract fistula in Ethiopia. International Journal of Gynecology & Obstetrics.

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