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Rectovaginal Fistula: Causes, Symptoms and Treatment

A rectovaginal fistula is an abnormal connection between the rectum and the vagina. It causes characteristic symptoms and usually requires surgical treatment.

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Things worth knowing about "Rectovaginal Fistula"

A rectovaginal fistula is an abnormal connection between the rectum and the vagina. It causes characteristic symptoms and usually requires surgical treatment.

What is a Rectovaginal Fistula?

A rectovaginal fistula is an abnormal channel that creates an unnatural connection between the rectum (the lower part of the large intestine) and the vagina. Through this channel, stool, mucus, and intestinal gas can pass uncontrollably through the vagina. In addition to significant physical discomfort, this condition often causes considerable psychological distress. Although rectovaginal fistulas are relatively rare, they can severely impact the quality of life of affected women.

Causes

Rectovaginal fistulas can develop due to a variety of causes:

Obstetric injuries: The most common cause is a severe perineal tear (grade III or IV) during childbirth that was inadequately repaired or healed poorly.
Crohn's disease: This chronic inflammatory bowel disease can lead to fistula formation involving the rectum and vagina.
Surgery: Pelvic surgical procedures, such as operations on the bowel, uterus, or vagina, can result in fistula formation as a complication.
Radiation therapy: Radiation treatment in the pelvic area, for example for cervical or rectal cancer, can damage tissue and trigger fistula development.
Infections and abscesses: Inflammatory processes in the perineum or rectum can lead to fistula formation.
Tumors: Malignant growths in the rectum or vagina can create fistulas through direct tissue invasion.

Symptoms

The symptoms of a rectovaginal fistula are often characteristic and can significantly affect daily life:

Involuntary passage of stool, mucus, or intestinal gas through the vagina
Recurrent vaginal infections and inflammation
Unpleasant odor from the vaginal area
Pain and pressure in the perineum and pelvic region
Skin irritation and inflammation in the genital area
Psychological burden, social withdrawal, and feelings of shame

Diagnosis

The diagnosis of a rectovaginal fistula is established through several examinations:

Gynecological and proctological examination: Visual inspection and manual examination of the vagina and rectum.
Endoscopy: Colposcopy (vaginal examination) and rectoscopy (rectal endoscopy) for direct visualization of the fistula tract.
Imaging: Pelvic MRI is considered the gold standard for precise localization and assessment of the fistula and for planning surgical intervention.
Dye test: Instillation of a dye (e.g., methylene blue) into the rectum to visualize the connection to the vagina.
Biopsy: Tissue sampling to rule out a malignant cause, particularly when a tumor or prior radiation therapy is suspected.

Treatment

Treatment of a rectovaginal fistula depends on the underlying cause, the location and size of the fistula, and the overall health of the patient.

Conservative Measures

For small, recently formed fistulas or in cases of underlying inflammatory conditions such as Crohn's disease, a conservative treatment approach may be attempted first. This includes anti-inflammatory medications, antibiotics, immunosuppressants, and dietary modifications to regulate bowel movements.

Surgical Treatment

In most cases, surgical repair is necessary. Various procedures may be used depending on the findings:

Fistulotomy: Simple opening and excision of the fistula tract, suitable for superficial fistulas.
Advancement flap: Coverage of the fistula opening with a mucosal flap from the rectum - a frequently used technique with good success rates.
Graciloplasty: Use of the gracilis muscle to reconstruct the pelvic floor in complex fistula cases.
Colostomy: In severe cases, a temporary stoma (artificial bowel opening) may be created to relieve pressure on the affected tissue and promote healing.

Treatment in Crohn's Disease

When fistulas are associated with Crohn's disease, close collaboration between gastroenterologists and surgeons is essential. Biologic agents such as TNF-alpha inhibitors (e.g., infliximab) can significantly reduce fistula activity.

Prognosis

The chances of successful healing depend strongly on the underlying cause, the size, and the location of the fistula. Simple fistulas resulting from obstetric trauma generally have a good prognosis following surgical repair. Radiation-induced fistulas or those caused by Crohn's disease are more difficult to treat and have a higher risk of recurrence. Close follow-up care is recommended in all cases.

References

Gajsek U. et al.: Systematic review of efficacy of treatment for rectovaginal fistula. International Journal of Colorectal Disease, 2018.
Pfeifer J. et al.: Practice parameters for the treatment of sigmoid diverticulitis. Diseases of the Colon and Rectum, 2006.
World Health Organization (WHO): Obstetric fistula - Guiding principles for clinical management and programme development. WHO Press, Geneva, 2006.

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