A rectovaginal fistula (RVF) is an epithelial-lined tract between the rectum and vagina.

CAUSES

1. Perineal lacerations during childbirth, especially those due to episioproctotomy, predispose patients to RVFs. Failure to recognize and correctly repair perineal lacerations, or secondary infection of perineal lacerations, further increases the chance of RVF.

2. Crohn disease  and,  ulcerative colitis have been associated with RVFs. The fistula may arise primarily or, more often, in relation to a perirectal abscess and/or fistula, manifesting as complicated perianal sepsis.

3. Radiation used in the treatment of pelvic malignancies may result in RVF.Fistulas that occur during such therapy usually result from tumor regression. Most other fistulas become apparent 6 months to 2 years after completion of treatment. Diabetes, hypertension, smoking, and previous abdominal or pelvic surgery increase the risk of fistula formation.

 4. A variety of infectious conditions can produce RVF. The most common are perirectal abscess/fistula and diverticulitis.

Signs and Symptoms:

• Can be asymptomatic
• Passage of stool and flatus through vagina (usually with Diarrhea)
• Vaginits or cystitis
• foul-smelling vaginal discharge

Medical Treatment:  Antibiotics for secondary infections.

Surgical Treatment: A transverse colostomy is always needed, however, for pelvic cancer patients who have rectovaginal fistulae secondary to irradiation.   Surgical procedures  include:

 1. Transanal advancement flap repair . This is a flap consisting of mucosa and submucosa, is raised; some surgeons include circular muscle as well. Circular muscle is closed over the fistula. The tip of the flap, which includes the fistula opening, is excised. The flap is sutured in place with simple interrupted, absorbable sutures, effectively closing the rectal opening of the fistula. The vaginal side of the fistula is left open for drainage. This approach separates the suture line from the fistula site and interposes healthy muscle between the rectal and vaginal walls. Proponents point out that the relatively high pressure within the rectum serves to buttress the repair, in contrast to a transvaginal repair, in which the intrarectal pressure is more prone to disrupt the repair

2. Transvaginal inversion repair (rarely performed) Two or 3 concentric purse string sutures are used to invert the fistula into the rectal lumen. The vaginal mucosa is reapproximated. This approach is suitable only for small, low fistulas in otherwise healthy tissues with an intact perineal body.

 A bowel resection may be necessary for 3-4 months post procedure to keep tension from the surgical site.