50 Review Article

Rectovaginal Fistulae
Bidhan Das, MD1 Michael Snyder, MD2

1 Division of Colon and Rectal Surgery, Department of Surgery, Address for correspondence Bidhan Das, MD, Department of Surgery,
University of Texas-Houston, Houston, Texas University of Texas-Houston, 6550 Fannin St., Suite 2307, Houston, TX
2 Department of Surgery, University of Texas-Houston, Houston, Texas 77030 (e-mail: [email protected]).

Clin Colon Rectal Surg 2016;29:50–56.

Abstract Rectovaginal fistulae are abnormal epithelialized connections between the rectum and
vagina. Fistulae from the anorectal region to the posterior vagina are truly best

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Keywords characterized as anovaginal or very low rectovaginal fistulae. True rectovaginal fistulae
► anovaginal fistula are less common and result from inflammatory bowel disease, trauma, or iatrogenic
► rectovaginal fistula injury. A very few patients are asymptomatic, but the symptoms of rectovaginal fistula
► advancement flap are incredibly distressing and unacceptable. Diagnostic approach, timing, and choice of
► Martius flap surgical intervention, including sphincteroplasty, gracilis flaps, Martius flaps, and
► fistula plug special circumstances are discussed.

Rectovaginal fistulae are a challenge of both diagnosis and undergo a median episiotomy but in 1% of those who suffer
treatment for surgeons and a misery to bear for patients. third- and fourth-degree lacerations.2 As expected, these fistulae
Successful management requires the understanding and are more common in developing countries due to less resources
accounting of many patient variables including tissue quality, to aid with the process of childbirth.3
etiology, size, and location of the fistula. The next most common cause of rectovaginal fistulae is
Crohn disease. The incidence has historically been  10% with
Radcliffe et al reporting an incidence of 9.8% in women with
Etiology
Crohn and Schwartz et al noting an incidence of 9%.4,5
Causes of rectovaginal fistulae are listed in ►Table 1. The most Additional causes include pelvic irradiation (particularly
common cause of rectovaginal fistulae is obstetrical trauma; irradiation for cervical or endometrial cancer), malignant
prolonged and obstructed labor creates an impaction of the processes, and postsurgical complications (stapler misfire
presented part of the child against the soft tissues of the pelvis from low anterior resection (LAR), hysterectomy, rectocele
and a widespread ischemic injury that results in tissue repair, and proctocolectomy with ileoanal pouch anastomo-
necrosis and weakness that leads to fistula formation. Third- sis). Malignancies may cause rectovaginal fistulae. These
and fourth-degree lacerations, along with episiotomies due to fistulae are usually seen in the setting of rectal, uterine,
difficult labor, are also a well-known cause of fistula forma- cervical, or vaginal malignancies that have significant local
tion. While these lacerations typically undergo primary extension or have been treated with radiation therapy. Fol-
repair after childbirth, this can break down due to infection lowing radiation therapy, the patient may develop proctitis
or poor wound healing. followed by ulceration of the anterior rectal wall. Rectal ulcers
These issues being noted, a remarkably small number of then progress to fistula formation around 6 months to 2 years
patients suffer from fourth-degree lacerations and far fewer posttherapy. The incidence of rectovaginal fistula increases
from anovaginal fistulae. In one historical report, out of 24,000 with high-dose radiation and previous hysterectomy.6,7
patients, 1.7% of patients suffered fourth-degree lacerations, and
0.5% of patients subsequently suffered rectovaginal fistulae.1 In a
Presentation and Evaluation
review of the literature, Homsi et al found that rectovaginal
fistulae were reported in the range of 0.1% of patients who Patients with rectovaginal fistulae can have a varying degree
underwent episiotomy during delivery. Notably, it was found of symptoms based on the location, size, and etiology of the
that rectovaginal fistulae develop in 0.05% of patients who rectovaginal fistula and on the patient’s tolerance of the

Issue Theme Approaches to Anorectal Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/
Disease; Guest Editor: Sean J. Langenfeld, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1570393.
MD, FACS New York, NY 10001, USA. ISSN 1531-0043.
Tel: +1(212) 584-4662.
 Rectovaginal Fistulae Das, Snyder 51

Table 1 Common causes of rectovaginal fistulae media fistulography, vaginography, barium enemas, and
other endoscopic procedures may be of value. ►Fig. 1 dem-
Obstetrical Injury onstrates a classic type of enterovaginal fistula: diverticular
Crohn disease inflammation has created a fistula to the vaginal cuff of a prior
Trauma, including previous surgeries hysterectomy.
Endoanal ultrasound, with or without the addition of
Infection/cryptoglandular abscess
hydrogen peroxide, is also useful in the evaluation of
Neoplasm rectovaginal fistulae. It can identify the location and char-
Radiation injury acteristics of the fistula tract, while simultaneously assess-
ing the width of the perineal body, and the integrity of the
internal and external anal sphincters.9 An alternative to
condition. Symptoms include the obvious passage of flatus or ultrasound is magnetic resonance imaging, which is less
stool through the vagina, with more subtle presentations operator-dependent with similar diagnostic accuracy.10
being slight discharge, a feculent odor, or recurrent vaginal

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mucosal inflammation. In these latter situations, stool may Classification
only be noted per vagina when the bowel movements are Classification of rectovaginal fistulae is based on location,
liquid in nature. The presence of fecal incontinence is also of size, and etiology. Admittedly, these methods are arbitrary
paramount importance, and obtaining a history regarding and not well grounded in the literature, but such rubrics are
sphincter function will direct the clinician to further appro- helpful when comparing operative approaches. Tradition-
priate investigation and help guide the operative approach. ally, a “low” fistula is located at or just slightly above the
Examination is critical to confirm the presence, size, and dentate line with the vaginal opening just inside the vaginal
location of the fistula, as well as the integrity of the anal fourchette. “High” fistulae are noted as vaginal openings
sphincter. In addition, direct exam allows the surgeon to evaluate behind or near the cervix, and “middle” when the fistula is
for fistulae to other organs, and the presence of absence of noted between the “high” and the “low” areas. The higher
inflammation that could suggest Crohn disease, radiation injury, the fistula the more difficult it can be to diagnose, and these
or incompletely controlled anovaginal sepsis. “high” fistulae are often resultant from a surgical procedure
A low fistula/anovaginal fistula is identified on digital such as hysterectomy or LAR with a stapled anastomosis.
examination with a dimple on palpation that can be con- Sizes of the fistulae are classified as “small” if < 0.5 cm,
firmed easily on anoscopic and speculum examination. Stool “medium” if 0.5 to 2.5 cm, and “large” if > 2.5 cm. 11 Fistulae
is often seen in the vagina, which may be the site of active are considered “complex” if they are large, high, or caused
infection. Notably, the dark red rectal mucosa contrasts with by inflammatory bowel disease or other pelvic processes
the lighter vaginal mucosa, and a small fistula may appear (diverticulitis), including irradiation. Recurrent fistulae are
only as a depression or a pit as a defect in the mucosa. Digital
examination should be performed with one finger in the
rectum and the other in the vagina, thus allowing an assess-
ment of tissue induration, as well as the width and bulk of the
anterior perineal body. Sphincter injury and perineal thin-
ning upon examination should prompt documenting the
extent of the prior injury. Examination under anesthesia
with biopsies may be necessary in patients with prior irradi-
ation or suspicion for malignancy. Overall, confirmatory
diagnostic studies are only necessary when the rectovaginal
fistula eludes identification on physical examination or if the
extent of underlying disease is unknown.
Multiple office maneuvers have been advocated for the
identification of more difficult rectovaginal fistulae.8 The
patient can be placed in lithotomy position with a Trendelen-
burg positioning, placing a proctoscope, and filling the vagina
with warm water; the proctoscope then insufflates the
rectum, allowing air to traverse through a possible fistulous
tract into the vagina to produce bubbling. Alternatively, a
tampon can be placed in the vagina, and a methylene blue
retention enema can be administered. The tampon is then
removed after 1 hour. Blue on the tampon indicates the
presence of a rectovaginal fistula.8
A fistula to other parts of the bowel should also be
excluded; vesicovaginal, rectovesical, rectoperineal, and oth- Fig. 1 Enterovaginal fistula. Contrast administered per vagina directly
er fistulae can accompany rectovaginal fistulae. Contrast communicates to segment of sigmoid colon, inflamed by diverticulitis.

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52 Rectovaginal Fistulae Das, Snyder

also considered complex due to their association with Antibiotic and Seton Use
tissue scarring and decreased blood supply.
Prior to any attempt at fistula repair, the surgeon must also
ensure that infection and local inflammation have resolved.
Treatment
Antibiotic therapy with appropriate drainage of any related
A reasonable algorithm for the treatment of rectovaginal abscess is often the mainstay of therapy. A draining seton may
fistula was presented by Dr. Hull, and is shown in ►Fig. 2. also be necessary to eliminate infection. In our practice, loose
setons are used selectively for unresolved sepsis and to
control ongoing symptoms of pain and drainage. We have
Watchful Waiting
found setons more useful in complex, high rectovaginal
Appropriate timing of surgical repair is crucial to successful fistulae compared with lower, simpler fistulae. If a seton is
healing. For small or minimally symptomatic fistulae, it is required, it is our practice to leave this in for 8 or more weeks,
appropriate to start with a period of watchful waiting. Some with removal at the time of fistula repair.
women with fistulae related to obstetric trauma will

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experience spontaneous closure within the early postpartum
Selection of Operative Technique
period, and a waiting period of 6 to 9 months is warranted if
symptoms remain manageable.12 Mattingly noted that 50% of Many factors must be considered when choosing an operative
small rectovaginal fistulae secondary to obstetric trauma heal approach to rectovaginal fistulae. The number and type of
spontaneously, and he recommended watchful waiting for at previous repairs, patient’s risk factors, additional concomi-
least 6 months.13 In our experience we have seen similar tant fistulae, and sphincter integrity are all concerns. Of these
progress, but interval follow-up throughout the healing factors, the cause of the rectovaginal fistula and the status of
process is warranted. the external anal sphincter are the most important.

Fig. 2 Algorithm for the management of rectovaginal fistula. (From: Hull T. Rectovaginal Fistula. In: Fazio VF, Church JM, Delaney CP, eds. Current
Therapy in Colon and Rectal Surgery. 2nd ed. Philadelphia, PA: Mosby, Inc.; 2005:39.)

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 Rectovaginal Fistulae Das, Snyder 53

Sphincteroplasty

A sphincteroplasty is advocated for rectovaginal fistula when the

patient has a defect in the anterior sphincter complex. In this
technique, a circumlinear incision is made on the anterior
perineal body, and dissection is taken in the plane between
the rectum and vagina through the fistula to the level of the
levator ani. It is our practice to perform routine levatorplasty at
this point. The ends of the damaged external sphincter are
mobilized, and brought together in an overlapping fashion using
several absorbable monofilament sutures. Success using this
technique has been well documented in the literature.
Tsang et al14 conducted a study to determine the effect of a
sphincter defect on the outcome of rectovaginal fistula repair. A

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total of 52 women underwent 62 repairs of simple obstetrical
rectovaginal fistulae. They noted results that were better after
sphincteroplasties versus endorectal advancement flaps (ERAFs)
in patients with sphincter defects, identified by endorectal
ultrasound (88 vs. 33%) and by manometry (86 vs. 33%). Poor
results correlated with prior operations in patients undergoing
endoanal advancement flaps (45 vs. 25%) but not sphinctero-
plasties (80 vs. 75%). It was their belief that rectovaginal fistulae
should undergo preoperative evaluation for occult sphincter
defects by ultrasound, manometry, or both.

Advancement Flap
When the anal sphincter complex is intact, and tissues are
readily viable, a common and durable approach is the ERAF. In
this technique, a wide-based flap of rectal mucosa, along with
a small amount of underlying sphincter muscle, is mobilized
and advanced over the fistula’s internal opening (►Fig. 3a, b).
Adequate perfusion and lack of tension are key to flap success.
Fig. 3 a, b Endorectal advancement flap. (From: Hull TL, Fazio VW.
Lowry et al15 described results for 81 ERAFs in women with Surgical approaches to low anovaginal fistula in Crohn’s disease. Am J
simple rectovaginal fistulae. Their overall success rate was Surg 1997;173:95–98.)
83%, with success correlating to the number of previous
repairs. Patients who had no previous repair had an 88%
success rate; one prior repair had an 85% success rate; and two skin flap can be raised without tension. After over 200 cases
prior repairs had a 55% success rate. This study suggests that a with the anodermal advancement flap for fistula-in-ano,
prior failure should not prevent the surgeon from trying the pouch-vaginal fistulae, and rectovaginal fistulae, the ano-
approach again; however, with two prior failed attempts one derm allows better affixation, an excellent and durable blood
should be reluctant to perform a mucosal advancement. supply, as well as possibly less retraction than a mucosal flap.
An alternative approach to flap closure is the dermal Publication of our case series is pending.
advancement flap anoplasty. This technique involves the
creation of a pedicled flap of adjacent anoderm, which is
Vaginal Repair
mobilized and brought into the anal canal to cover the fistula
opening. This was initially conceived for the treatment of anal One of the traditional tenets of fistula repair is the elimination of
stenosis, but has since been described for the treatment of inflow into the fistula tract. For rectovaginal fistulae, this means
both rectovaginal and cryptoglandular anal fistulae.16–18 closure on the rectal side of the fistula, which is the side of higher
Several flap configurations have been described, including intraluminal pressure. However, gynecologists have long re-
V-Y flaps, diamond-shaped flaps, rhomboid flaps, and in- ported on outcomes of transvaginal repairs with relatively
verted house-shaped flaps.19 impressive reported outcomes. Rahman et al reported a 100%
In our experience, both anodermal and ERAFs may be used healing rate among 39 patients treated with a transvaginal
for this purpose; however, historically the vast predominance approach.12 Bauer et al repaired 13 patients transvaginally
of the literature describes ERAF to treat these fistulae, and so with diverting stomas for low or middle septal fistulae. A total
the dermal advancement flap has much less supportive of 12 out of 13 patients succeeded during an average follow-up
literature. However, we have changed our practice to using period of 50 months.20 In this study, fecal diversion may have
an anodermal advancement flap in lieu of an ERAF when the eliminated the pressure gradient alluded to above.

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54 Rectovaginal Fistulae Das, Snyder

Transvaginal repairs have traditionally been described in two limited symptoms from fistulae do not require operative
main techniques. If the fistula is low and small, the fistula can be care, whereas severely symptomatic patients may require a
“inverted,” in which a circular incision is made around the proctocolectomy. Local repair may be warranted in the
vaginal introitus, and a mucosal flap is mobilized. Purse-string absence of active proctitis, but high rates of recurrence are
sutures are placed to invert the fistula into the rectum, and then reported. Often, patients with Crohn related fistulae will
the vaginal mucosa is reapproximated with the flap that is require tissue interposition and temporary fecal diversion,
mobilized.12 Another method of transvaginal closure is the which will be discussed shortly. Persistently active disease
creation of a mucosal flap with the dissection extended laterally refractory to medical therapy or with destruction of the anal
to the ischial tuberosities and then cephalad, with the vaginal sphincter with persistent disease and subsequent inflamma-
defect previously closed with interrupted suture.20 tion warrants proctectomy.
In our practice, Crohn patients with minimal anorectal
disease, excellent tissue pliability, and minimal stricturing
Fibrin Glue
disease are offered an endorectal or anodermal advancement
Fibrin glue injection has been extensively studied for crypto- flap. In two Crohn patients with rectovaginal fistulae, we have

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glandular anal fistulae, with reported success rates as low as performed a fistula plug closure, which was successful. Some
10%21 and as high as 64%.22 In a small series of five patients centers prefer a transvaginal approach to prevent manipula-
with rectovaginal fistulae, Abel et al treated four patients with tion on the anorectal aspect; however, we feel that the
fibrin glue, and reported a 100% healing rate.23 Another series pressure gradient is not hospitable for this type of approach.
from Loungnarath et al showed one successful outcome out of Active Crohn disease elsewhere in the bowel should be
three patients treated with fibrin glue.24 Currently, the role treated medically and seems to correlate with rectovaginal
for fibrin glue in the definitive treatment of rectovaginal fistula recurrence when flaring after treatment.
fistulae appears to be very limited.
Radiation-Induced Fistulae
Pelvic radiation is a part of the treatment of several malig-
Fistula Plug
nancies, including squamous cell carcinoma of the anus and
The fistula plug has also been extensively studied for use in cervix. Radiation can cause significant damage to the tissue
cryptoglandular anal fistulae, with much less supportive adjacent to these cancers, causing fibrosis and endarteritis
evidence for use in rectovaginal fistulae. The technical steps results in vascular compromise. Tissue loss and difficult
to fistula plug placement are relatively simple, and involve dissection plains often preclude local repair of rectovaginal
debridement of the tract followed by suture fixation of the fistulae. Definitive repair of these fistulae often requires the
plug within the fistula tract. interposition of healthy, nonirradiated, well-vascularized
This technique was described by Dr. Ellis in 2008 with tissue to the rectovaginal septum. A host of tissue transfer
primary healing in six out of seven (86%) patients.25 In 2009 options are available, with the most common approaches
Gonsalves et al26 reported on the use of the fistula plug for listed below.
rectovaginal fistulae and ileoanal pouch-vaginal fistulae. A
total of 60% (three out of five) of rectovaginal fistulae experi-
Tissue Interposition
enced healing, along with 57% (four out of seven) of the
pouch-vaginal fistulae. Of note, several repeat plug proce- When a rectovaginal fistula is recurrent or refractory to
dures were needed, with a first-time procedural success rate sphincteroplasty and/or advancement flap, or when the
of 35% and overall success rate of 58%. surrounding tissue is heavily damaged or scarred, the best
In general, outcomes with fistula plug for cryptoglandular approach to definitive fistula management is the interposi-
fistulae were less impressive as studies emerged with longer tion of healthy, well-perfused tissue. This is particularly
periods of follow-up. This makes the authors skeptical that important for patients with a very thin rectovaginal septum,
the fistula plug will have an enduring role on the repair of and for patients with a history of radiation injury.
rectovaginal fistulae. However, undeniable benefits of the When a tissue interposition is planned, it is often accom-
approach include its simplicity, patient tolerance, and the lack panied by temporary fecal diversion. While previous studies
of disturbance to fecal continence. In our practice, the fistula have not shown a definitive benefit to diversion, they were
plug is reserved for patients where the tissue is largely healed retrospective in nature, and it is likely that the lack of benefit
from prior repairs, and the plug can create pliability for can be explained by selection bias, with the diverted patients
fibrosis to allow closure. Such a use allows the plug to spare have more complex fistulae or more severe baseline
precious tissue for future attempts, and it is well tolerated by disease.27 It is our practice to routinely protect these complex
the patient with minimal associated risk. repairs with a temporary loop ileostomy.

Special Situations Gracilis Flap

Crohn Disease The gracilis muscle is often used as an interposition flap. The
Fistulae as a result of Crohn disease are particularly difficult to procedure can be performed by the fistula surgeon or in
manage. As with Crohn fistulae-in-ano, asymptomatic or conjunction with a plastic surgeon with similar results.28,29

Clinics in Colon and Rectal Surgery Vol. 29 No. 1/2016

 Rectovaginal Fistulae Das, Snyder 55

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Fig. 4 Gracilis muscle interposition flap. (From: Keighley MRB, Williams NS, Church JM Pahlman L, Sholefield JH, Scott NA. Surgery of the Colon,
Rectum, and Anus. 3rd ed. Philadelphia, PA: Elsevier Limited; 2008:509.)

The surgery is typically performed in the lithotomy position, Martius Flap

with the gracilis muscle being harvested from a 8 to 10 cm
incision on the medial thigh. A perineal incision is then made, Another well-described tissue transfer and local flap repair is
dissecting well above the fistula itself with care taken not to the use of the Martius or bulbocavernosus flap. (►Fig. 5)
violate the rectal or vaginal mucosa. The pedicled muscle flap Using a longitudinal incision over the labia majora, skin flaps
is tunneled to the perineal incision and secured into place are raised laterally and medially, with dissection continuing
with absorbable sutures (►Fig. 4). to the periosteum of the pubis and to the pubic symphysis.
Reported primary healing rates for gracilis interposition Once the entire fat pad with the bulbocavernosus muscle is
grafts generally range from 75 to 92%.30,31 It should be noted mobilized, the anterior aspect is cut and used as a vascular-
that most case series on this topic involve complex fistulae with ized pedicled flap (perineal branch of the pudendal artery)
multiple previous attempts at repair. A large number of these and tunneled subvaginally. The flap is then sutured to the
fistulae were secondary to Crohn disease and radiation injury, posterior vaginal wall to interpose it over the closed rectal
with a small number being secondary to obstetrical injury. In aspect of the fistula.
addition, most case series employed routine fecal diversion. Aartsen and Sindram32 initially reported 100% success in
Wexner et al noted healing rates to be lower for patients 14 patients with fistulae secondary to radiation damage, but
with Crohn disease (33%) when compared with other etiolo- after a 10-year follow-up, 8 of the 14 patients required
gies such as pouch-vaginal fistulae and radiation-induced diversion for continued damage from radiation. Pitel et al33
fistulae (75%),28 whereas other series report healing rates in reported a 65% overall healing rate for Martius flap, with a
Crohn disease to be equivalent to other etiologies.30 50% rate in patients with Crohn disease.

Conclusion
In general, rectovaginal fistulae are difficult to manage, and
the level of evidence for surgical approaches to this disease
remains poor, consisting primarily of case series.34 It is
important that the surgeon and the patient alike be prepared
for possible treatment failures and the need for further
interventions. When a sphincter defect exists, the best
approach is sphincteroplasty, while an advancement flap is
appropriate for patient with intact sphincters. Complex
recurrent fistulae, especially in patients with Crohn disease
or radiation injury, often require fecal diversion and tissue
Fig. 5 Martius flap with the bulbocavernosus flap from the left labia exposed. interposition to achieve long-term healing.

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56 Rectovaginal Fistulae Das, Snyder

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