Farnaz Almas Ganj, MD. FACOG, FPMRS   RECTOVAGINAL FISTULA   Farnaz Almas Ganj, MD. FACOG, FPMRS

Etiologies Obstetrics IBD Infections Diverticulitis Crohn’s disease. 5-10% develops RVFs Less with Ulcerative Colitis Other autoimmune diseases. Behcet’c syndrome Infections Cryptoglandular abscess Bartoline’s, rectovaginal hematoma LGV, TB Diverticulitis Surgeries, Pelvic Reconstruction, Colorectal surgery Cancer Radiation, up to 6% Early onset- tumor necrosis Late onset- radiation injury IMPORTANCE OF EXAMINATION AND BIOPSY TO R/O CANCER RECURRENCE If no h/o OB event, trauma, IBD: consider pelvic malignancy: Abdominopelvic CT Mechanical pessaries. Violence. Sexual objects, intercourse Congenital: higher level of complexity  

Symptoms Vaginal passage of stool. Gas. Mucopurulant drainage Dyspareunia, pelvic pain or vaginal infections Evaluation of continence status 48% pre-operative anal incontinence Patients with post-operative AI, unsatisfied despite success in RVF repair

Diagnostic evaluation Examination: vagina, rectum and perineum Vaginal instillation with water and soap to evaluate for air bubbles upon rectal instillation Vaginal tampon with rectal instillation of dye Vaginography Fistulogram Ultrasound CT with oral contrast MRI Proctoscopy

Classification: Daniels Anatomic location High- Apical Midlevel- above the sphincter complex Low- involving sphincter complex (ano-vaginal fistula) Size Small < 2.5 cm Large > 2.5 cm

Tsang classification: also considers etiologies Simple complex Low or mid-vaginal location Size < 2.5 cm Trauma or infection High vaginal location Size >= 2.5 cm IBD- radiation or cancer Previous failed repairs

Treatment options

Principles of surgery Optimize granulation, infection, edema Interrupt continuity of the tract Interpose a layer of fresh, vascularized tissue Excise the tract, evert the ostial edges 2nd layer closure to reduce the tension on the first layer Vaginal side (low pressure side) may be left open to drain

Approach and Technique Surgical treatment High fistula Usually related to IBD or diverticulitis Abdominal approach Resection of bowel segment Low or mid-level fistula Approach and Technique Success Rate Transvaginal Layered closure Fistula Inversion (Latzko) Transanal Advancement flap Transperineal Perineoproctotomy with layered closure sphincteroplasty   84-100% 73% 78-100% 88-100%

Surgical treatment, con.

Rectovaginal fistula repair

Transperineal approach

Transanal Rectovaginal fistula repair

Perineoproctotomy fistula repair

Perioperative management Bowel preparation (optional only) Mechanical Clear liquids Oral antibiotics not supported Intraoperative: Broad spectrum antibiotics Postoperative (optional only) Liquid and low or non-residue diet Stool softener and gentle laxative day 4-5 with advancement of diet Stool softeners for one month Avoidance of intercourse for 4-8 weeks