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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Treatment options

8. 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

9. 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%

10. Surgical treatment, con.

11. Rectovaginal fistula repair

12. Transperineal approach

13. Transanal Rectovaginal fistula repair

14. Perineoproctotomy fistula repair

15. 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