Rectovaginal Fistula Repair

How Does a Rectovaginal Fistula Form?

• Injuries during childbirth: Delivery-related injuries are the most common cause of rectovaginal fistulas. This includes tears in the perineum that extend to the bowel, or an infection of an episiotomy — a surgical incision made to enlarge the perineum during vaginal delivery. These can occur after a long, difficult, or obstructed labor. These fistulas may also involve injury to the anal sphincter, which are the muscles at the end of the rectum that help control stool retention.
• Crohn’s disease: The second most common cause of rectovaginal fistulas, Crohn’s disease is an inflammatory bowel condition where the lining of the digestive tract becomes inflamed. While most women with Crohn’s disease do not develop a fistula, the condition increases the risk of it occurring.
• Cancer or radiation treatment in your pelvic area: Tumors in the rectum, cervix, vagina, uterus, or anal canal can lead to rectovaginal fistulas. Radiation therapy for cancers in these areas also increases the risk, with fistulas typically forming within six months to two years after treatment.
• Surgery involving your vagina, perineum, rectum, or anus: Previous surgeries, such as a hysterectomy, may result in a fistula. These may develop due to surgical injury, infection, or complications after the procedure.
• Other causes: Rarely, infections in the anus or rectum, diverticulitis (infections in the digestive tract), long-term inflammation of the colon and rectum (ulcerative colitis), fecal impaction, or vaginal injury unrelated to childbirth can cause a rectovaginal fistula.

What Are the Symptoms of a Rectovaginal Fistula?

Symptoms of a rectovaginal fistula can vary depending on its size and location, ranging from mild to severe. Common symptoms include:

• Foul-smelling vaginal discharge
• Irritation or pain in the vulva, vagina, or the perineum (the area between the vagina and anus)
• Passage of gas, stool, or pus from the vagina
• Recurrent vaginal or urinary tract infections
• Pain during sexual intercourse

How is a Rectovaginal Fistula Treated?

Most cases of rectovaginal fistulas require surgical repair, typically performed by urogynecology specialists like Dr. Ghomi.
Before surgery, it’s crucial to ensure the surrounding skin and tissue are free of infection or inflammation. Your doctor may recommend waiting three to six months to allow the tissue to heal and observe whether the fistula closes on its own.

Surgery to close a fistula may involve a gynecologic surgeon, a colorectal surgeon, or both working together. The primary goal is to remove the fistula tract and close the opening by stitching healthy tissue together. Surgical options include:

• Sewing an anal fistula plug or biological tissue patch into the fistula: This allows surrounding tissue to grow into the patch and heal the fistula.
• Using a tissue graft: A graft taken from a nearby part of your body or a flap of healthy tissue may be used to cover the fistula opening.
• Repairing the anal sphincter muscles: If damaged by the fistula or by scarring from radiation or Crohn’s disease, these muscles may need to be repaired.
• Performing a colostomy before repairing the fistula: In complex or recurrent cases, a colostomy may be needed to divert stool through an opening in your abdomen instead of your rectum. This step is typically not required but may be necessary if there is significant tissue damage, scarring, ongoing infection, or cancer. If a colostomy is performed, your surgeon may wait eight to 12 weeks before repairing the fistula, and it can typically be reversed after three to six months once healing is confirmed, restoring normal bowel function.