RECTOVAGINAL FISTULA

Dr. Nurhilal Kızıltoprak, FTBS

İstanbul Sultan Abdulhamid Han Training and Research Hospital, Department of General Surgery, İstanbul, Türkiye

ABSTRACT

Rectovaginal fistula (RVF) is an epithelialised passage between the rectum and vagina, forming an abnormal connection between these two structures. It is endemic in sub-Saharan Africa and South Asia. There are 50.000 – 100.000 new cases per year.

The most common cause of RVF is vaginal trauma. Other causes include Crohn’s disease, radiation, infections, malignancy and iatrogenic factors. Symptoms of RVF include passage of gas or faeces from the vagina, vaginal discharge, perineal pain, dyspareunia, recurrent vaginitis, sepsis, stricture and depression. At initial presentation, women most commonly report symptoms of passing gas or faeces from the vagina or vaginal discharge. After history taking and physical examination, imaging techniques should be utilised. Rectal radiological contrast agents, methylene blue, hydrogen peroxide and vaginography can be used in the initial evaluation. Further evaluation imaging techniques include computed tomography (CT), magnetic resonance imaging (MRI) and endorectal ultrasound (EUS).

The choice of treatment should be tailored to the individual patient. Existing abscess, inflammation, sepsis, Crohn’s disease will reduce the chance of success of treatment. A wide range of treatments is available depending on the disease state. It is thought that new options such as biosynthetic plugs, fat injections, stem cell transplantation, endoscopic clips and stents will become widespread in the treatment of RVF in the future.

Keywords: Advancement flap; Crohn’s disease; Rectovaginal fistula; Rectovaginal septum; Vaginal trauma

Referanslar

  1. World Health Organization. Prevention and treatment of obstetric fistulae: report of a technical working group. Geneva: World Health Organization. [Link]
  2. Rothenberger D A, Goldberg S M. The management of rectovaginal fistulae. SurgClin North Am. 1983;63:61-79. [Crossref]  [PubMed]
  3. Angioli R, Gomez-Marin O, Cantuaria G, et al. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol 2000; 182:1083-5. [Crossref]  [PubMed]
  4. Champagne BJ, McGee MF. Rectovaginal fistula. Surg Clin North Am. 2010 Feb;90(1):69-82, Table of Contents. [Crossref]  [PubMed]
  5. Saclarides TJ. Rectovaginal fistula. Surg Clin North Am 2002;82:1261-72. [Crossref]  [PubMed]
  6. Schwartz DA, Loftus EV Jr, Tremaine WJ, et al. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002;122: 875-80. [Crossref]  [PubMed]
  7. Scott R. Steele The ASCRS Manual of Colon and Rectal Surgery Third Edition. [Link]
  8. Andreani SM, Dang HH, Grondona P, et al. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 2007;50:2215-22. [Crossref]  [PubMed]
  9. Kosugi C, Saito N, Kimata Y, et al. Rectovaginal fistulas after rectal cancer surgery: incidence and operative repair by gluteal-fold flap repair. Surgery 2005;137:329-36. [Crossref]  [PubMed]
  10. Abu Gazala M, Wexner SD. Management of rectovaginal fistulas and patient outcome. Expert Rev Gastroenterol Hepatol. 2017 May;11(5):461-471. Epub 2017 Mar 1. [Crossref]  [PubMed]
  11. Baig MK, Zhao RH, Yuen CH, Nogueras JJ, Singh JJ, Weiss EG, Wexner SD. Simple rectovaginal fistulas. Int J Colorectal Dis. 2000;15(5-6):323-7. [Crossref]  [PubMed]
  12. Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol. 2002;178(3):737-41. [Crossref]  [PubMed]
  13. Fazio VW, Church Jm, Delaney CP. Current therapy in Colon and Rectal surgery. 2nd ed. Philadephia, Pa: elsevier mosby; 2005. [PMC]
  14. Oakley SH, Brown HW, Yurteri-Kaplan L, et al. Practice patterns regarding management of rectovaginal fistulae: a multicenter review from the fellows' Pelvic Research network. [Crossref]  [PubMed]  [PMC]
  15. Hull TL, el-Gazzaz G, Gurland B, Church J, Zutshi M. Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum. 2011;54:54-59. [Crossref]  [PubMed]
  16. Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y. Rectovaginal fistula: what is the optimal strategy?: an analysis of 79 patients undergoing 286 procedures. Ann Surg. 2015;262:855-860. [Crossref]  [PubMed]
  17. Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, Steele SR. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec;59(12):1117- 1133. [Crossref]  [PubMed]
  18. O'leary DP, Milroy CE, Durdey P. Definitive repair of ano vaginal fistula in Crohn's disease. Ann R Coll Surg Engl. 1998;80:250-252. [PMC]
  19. Chew SS, Rieger NA. Transperineal repair of obstetric-related anovaginal fistula. Aust N Z J Obstet Gynaecol. 2004;44:68-71. [Crossref]  [PubMed]
  20. Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD. Are there predictors of outcome following rectovaginal fistula re pair? Dis Colon Rectum. 2010;53:1240-1247. [Crossref]  [PubMed]
  21. Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY. Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis. 2017 Jul;32(7):1029-1032. Epub 2017 Feb 16. [Crossref]  [PubMed]
  22. Pitel S, Lefevre JH, Parc Y, Chafai N, Shields C, Tiret E. Martius advancement flap for low rectovaginal fistula: short- and long-term results. Colorectal Dis. 2011;13:e112-e115. [Crossref]  [PubMed]
  23. van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis. 2011;26:1463-1467. [Crossref]  [PubMed]  [PMC]
  24. Patsouras D, Yassin NA, Phillips RK. Clinical outcomes of colo-anal pull-through procedure for complex rectal conditions. Colorectal Dis. 2014;16:253-258. [Crossref]  [PubMed]
  25. Gecse KB, Bemelman W, Kamm MA, et al. A global consensus on the classification, diagnosis and multidisci plinary treatment of perianal fistulising Crohn's disease. Gut. 2014;63:1381-1392. [Crossref]  [PubMed]
  26. Sands BE, Blank MA, Patel K, van Deventer SJ. Long-term treatment of rectovaginal fistulas in Crohn's disease: response to infliximab in the ACCENT II Study. Clin Gastroenterol Hepatol. 2004 Oct;2(10):912-20. [Crossref]  [PubMed]
  27. McKee RF, Keenan RA. Perianal Crohn's disease-is it all bad news? Dis Colon Rectum. 1996;39:136-142. [Crossref]  [PubMed]
  28. Colombel JF, Sandborn WJ, Rutgeerts P, et al. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology. 2007;132:52-65. [Crossref]  [PubMed]
  29. Löffler T, Welsch T, Mühl S, Hinz U, Schmidt J, Kienle P. Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn's disease. Int J Colorectal Dis. 2009 May;24(5):521-6. Epub 2009 Jan 27. [Crossref]  [PubMed]
  30. El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M. Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function. J Gastrointest Surg. 2010 Nov;14(11):1758-63. Epub 2010 Jul 1. [Crossref]  [PubMed]
  31. Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn's disease. Am J Surg. 1997 Feb;173(2):95-8. [Crossref]  [PubMed]