Rectovaginal Fistula
- What is a Rectovaginal Fistula?
- Causes of Rectovaginal Fistula?
- Diagnosis of Rectovaginal Fistula
- Rectovaginal Fistula Treatment
What is a Rectovaginal Fistula?
Rectovaginal fistula is a condition in which there is an opening between the rectum, the last part of the large intestine, and the vagina in women. If this opening is between the large intestine and the vagina, it is called a colovaginal fistula, and if it is between the vagina and the anus, it is called an anovaginal fistula. While patients experience serious health problems due to recurrent vaginal infections, there are significant restrictions in their social lives due to uncontrolled gas and/or bowel movements from the vagina. Complaints vary depending on the width and level of the opening between the rectum and vagina. Frequent recurrent vaginal infections, vaginal foul-smelling discharge, flatulence or stool, and pain during sexual intercourse are the main patient complaints.
Causes of Rectovaginal Fistula?
Postpartum and Vaginal Traumas
They are the most common causes of rectovaginal fistula. It is seen at a rate of 0.1% after difficult births in which ruptures develop.
Inflammatory Bowel Diseases
Especially in inflammatory bowel diseases such as Chron, the risk of the disease is high.
Radiation Therapy (Radiotherapy)
The incidence of rectovaginal fistula and vesicovaginal fistula (fistula between the vagina and urinary bladder) increases in patients with uterine, cervix, vagina and rectum cancers after radiation therapy applied to this region.
Past Operations
Rectovaginal fistula can be seen after hemorrhoids, breech prolapse, rectocele, uterine and rectal cancer surgeries. Fistula may develop due to recurrence of the disease after surgery in uterine, vaginal and rectum cancers.
The case of a rectovaginal fistula that developed as a result of anastomotic separation in a patient who had previous rectal cancer surgery, the fluid given through the anal canal comes from the vagina.
Infections
RVF can be seen after abscesses in the breech and genital area. As age progresses in the sigmoid colon, some people develop bubbles called diverticula. With their spontaneous perforation, diverticulitis and intra-abdominal abscess may develop. Especially in women whose uterus is removed, this abscess empties into the vagina and the disease we call colovaginal fistula develops.
Diagnosis of Rectovaginal Fistula
Although most of the patient’s complaints lead to a direct diagnosis, a detailed gynecological, proctological examination and endoscopic examination are required. The patient’s previous health history should be examined and necessary radiological examinations should be performed in order to reveal diseases that may cause fistula development. It is also important to evaluate the muscles that surround the anus and provide gas and stool. Only in this way, the level, size and cause of the fistula can be determined and a correct treatment choice can be made.
Rectovaginal Fistula Treatment
The chance of spontaneous healing of rectovaginal fistulas is negligible except in some special cases, so the main treatment is surgery. The choice of surgical treatment completely depends on the cause, location and size of the fistula.
In RVF patients who develop due to birth trauma, tears in the breech muscles are often accompanied. The primary treatment is to remove the infection in this area. Afterwards, the opening is closed with an anus (transanal approach), vaginal (transvaginal approach) or an approach from the anus-vaginal region (transperineal approach) and the torn breech muscles are repaired.
Treatment of RVFs due to Crohn’s disease is difficult and recurrence rates are high. First of all, the infection should be eliminated, if there is an abscess, it should be drained and colitis should be controlled. Afterwards, the fistula can be closed using rectum or vaginal tissues (Endorectal or transvaginal advancement flap methods). Temporary removal of stool (stoma) and advanced flap methods (rectal sleeve technique) can be performed in recurrent RVFs due to Crohn’s disease.
In RVFs that develop due to radiotherapy (radiation therapy), it must first be shown that the cancer disease does not recur. Local repairs often fail because of extensive damage to the rectum by radiotherapy. For this reason, closure of the opening using muscle tissues (Gracilis muscle interposition and Martius flap methods) can be tried in such fistula types. However, in these fistula patients, successful results can only be obtained with the abdominal approach. In this surgical technique (lower anterior resection and perianal pull-through colon-anal anastomosis), the diseased rectum affected by radiotherapy is removed and the large intestine is reconnected to the anus, thus ensuring intestinal continuity.
Colovaginal fistulas are most common due to infections, and the treatment is almost always surgical. After recurrent diverticulitis attacks in the abdomen, usually in the sigmoid colon, a fistula may develop over time between the vagina and the sigmoid colon. The success rate is 100% by removing the diseased intestine from the abdominal tract, preferably laparoscopically, and re-establishing the continuity of the intestine.