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Recto-Vaginal Fistula
a
A. C. V. Montgomery
a
Royal Marsden Hospital, London
Published online: 09 Jun 2015.

To cite this article: A. C. V. Montgomery (1984) Recto-Vaginal Fistula, Journal of Obstetrics and
Gynaecology, 5:sup1, S35-S37

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 Journal of Obstetrics and Gynaecology (1984) 5 (Suppi. 1 ) S35-S37 Printed in Great Britain s35

Recto-vaginal fistula
A. C.V. Montgomery
Royal Marsden Hospital, London

ONE of the most distressing conditions which a
woman can endure without danger to her health is
the involuntary discharge of faeces through the
vagina. This may arise from a variety of causes
and may be classified (Figure):
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In high recto-vaginal fistulae symptoms of flatus
and faecal discharge are usually obvious, although
when the defect is small and the path tortuous
symptoms may be overlooked. With low fistulae
symptoms may be dismissed by the patient if the

rectal communication involves the anal sphincter

and faecal continence is preserved. Occasionally
1High
the rectal mucosa may act as a flap valve and
n e c ~ o ~ v a ~ , a Above l ~ ~pubo-rectalis
~ ~ ~ ~ prevent
~ ~ ~faecal
o wloss~ even in high fistulae.

fistula Below pubo-rectalis The diagnosis may be simply confirmed by

Indirect routine examination, but frequently the contami-
Figure. Classification of recto-vaginal fistulae. nation of the vagina as well as its mucosal folds
render the fistulous opening difficult to define
without recourse to examination under anaes-
Direct or true recto-vaginal fistula must be thesia, when the passage of a probe between rec-
differentiated from indirect fistula where faecal tum and vagina is diagnostic. Radiography may
discharge enters the vagina through the uterus or also be used to demonstrate a fistula and deter-
fallopian tubes. Both may give rise to similar mine its exact communication, particularly with a
symptoms and are easily confused, at least initially. high fistula. It is also essential in determining acause
Direct fistulae have been classified as high when of the fistula, such as diverticular disease, and in
involving the upper half of the vagina or low when assessing the bowel above and below the defect, as
the communication is entirely below this level in Crohns disease and after irradiation.
(Lawson, 1967). It may be simpler to consider the
segment of bowel involved, using the terms ileo-
vaginal, colo-vaginal, recto-vaginal, ano-vaginal, MANAGEMENT
or ano-vulva1 in classifying these fistulae. In all patients with these fistulae management
Congenital defects of cloacagenic development depends on both the site and the causative agent.
are well described and classified but with appro- Several factors may be implicated in the indivi-
priate treatment do not usually persist into adult life dual. The patient may be seen early or late with
(Stephens and Smith, 1971). In adults causative either major or minor symptoms. Management of
factors involved in these fistulae can be classified the individual is, therefore, best considered with
as obstetric, inflammatory, traumatic, malignant knowledge of the primary cause as well as the site
or irradiation. These factors must also be included of the fistula.
in the classification of recto-vaginal fistulae and
are important in the management of the individual 0 bstetric injuries
(Hudson, 1970). This is the commonest cause of recto-vaginal
Normal continence is maintained by the anal fistula reported (Hudson, 1970). Injuries may
sphincters where the resting tone is usually about occur due to necrosis of the recto-vaginal septum
40cm of water and with voluntary contraction during labour or to perineal lacerations and
pressures between 100 and 200 cm of water can be episiotomies during delivery, the former often
exerted. Since the intra-rectal pressure is at least being associated with vesico-vaginal fistulae
20 cm of water greater than the atmospheric pres- (Lawson, 1972). Recto-vaginal fistula and delayed
sure within the vagina, faecal discharge and escape healing of episiotomy wounds are most likely to
of flatus through the track is usually obvious. This occur in patients with Crohns disease (Hudson,
may be modified by certain factors. 1963).
 S36
Perineal lacerations and tears are most often
repaired successfully at the time of injury. When
this has failed, the experience at St Marks Hos-
pital is that a delayed repair and reconstruction of
the anal sphincters is totally or partially successful
in 91 per cent of cases (Motson et al., 1983). In
high obstetric injuries the associated bladder,
ureteric and rectal damage must be considered.
Repair in layers by the vaginal or the anal route is
indicated. The abdominal route is reserved for
those fistulae which cannot be easily repaired from
below (Lawson, 1972). Late repair, even following
initial failure, is often successful usually with a
temporary colostomy (Motson et al., 1983).
Inflammation
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Acute and chronic inflammation, usually arising in
anal glands, is a frequent cause of low recto-
vaginal fistula. Inflammatory bowel disease is
associated with recto-vaginal fistulation in 13.6per
cent of patients with Crohns disease (Hudson,
1963). Diverticular disease may present with fistu-
lation. Laying open of a low fistula and curettage
of the fistulous track is preferred when the cause
is simple sepsis, sphincter repair being sometimes
necessary (Motson et al., 1983). In Crohns disease
curettage is often all that is indicated; with clinical
disease of the adjacent bowel, proctocolectomy
may be the only curative procedure possible
(Hudson, 1963).
Trauma
The trauma most often associated with recto-
vaginal fistula is surgical, both gynaecological and
proctological procedures being implicated. Most
fistulae follow direct injury to the rectum but may
be potentiated by other factors such as irradiation
and is a well recorded complication following
Wertheims hysterectomy. In the unirradiated
patient spontaneous healing may occur but formal
repair is often necessary after sufficient time has
elapsed to allow the initial sepsis to settle, and
organisation and maturation of scar tissue to
occur. Faecal diversion is frequently necessary,
especially where the fistula is l c m or larger in
diameter (Lawson, 1972).
Malignancy
Malignant fistulae usually present late in the pro-
gression of the disease. In some cases radical
potentially curative resection of the tumour may
be possible, usually with a permanent stoma.
Recurrent disease, particularly after irradiation
for cancer of the cervix, accounts for about 80 per
Journal of Obstetrics and Gynaecology (1984) Vol. 5/Suppl. 1
cent of recto-vaginal fistulae found in these pa-
tients. Palliative colostomy may render life more
tolerable for these individuals.
Irradiation
Recto-vaginal fistulae arising after irradiation are
uncommon, with an incidence of about 1.6 per
cent following treatment for carcinoma of the
cervix (Jimenez et al., 1980). Radiation injury may
involve ileum, sigmoid colon, bladder or ureters as
well as the rectum. It may present early, within 6
months, or late. Early damage is characterised by
rapidly spreading necrosis of the irradiated tissue,
and fistulation occurs early. Urgent faecal and
often urinary diversion is necessary to afford relief
of symptoms. The difficulties of operating on
radiation damaged tissues may, unfortunately,
lead to anastomotic breakdown, and in some cases
death (Smith et al., 1969).
Late or delayed radiation damage is often as-
sociated with surgical trauma or other pathologi-
cal processes such as diverticular disease. To
ensure healing, healthy unirradiated bowel must
be anastornosed to healthy bowel below the fistula.
Using a sleeve anastomosis (Soave, 1964) closure
of the fistula was achieved in 10 of 11 cases treated,
although one has persistent faecal leakage and
another has not had her colostomy closed (Jeffery
and Parks, 1983).
SURGICAL ACCESS
Routes for surgical closure of recto-vaginal fis-
tulae are directed at closure of the rectal defect
using healthy bowel without tension. The vaginal
defect is usually left open to facilitate drainage and
prevent haematoma formation and subsequent
sepsis. The approach to the fistula for closure may
be from above or below. Indications for the
abdominal approach are when access from below
by either the vaginal or anal route is impossible or
when the condition responsible dictates.
The low approach may be via the vagina, anal
canal, posteriorly by the parasacral incision
(Mason, 1970) or by the perineal approach. The
route which often affords direct visualisation and
repair of the fistula is anal. The route selected in
the individual will depend on the site of the fistula
as well as the aetiological agent and the experience
of the operator (Lawson, 1972). With low fistulae,
traversing the anal sphincter, laying open the track
may ensure healing and preserve continence if
below the bulk of the anal musculature. If not, an
immediate or delayed sphincter repair will be
required (Motson, et al., 1983).
 Montgomery: Recto-vaginal fistula
STO M A S
The indications for the creation of a defunctioning
stoma are relative. Symptoms may dictate its use
before definitive treatment or it may be created at
the time of repair. In fistulae larger than 1 cm
diameter and particularly when the causative
agent or site of the fistula renders an abdominal or
posterior approach necessary, a temporary stoma
should be raised (Lawson, 1972). For the treat-
ment of irradiation associated fistulae a colostomy
is vital whilst healing takes place.
When a colostomy is raised. if resection of the
rectum is considered, a right transverse colostomy
will allow mobilisation of the descending colon
and splenic flexure to be performed more easily. A
left iliac fossa sigmoid colostomy is preferred when
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a permanent stoma is required or a low fistula
needs re-operation.
When there is associated sepsis in the develop-
ment of the fistula a temporary colostomy may
allow healing to occur and possibly spontaneous
closure of the fistula itself.
60NCLUSlO NS
Recto-vaginal fistulae are a distressing complica-
tion found in a small number of patients. Clas-
sification of the aetiological factors and the site of
the fistula may help us to deal with this com-
plication effectively. Where the condition allows
and the symptoms dictate, surgical repair is suc-
cessful in the majority of patients. Palliation of
symptoms by the creation of an artificial stoma is
occasionally all that is possible. Care in creation of
the stoma should enable resumption of normal
activities.
C o r r P q m f m c e h u l d he addressed 10: M r A . C . V. Montgomery, The Royal Marsden Hospital, Fulham Road, London SW3 655.
S37
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