Rectovaginal and Anovaginal Fistulas

Rectovaginal and anovaginal fistulas - UpToDate 1/21/21, 9'48 PM
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Rectovaginal and anovaginal fistulas

Author: Marc R Toglia, MD
Section Editor: Linda Brubaker, MD, FACOG
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2020. | This topic last updated: Sep 16, 2019.
INTRODUCTION
Anovaginal and rectovaginal fistulas are abnormal tracts that connect the lower
gastrointestinal tract with the vagina. Other types of urogenital or anorectal fistulas are
discussed elsewhere. (See "Urogenital tract fistulas in women" and "Anorectal fistula: Clinical
manifestations, diagnosis, and management principles".)
ETIOLOGY
Anovaginal fistulas (AVFs) and rectovaginal fistulas (RVFs) most frequently result from
obstetric trauma, especially in undeveloped countries where prolonged obstructed labor can
lead to pressure necrosis of the rectovaginal septum. These fistulas can also occur following
a failed repair of a third- or fourth-degree laceration of the perineum, from unrecognized
injury at the time of vaginal delivery, and from episiotomy infection. Radiation damage and
Crohn disease are two other important causes of RVFs [1,2].
RVFs may also occur following difficult hysterectomies, especially those performed for severe
endometriosis with involvement or obliteration of the posterior cul-de-sac (pouch of
Douglas); from extension or rupture of perirectal, perianal, and, rarely, Bartholin's abscesses;
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and from any surgical procedures involving the posterior vaginal wall, perineum, anus, or
rectum.
In older women, RVFs can occur as a result of diverticulitis, colon cancer, or fecal impaction.
In addition, treatment options for pelvic organ prolapse such as pessaries [3] and various
mesh repair procedures have been associated with RVFs [4].
CLASSIFICATION OF FISTULAS
Although the term "rectovaginal fistula" is sometimes used loosely in clinical practice to refer
to all fistulas that involve the bowel and vagina, it is preferable to subclassify female genital
fistulas according to anatomic landmarks:
● Fistulas that occur below the dentate line are called anovaginal fistulas (AVFs) or low
fistulas. AVFs are usually found within the first 3 cm from the anal verge. Fistulas that
open on the perineal body are called anoperineal fistulas.
● Fistulas cephalad to the dentate line are true rectovaginal fistulas (RVFs) and are
classified by some experts as high fistulas. The distinction between AVFs and RVFs is
important as the anal sphincter complex is often involved with the former.
● Fistulas of the colon above the rectum are referred to as colovaginal fistulas.
Although a variety of classification systems exist for these fistulas by size, location, or
etiology, none is correlated with patient outcomes [5-7].
CLINICAL MANIFESTATIONS
Women suffering from anovaginal fistulas (AVFs) or rectovaginal fistulas (RVFs) present with
uncontrollable passage of gas or feces from the vagina. A malodorous vaginal discharge and
fecal soiling of the undergarments are also common complaints. These symptoms may be
more pronounced when patient bowel movements are loose. Occasionally, a small fistula
may be asymptomatic.
Patients suspected of having AVFs should also be questioned about symptoms of fecal
urgency as well as fecal incontinence associated with urgency. These additional symptoms
often suggest disruption of the external anal sphincter. (See "Delayed surgical management
of the disrupted anal sphincter".)
EVALUATION AND DIAGNOSIS
All patients suspected of having anovaginal fistulas (AVFs) or rectovaginal fistulas (RVFs)
should undergo a vaginal examination. The diagnosis is made on vaginal examination.
In addition, patients diagnosed with fistulas should have a complete evaluation of their anal
sphincter complex to rule out concomitant sphincter injury. If a surgeon is unclear as to
whether the anal sphincter is intact, endoanal ultrasound can detect defects in both the
internal and external anal sphincter complexes.
It is critical that the clinician evaluate the entire sphincteric mechanism in women with RVFs
to exclude coexisting causes for incontinence, such as a disrupted anal sphincter. Although
concomitant sphincter injury has been reported to exist in up to one third of women
presenting with RVFs [8,9], concomitant internal or external sphincter injuries (or both) are
probably more frequent when the location of the fistula is within the distal 3 cm of the anal
canal. Anatomic and physiologic studies have shown that this is the normal length of the
sphincter complex. Failure to recognize and repair such a sphincter injury may result in
continued incontinence following a successful fistulectomy.
Pinpoint fistulas can be difficult to locate on vaginal examination. The use of a Sims
speculum and magnification, such as a colposcope, may be helpful. Lacrimal duct or silver
wire probes can also be used to assist in identifying the fistula tract. A few drops of
methylene blue dye can be mixed with lubricating gel and massaged into the anterior rectal
wall. Alternatively, an enema consisting of warmed saline and a few drops of methylene blue
dye can be instilled into the rectum using a genitourinary syringe. Using a peroxide solution
will avoid staining the tissues [10]. If a tract cannot be found easily, the patient's hips can be
elevated, water placed in the posterior vagina, then air (50 to 100 cc) placed in the rectum
with a catheter-tip syringe connected to a Robertson catheter. Air will generally pass
anteriorly through a small tract and bubble through the vaginal water. Proctoscopy or an
anorectal speculum may also be useful in visualizing the fistulous tract from the rectal side.
The role of imaging tests, such as endoanal ultrasound and magnetic resonance imaging, in
the diagnosis of fistulas is discussed separately. (See "The role of imaging tests in the
evaluation of anal abscesses and fistulas".)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of anovaginal and rectovaginal fistulas (AVFs and RVFs) includes
conditions that cause fecal soiling, such as fistula-in-ano, perianal abscess, and anal
incontinence, and conditions that cause malodorous vaginal discharge, such as vaginal
infection. AVFs and RVFs can be distinguished from these entities based upon the patient's
symptoms and the physical examination. Among the conditions in the differential diagnosis,
fistula-in-ano is most commonly confused with AVF.
Distinguishing AVFs and RVFs from fistula-in-ano — Another type of perineal fistula,
fistula-in-ano, is an abnormal connection between the anal canal and the perianal or perineal
skin. Fistula-in-ano can occur as a complication of episiotomy [8] but is caused far more often
by perianal abscesses or trauma. A detailed discussion of fistula-in-ano can be found
elsewhere. (See "Anorectal fistula: Clinical manifestations, diagnosis, and management
principles".)
Clinically, fistula-in-ano is characterized by chronic purulent drainage or cyclical pain.

Palpation of the fistula tract is painful for the patient with a fistula-in-ano, in contrast to the
relatively painless tract of an AVF or RVF. The location of a fistula-in-ano is usually lateral to
the midline, whereas most AVFs and RVFs are located close to the midline (related to their
obstetric origin). Morphologically, an anal fistula tract is lined with chronically inflamed
granulation tissue, instead of the epithelialized tract typical of AVFs and RVFs.
INDICATIONS FOR SURGERY
For women with small fistulas and minimal symptoms, nonsurgical management is
appropriate. Optimizing the patient's bowel function, particularly controlling diarrhea, is
beneficial. However, for the majority of patients with anovaginal or rectovaginal fistulas, the
symptoms are intolerable. Thus, surgical repair is indicated.
The surgical approaches to fistula repair vary by the etiology of the fistula, its location and
size, the quality of the surrounding tissue, the patient's underlying comorbidities, and any
previous attempts at repair. Most published studies are small case series, which makes
comparison of techniques and outcomes difficult [11].
PREOPERATIVE PREPARATION
There is no consensus regarding the best preoperative regimens for women undergoing
repair of anorectal fistula (AVF) or rectovaginal fistula (RVF). In our practice, we prescribe a
liquid diet for 24 to 48 hours prior to surgery, followed by a mechanical bowel cleansing; we
give a single dose of preoperative antibiotic 30 minutes before surgery.
Diet — Dietary manipulation is required in all women undergoing AVF or RVF repair. The
ultimate goal is to avoid fecal seeding of the wound during the procedure and to decrease
the amount of stool that will pass over the repaired area in the first few weeks of healing. In
most cases, a liquid diet should be followed for 24 to 48 hours prior to surgery.
Mechanical bowel cleansing — Mechanical bowel cleansing is routinely recommended. The

author prefers to give oral agents (32 ounces of magnesium citrate or 4 to 6 liters of Golytely)
48 hours preoperatively. Administering these agents within 24 hours of the procedures can
result in a thin fecal effluent being present at the time of the repair.
In addition, a tap water enema or a Fleet enema can be given the night before surgery to
complete the emptying of the lower colon and rectum. Alternatively, a Fleet enema can be
given an hour prior to surgery.
Antibiotic prophylaxis — We administer a single dose of a broad-spectrum antibiotic, such

as cefoxitin or cefotetan, intravenously 30 minutes before the procedure. Alternatively, a
combination of cefazolin and metronidazole also provides adequate coverage. For patients
with a beta-lactam allergy, clindamycin plus gentamicin can be used as an alternative
regimen; gentamicin should be dosed based upon actual patient weight [12]. Additional
antibiotic therapy is typically not indicated, unless there is fecal soiling during the procedure.
In most patients, prophylactic antibiotics should be discontinued within 24 hours after the
surgical procedure.
SURGICAL PRINCIPLES
Basic principles — The basic principles essential to all successful fistula repairs include:
● Wide mobilization of the adjacent tissue planes

● Complete excision of the fistula tract
● Multilayered closure, which reapproximates broad tissue surfaces without tension and
avoids "dead space"
● Proper timing of the repair
Timing of repair — Most rectovaginal and anovaginal fistulas are amenable to early repair,
provided there is no infection, induration, or inflammation present in the tissues involved.
When active wound infection or tissue induration is present, patients should be provided
with aggressive wound care (eg, sitz baths, debridement) and a 10 to 14 day course of broad-
spectrum oral antibiotics. In addition, a low residue diet helps to decrease the frequency of
bowel movements, prevent continuous seeding of the wound with liquid stool, and restore
some degree of fecal continence. In these patients, surgery is deferred until all signs of
infection, induration, and inflammation have subsided.
Choice of sutures — The choice of suture materials is determined by individual surgeon

preference. We prefer to use delayed absorbable sutures, such as polyglactin or polyglycolic
acid, instead of chromic catgut in the repair of these fistulas. The tensile strength of delayed
absorbable sutures is maintained longer and the knot is more secure and smaller in size
when compared with catgut sutures. Tissue reaction is also less with these suture types.
There may also be a role for small-diameter monofilament delayed absorbable and
permanent nonbraided sutures in selected patients.
SURGICAL APPROACH
Surgical approaches to anovaginal or rectovaginal fistula repair are dictated by fistula

etiologies. Given that most rectovaginal fistulas result from obstetric trauma, the discussion
below will focus on obstetric fistulas.
Fistulas due to obstetric injury — For women with anovaginal or rectovaginal fistulas from
childbirth, we suggest a simple local repair with or without sphincteroplasty.
Fistulas with intact sphincter: Simple fistulectomy — Small rectovaginal fistulas that do
not involve the anal sphincter complex can often be repaired by simple fistulectomy via a
transvaginal or transrectal approach.
An incision is first made around the fistula opening ( figure 1). The surgeon's nondominant
index finger can be inserted into the rectum during the procedure to assist the repair (
figure 2). Sharp mobilization of the vagina and rectum in a circumferential fashion should
be accomplished next, by providing traction and countertraction on the edges of the fistula (
figure 3).
After the tissue planes are widely mobilized, the entire fistulous tract and any adjacent scar
tissue are excised ( figure 4). The edges of the surgical wound should only contain fresh,
viable tissue. The edges of the anterior rectal wall are then inverted, either by placing
interrupted submucosal stitches of 3-0 or 4-0 delayed absorbable sutures ( figure 5) or by
placing a pursestring suture. The most cephalad and most caudal sutures should be placed
at least 5 mm above and below the fistula. A second layer of sutures of 2-0 delayed
absorbable type is then placed in the muscularis of the anterior rectal wall to invert and take
tension off of the first suture line ( figure 6). This layer should begin and end
approximately 5 mm above and below the first suture line.
An additional layer of adjacent rectovaginal tissue is then approximated to provide a third

layer of closure and take tension off of the underlying layers of repair ( figure 7). If
necessary, a modified Martius graft can be interposed between the rectum and vagina
before this step (see 'Modified Martius graft' below). Finally, the vaginal mucosa is
approximated with a continuous 3-0 suture ( figure 8).
Complete hemostasis and closure of all potential dead space must be ascertained.
Depending upon the extent of repair, we frequently will place a small vaginal pack soaked in
a very dilute Betadine solution or use a petroleum-impregnated gauze to promote

hemostasis and provide gentle pressure against the incision line. If placed, the vaginal pack
is typically removed within the first 12 to 24 hours postoperatively.
Fistulas with injured sphincter: Transsphincteric approach — In patients with

concomitant sphincter injury and absent perineal body or a small bridge of perineal skin,
fistula repair may be performed in conjunction with repair of the external and internal
sphincters and reconstruction of the perineal body and rectovaginal septum. The preferred
approach in these patients is a midline perineal incision (transsphincteric or
perineoproctomy) with wide mobilization of the posterior vaginal wall, followed by a
multilayered closure as described for a chronic third- or fourth-degree laceration (see
"Delayed surgical management of the disrupted anal sphincter"). In all cases, it is important
that the fistula tract be excised in its entirety, as discussed above.
Fistulas above the sphincter: Transverse transperineal approach — Rectovaginal

fistulas located above the sphincter complex should be approached with a transverse
transperineal incision. This approach allows the surgeon to preserve the intact internal and
external anal sphincter and allows wide mobilization of the rectal and vaginal tissue [13]. A
transverse incision is made across the perineal body above the sphincter complex. Dissection
is then carried out in the true rectovaginal space between the anterior rectal wall and the
posterior vaginal wall to mobilize the tissues widely laterally and cephalad to the fistula tract
( figure 9 and figure 10). Dissection above the fistula tract is usually easy because the
vagina and rectum are only loosely connected above this point.
The fistula tract and any adjacent scar tissue are then excised with Metzenbaum or Cooley
scissors ( figure 11). The rectal wall defect can be closed either longitudinally or
transversely with interrupted 3-0 or 4-0 delayed absorbable sutures to invert the rectal
mucosa without tension. We prefer to close the other layers longitudinally in all but the
smallest fistulas ( figure 12). By closing the rectal mucosal and perirectal fascial layers
longitudinally, the anal canal is lengthened, which may help to reestablish the high-pressure
zone of the anal canal. Closing the vaginal mucosa and perineal body longitudinally helps to
avoid narrowing the vaginal introitus and also lengthens the perineal body.
Alternatively, the rectal and vaginal defects may be closed in perpendicular directions to each
other to avoid overlapping suture lines. With this approach, the rectal defect should be
closed transversely and the vaginal mucosa closed longitudinally to minimize narrowing of
the vaginal introitus and avoid creation of a transverse ridge across the posterior vaginal
wall, which can cause dyspareunia.
The second layer of closure is placed into the muscularis of the rectum in the same direction
as the first layer, thus imbricating the first layer and reinforcing the closure ( figure 13).
The puborectalis muscles are approximated in the midline, providing an additional
reinforcing layer between the anterior rectal and posterior vaginal walls ( figure 14).
The subcutaneous tissues and skin of the perineal body can be approximated with a running
nonlocking suture. The skin is closed with interrupted mattress sutures or a running closure
of 4-0 delayed absorbable suture ( figure 15).
Following this procedure, patients are generally hospitalized overnight for pelvic rest (no
vaginal insertions), pain control, observation for bleeding, and vaginal pack removal.
Fistulas due to radiation — Fistula formation following radiotherapy is believed to be the

result of progressive endarteritis obliterans and tissue hypoxia. These fistulas can occur
years after the completion of radiotherapy, can be large, and can appear high in the
posterior vaginal wall. They are often associated with rectal stricture due to perirectal
fibrosis. Refinements in modern radiotherapy have led to a decline in radiation-induced
fistulas.
Radiation-induced fistulas can be either low fistulas or high fistulas. Low fistulas can be
repaired locally with interposition of a fat graft, usually of a modified Martius type. High
fistulas need to be approached transabdominally with interposition of an omental flap, a
muscle flap, or a bowel onlay patch (Bricker-Johnson procedure). Permanent diverting
colostomy should be performed when radiation necrosis is extensive, and temporary
colostomy or ileostomy should be considered for all radiation-related fistulas.
Low fistulas: Local repair with Martius graft interposition — Successful local repair of
radiation-induced fistulas needs to follow the basic surgical principles of other fistula repairs
(see 'Basic principles' above). Repair should be delayed until the radiation-induced necrosis
process has resolved. A preoperative diverting colostomy diverts fecal stream away from the
fistula area to allow for healing. At the beginning of the repair, margins of the fistula should
be biopsied to exclude residual or recurrent malignancy. At the end of the repair, a Martius
graft should be interposed between the vagina and the rectum to bring in new blood supply,
especially in patients with extensive tissue excision. Before the temporary diverting ostomy is
taken down, the closure of the defect should be tested by placing water in the vagina and air
in the rectum as described above. The success of radiation-induced fistula repair varies
widely between series [14,15]. (See 'Modified Martius graft' below.)
High fistulas: Transabdominal repair with tissue interposition — High rectovaginal

fistulas caused by radiation damage often need to be approached transabdominally. The
transabdominal approach is facilitated by use of long instruments and retractors, such as
those used in thoracic or deep pelvic surgery. A preoperative diverting colostomy diverts
fecal stream away from the fistula area to allow for healing.
First, the rectum and vaginal apex are widely mobilized from the fistulous communication. All
of the scarred, fibrous, and nonviable tissues are then resected from the fistulous site. This is
then followed by multilayered closures of the rectum and vagina.
Serosal dissection on the rectal side can be extensive, especially when the fistula opening is
large. Excessive dissection can disrupt a significant portion of the blood supply to the bowel,
thereby interfering with successful closure and healing of the fistula. If extensive bowel
ischemia is present, a segmental resection and primary anastomosis of compromised bowel
may be necessary. Extensive radiation-induced bowel ischemia may necessitate the use of a
permanent diverting colostomy as the definitive procedure to control a rectovaginal fistula.
In repairing high fistulas due to radiation, it is also essential to interpose well-vascularized

tissue between the rectum and the vagina to bring in new blood supply, fill in dead space,
and therefore prevent recurrence. Such well-vascularized tissues include omentum, muscle,
or healthy bowel, as long as they can be mobilized to the deep pelvis [16].
● An omental J-flap is created by detaching the omentum from the transverse colon while
leaving it attached to the stomach. A J-shaped incision is then made approximately 4 cm
inside the lateral border of the omentum adjacent to the edge of the stomach, down
past the most distal and lateral termination of the mesenteric vessels within the omental
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apron. This flap is then rotated down to the fistula site and sutured in place between the
rectum and the vagina.
● A segment of the rectus abdominis muscle can be interposed between the rectum and
vagina. This also provides excellent neovascularity and tissue support to the fistula repair
site.
● Because patients will have undergone a diverting colostomy, it is possible to use the
proximal end of the bypassed colon as an onlay patch for the fistula repair ( figure 16).
The proximal colon is nonradiated and brings its own blood supply. The procedure
requires minimal dissection of the rectal ampulla, and the presacral space is never
entered. After fistula healing is confirmed, the colostomy can be reversed by suturing to
the loop of colon used in the fistula repair [17].
Fistulas due to inflammatory bowel disease — Rectovaginal fistulas have been associated
with inflammatory bowel disease, particularly Crohn disease. Successful local repair is
predicated upon controlling the disease process itself and timing the repair during periods of
remission. (See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in
adults".)
Fistulas associated with Crohn disease may be single or multiple, and a single vaginal
opening may be connected with multiple tracts leading to the anus with microabscesses
developing along the way.
Local repair of Crohn fistula should not be attempted until the patient's Crohn symptoms are
fully controlled and there is no longer any evidence of active proctitis on proctoscopy
examination. The timing of such a repair procedure is usually decided jointly by a
gynecologist, a colorectal surgeon, and a gastroenterologist treating the patient.
A transverse, transperineal approach is often ideal in these women as the sphincter complex
tends to be uninvolved (see 'Fistulas above the sphincter: Transverse transperineal approach'
above). All branches of the fistulous tract should be resected. A modified Martius graft can
bring in additional tissue and blood supply to cover large tissue defects resulting from
complete excision of the affected area (see 'Modified Martius graft' below). A colostomy is
often performed in these patients to promote healing by diverting fecal stream. Despite all
the efforts, recurrence rates remain high in this group of patients. Thus, they need to be
appropriately counseled.
Other complex fistulas — Rectovaginal fistulas can also develop from pelvic malignancies,
or as complications following pelvic surgeries done for endometriosis or diverticular disease.
These fistulas are usually high fistulas, and therefore a transabdominal procedure should be
used for their repair. Minimally invasive, including robotic, techniques have been employed
successfully, using the same surgical principles described above to achieve adequate
visualization and bowel mobilization [18]. (See 'High fistulas: Transabdominal repair with
tissue interposition' above.)
Adjuvant techniques
Modified Martius graft — A modified Martius graft is a bulbocavernosus muscle or labial

fat pad graft used in closing large or difficult rectovaginal or vesicovaginal fistulas. A Martius
graft does not provide any significant structural support to the repair, but it provides
neovascularity, fills in dead space, and enhances granulation tissue formation at the site of
repair.
A modified Martius graft can be used in patients with complex fistulas caused by
inflammatory bowel disease or radiation injury, as well as in patients with recurrent fistulas.
It is most useful in the repair of rectovaginal fistulas located in the middle to upper third of
the vaginal vault, where there may not be sufficient tissue to transpose between the vagina
and the rectum.
The procedure involves transposing a vascularized graft made of healthy tissue to the repair
site [19]. First, a vertical incision is made over the labia majora to expose the labial fat pad (
figure 17). The labial fat pad is then sharply mobilized with care taken to preserve the
blood supply either superiorly or inferiorly ( figure 18). For most repairs, the base of the
pedicle should be on the inferior border of the graft, thus allowing the graft to be rotated
medially without significant tension. The graft is tunneled subcutaneously beneath the
vaginal mucosa and labia minora to overlay the repaired fistula site ( figure 19) and
secured at its edges with interrupted sutures of 3-0 chromic or delayed absorbable sutures (
figure 20). The labial incision is closed in two layers ( figure 21). A typical Martius graft
repair of a rectovaginal fistula is depicted in a video clip ( movie 1).
Diverting colostomy — Diversion of the fecal stream is not required in the management
of most anovaginal or rectovaginal fistulas. However, a colostomy is a useful adjunct to the
care of complex fistulas associated with a lower healing rate. Examples of such complex
fistulas include radiation-induced fistulas, large rectovaginal fistulas with diameter greater
than 4 cm, and some fistulas secondary to inflammatory bowel disease. Retrospective series
reported improved outcomes with fecal diversion in the management of rectovaginal fistulas
associated with Crohn disease [20,21].
In patients with preexisting stoma, surgical repair of the fistula should be delayed until all
evidence of inflammation and cellulitis has resolved, typically 8 to 12 weeks after the start of
fecal diversion. Takedown of the colostomy is usually performed three to four months after
the fistula repair.
The construction and maintenance of a diverting colostomy is discussed elsewhere. (See

"Overview of surgical ostomy for fecal diversion".)
POSTOPERATIVE CARE
Following an anovaginal or rectovaginal fistula repair, patients are observed overnight in the
hospital, then discharged home with specific instructions on diet, bowel regimen, and
general care.
In-hospital care — Most patients can be discharged home on the first postoperative day, as
long as they can be seen within one week for a wound check. It is unnecessary to keep
women in the hospital until their first bowel movement. While the patient is on a low residue
diet, it is common to have a bowel movement as infrequently as twice weekly.
Urinary retention is a common problem following fistula repair. It is reasonable to place a

Foley catheter and a vaginal pack at the end of the surgical procedure and remove them both
on the evening of the surgery or, alternatively, the morning of the first postoperative day.
Antibiotics in the postoperative period are probably unnecessary in the absence of clinical
infection.
Diet — Dietary manipulation should be considered to decrease the amount of stool that will
pass over the repair in the first few weeks of healing. A clear liquid diet is prescribed for the
first 24 to 72 postoperative hours. A low residue diet should then be instituted for at least
three to four weeks. The low residue diet should be discontinued if constipation develops.
Bowel regimen — A stool softener should be given for one month to lubricate the stool. If
the patient complains of constipation, milk of magnesia or other laxatives can be given to
ease bowel movements. Enemas should be avoided.
General care — Ambulation is allowed. Women should be instructed in wound care and
taught how to perform Sitz baths starting two to three days following the procedure. A heat
lamp or a blow dryer on a cool setting can also be used to keep the area dry.
MORBIDITY AND MORTALITY
Perioperative deaths are rare following anovaginal (AVF) and rectovaginal (RVF) fistula repair.
The major morbidities associated with AVF or RVF repair include recurrent fistula; wound
infection; urinary tract infection; bowel obstruction or perforation; vaginal, anal, or rectal
stenosis; fecal incontinence; and sexual dysfunction. The rates vary depending upon the
etiologies that cause the fistulas.
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Rectovaginal fistula (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) frequently result from
obstetric trauma. Patients present with uncontrollable passage of gas or feces from the
vagina. (See 'Clinical manifestations' above.)
● RVFs and AVFs are diagnosed on vaginal examination. Patients diagnosed with a fistula
should be evaluated for concomitant anal sphincter injury before undergoing surgical
repair. (See 'Evaluation and diagnosis' above.)
● Patients with childbirth-related fistulas should undergo local repair via transvaginal,
transanal, transsphincteric, or transverse transperineal approach, depending upon their
sphincter status and the location of the fistula. (See 'Fistulas due to obstetric injury'
above.)
● Patients with radiation-induced fistulas should undergo repair with tissue interposition.
The approach (local versus transabdominal) is dictated by fistula location (low versus
high). (See 'Fistulas due to radiation' above.)
● Patients with Crohn fistulas should not undergo repair until adequate medical control of
their disease has been achieved. Surgically, we use a transverse, transperineal approach
to the repair with a Martius graft interposition. (See 'Fistulas due to inflammatory bowel
disease' above.)
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REFERENCES
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3. Torbey MJ. Large rectovaginal fistula due to a cube pessary despite routine follow-up;
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4. Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requiring reoperation

following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol 2008;
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5. Rosenshein NB, Genadry RR, Woodruff JD. An anatomic classification of rectovaginal

septal defects. Am J Obstet Gynecol 1980; 137:439.
6. Thompson JD. Relaxed vaginal outlet, rectocele, fecal incontinence, and rectovaginal fist
ula. In: TeLinde's Operative Gynecology, 7th ed, Thompson JD, Rock JA (Eds), JB Lippincot
t, Philadelphia 1992. p.941.
7. Fundamentals, symptoms, and classification. In: Surgical Repair of Vaginal Defects, Bad
en WF, Walker T (Eds), Lippincott, Philadelphia 1992. p.9.
8. Whiteford MH, Kilkenny J 3rd, Hyman N, et al. Practice parameters for the treatment of
perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005; 48:1337.
9. Corman ML. Anal incontinence following obstetrical injury. Dis Colon Rectum 1985;
28:86.
10. Shieh CJ, Gennaro AR. Rectovaginal fistula: a review of 11 years experience. Int Surg
1984; 69:69.
11. Göttgens KW, Smeets RR, Stassen LP, et al. The disappointing quality of published
studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective
multi-institutional study. Dis Colon Rectum 2014; 57:888.
12. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial
prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
13. Wiskind AK, Thompson JD. Transverse transperineal repair of rectovaginal fistulas in the
lower vagina. Am J Obstet Gynecol 1992; 167:694.
14. Boronow RC. Repair of the radiation-induced vaginal fistula utilizing the Martius
technique. World J Surg 1986; 10:237.
15. Aartsen EJ, Sindram IS. Repair of the radiation induced rectovaginal fistulas without or
with interposition of the bulbocavernosus muscle (Martius procedure). Eur J Surg Oncol
1988; 14:171.
16. Schloericke E, Hoffmann M, Zimmermann M, et al. Transperineal omentum flap for the
anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal
fistulas. Colorectal Dis 2012; 14:604.
17. Bricker EM, Johnston WD, Patwardhan RV. Repair of postirradiation damage to
colorectum: a progress report. Ann Surg 1981; 193:555.
18. 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.
19. Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive
technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727.
20. Bauer JJ, Sher ME, Jaffin H, et al. Transvaginal approach for repair of rectovaginal
fistulae complicating Crohn's disease. Ann Surg 1991; 213:151.
21. Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn's disease. Am J
Surg 1997; 173:95.
Topic 1385 Version 15.0
GRAPHICS
Repair of a small rectovaginal fistula through a transvaginal

approach
An elliptical incision is made about the fistula tract.
Graphic 81075 Version 1.0

approach
The surgeon places the nondominant index finger into the rectum to demonstrate
the fistula.

approach
The posterior vaginal wall is sharply mobilized off of the anterior rectal wall.

approach
The fistula tract is excised, including the adjacent vaginal and rectal mucosa.

approach
The rectal mucosa is closed using a delayed absorbable suture. Note that the
suture line is begun at least 5 mm above the apex of the fistula.

approach
Second layer of the closure, which inverts the first layer.

approach
The puborectalis fibers are reapproximated in the midline to give a third layer of
closure.

approach
Closure of the vaginal mucosa.
Transverse transperineal approach to a rectovaginal fistula

located at the sphincter complex
A wire probe is used to identify the fistula tract. A transverse transperineal incision
is made above the sphincter complex.

located at the sphincter complex
Dissection above and lateral to the fistula tract is carried out using sharp
dissection.

located about the sphincter complex
The fistula tract is excised.

The anterior rectal wall defect is closed longitudinally with interrupted 4-0 delayed
absorbable sutures.

The second layer of closure is placed into the muscularis of the rectum in the same
direction as the first layer, thus imbricating the first layer and reinforcing the
closure
https://www.uptodate.com/contents/rectovaginal-and-anovaginal-fist…earch_result&selectedTitle=5~150&usage_type=default&display_rank=5 Page 30 of 39

The puborectalis fibers are reapproximated in the midline, providing an additional

reinforcing layer between the anterior rectal and posterior vaginal walls.

The perineal body is reapproximated longitudinally with interrupted sutures to

lengthen it.
Onlay patch (Bricker procedure)
Colonic onlay patch (Bricker procedure) for repair of rectovaginal fistula. After colostomy,
the proximal end of bypassed colon is brought down to cover the rectal defect as an onlay
patch (panel A). After healing of the fistula, bowel continuity is restored by reversing the
colostomy (panel B).
Modiﬁed from: Lowry AC, Hoexter B. Benign anorectal: Rectovaginal ﬁstulas. In: The ASCRS Textbook of
Colon and Rectal Surgery, 1st ed, Beck DE, Wolf BG, Fleshman JW, et al (Eds), Springer 2007.
Modified Martius labial fat pad graft
A vertical incision is made over the labia majora.
Modified Martius fat pad graft
The graft is sharply mobilized with care taken to preserve the inferior blood supply.
The graft is tunneled subcutaneously beneath the vaginal mucosa.
The graft is secured at its edges with interrupted sutures.
The labial incision is closed in two layers.
Contributor Disclosures
Marc R Toglia, MD Nothing to disclose Linda Brubaker, MD, FACOG Grant/Research/Clinical Trial
Support: National Institutes of Health [Prevention of lower urinary symptoms]. Other Financial Interest:
Journal of the American Medical Association [Women's health]; Female Pelvic Medicine and Reconstructive
Surgery [Female pelvic medicine and reconstructive surgery]. Wenliang Chen, MD, PhD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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EVALUATION AND DIAGNOSIS

Clinically, fistula-in-ano is characterized by chronic purulent drainage or cyclical pain.

INDICATIONS FOR SURGERY

Mechanical bowel cleansing — Mechanical bowel cleansing is routinely recommended. The

Antibiotic prophylaxis — We administer a single dose of a broad-spectrum antibiotic, such

● Wide mobilization of the adjacent tissue planes

Choice of sutures — The choice of suture materials is determined by individual surgeon

Surgical approaches to anovaginal or rectovaginal fistula repair are dictated by fistula

An additional layer of adjacent rectovaginal tissue is then approximated to provide a third

a very dilute Betadine solution or use a petroleum-impregnated gauze to promote

Fistulas with injured sphincter: Transsphincteric approach — In patients with

Fistulas above the sphincter: Transverse transperineal approach — Rectovaginal

Fistulas due to radiation — Fistula formation following radiotherapy is believed to be the

High fistulas: Transabdominal repair with tissue interposition — High rectovaginal

In repairing high fistulas due to radiation, it is also essential to interpose well-vascularized

Modified Martius graft — A modified Martius graft is a bulbocavernosus muscle or labial

repair of a rectovaginal fistula is depicted in a video clip ( movie 1).

The construction and maintenance of a diverting colostomy is discussed elsewhere. (See

Urinary retention is a common problem following fistula repair. It is reasonable to place a

MORBIDITY AND MORTALITY

INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Rectovaginal fistula (The Basics)")

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

2. Saclarides TJ. Rectovaginal fistula. Surg Clin North Am 2002; 82:1261.

4. Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requiring reoperation

5. Rosenshein NB, Genadry RR, Woodruff JD. An anatomic classification of rectovaginal

Topic 1385 Version 15.0

Repair of a small rectovaginal fistula through a transvaginal

An elliptical incision is made about the fistula tract.

Graphic 81075 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Graphic 77833 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Graphic 73114 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Graphic 56251 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Graphic 52097 Version 2.0

Repair of a small rectovaginal fistula through a transvaginal

Second layer of the closure, which inverts the first layer.

Graphic 63815 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Graphic 75611 Version 1.0

Repair of a small rectovaginal fistula through a transvaginal

Closure of the vaginal mucosa.

Graphic 55071 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

Graphic 62973 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

Graphic 77809 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

The fistula tract is excised.

Graphic 57814 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

Graphic 64462 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

Graphic 77342 Version 1.0

Transverse transperineal approach to a rectovaginal fistula

The puborectalis fibers are reapproximated in the midline, providing an additional