Treatment of Rectovaginal Fistula

Abstract

Rectovaginal fistula (RVF) is a challenging complication with unsatisfactory success and a significant burden for the patients. With insufficient clinical data due to the rare entity, the present state of treatments for RVFs was reviewed especially form the point of factors to determine management, classifications, principle of treatment, conservative and surgical treatments with outcomes. Size, fistula localization and etiology, type of fistula; “simple” or “complex,” status of anal sphincter complex and surrounding tissue, presence or absence of inflammation, presence of diverting stoma, previous attempted repair and radiation therapy, patient's condition with co-morbidities, and surgeon's experience are important factors to determine the management of RVF. The inflammation should initially subside in cases with infection. Starting with conservative surgical options and interposing healthy tissue for complex or recurrent fistulas, invasive procedures will be performed if conservative treatment failed. Conservative treatment may be effective in RVFs with minimal symptoms and should be done for small RVFs for a 36 months usual period. Anal sphincter damage might need a repair of sphincter muscles along with RVF repair. Diverting stoma can initially be constructed in patients with severe symptoms and larger RVFs to relief the patient's pain. Simple fistula is usually indicated for local repair. Local repairs to transperineal and transabdominal approaches can be used for complex RVFs. Interposition of healthy, well-vascularized tissue can be required for more complex fistulas and abdominal procedures for high RVFs.

Successful Fistula Closure After Treatment with Colostomy and Infliximab in a Patient with Ulcerative Colitis Complicated by Rectovaginal Fistula

“…The size of RVF is an important factor in the choice of treatment, as the diameter of the fistula is classified as small (<0.5 cm), medium (0.5-2.5 cm), and large (>2.5 cm). 8 The size of her RVF confirmed from the vaginal side is 1.0 cm, indicating that her RVF as medium size and we expected it was difficult to repair with single treatment. Because of that, we chose colostomy and infliximab treatment.…”

“…The treatment procedures that are attempted include drainage seton, fibrin glue application, endorectal or vaginal advancement flap, episioproctotomy, transverse transperineal repair, fistulectomy and closure, Martius (bulbocavernosus) flap, gracilis muscle flap, interposition of levator ani muscles, and abdominal procedures with colorectal or coloanal anastomosis. 7,8 Regarding treatment outcomes for primary diseases causing RVF, the closure rate after treatment of IBD is as low as 46.1%-60.0%. 9,10 Thus, RVF in patients with IBD often requires repeated surgery to achieve complete cure, and most patients ultimately undergo ileostomy or proctocolectomy.…”

Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas

“…Thus, the timing of surgery is strongly dependent on the surgeon's experience. 20 The surgical treatment of RVF is challenging, and the success rate of surgical intervention across the globe is between 41-78%. 1,[21][22][23] In this study, most females with RVF were of middle age, in reproductive and sexually active age, all were symptomatic, and hence, there was a need for surgery.…”

Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned

“…However, the classification of RVFs into simple and complex types based on factors such as size, location, etiology, and their relationship to the anal sphincter complex can guide treatment decisions ( 11 , 12 ). Simple fistulas, typically smaller and more distally located, often result from trauma or infection and they are associated with better prognosis, while complex fistulas are associated with more severe conditions like inflammatory bowel disease, invasive cancer or radiation ( 10 , 12 ).…”