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What is a rectovaginal fistula (also referred to as RVF)?
A fistula is an abnormal connection between two surfaces in the body, like a tunnel between two underground stations. In this case, the tunnel runs between the anus (or rectum) and the vagina. This tunnel allows the content of the bowel such as wind, mucus, bacteria or even stool to pass from the rectum into the vagina.
What causes a rectovaginal fistula?
The most common cause is injury to the tissue between the rectum and the vagina during childbirth. This is called an obstetric injury and occurs in a very small proportion of women who undergo a severe tear during vaginal delivery. The next most common cause is an inflammatory bowel disease called Crohn’s disease. Surgery to the rectum or gynaecological organs, cancer, radiotherapy and some infections can also cause them.
How do I know if I have one?
The commonest symptom is to experience the passage of wind out through the vagina. Women with a rectovaginal fistula may also experience frequent gynaecological or urinary infections and may even pass mucus or stool through the vagina.
What investigations can be done to find out?
When you are seen in the clinic the doctor will ask you about your symptoms and examine the rectum and/or the vagina with a short telescope to try and visualise and assess the fistula. If a fistula is suspected, tests such as an ultrasound may be used. Interestingly, MRI is not usually very helpful because of the nature of the fistula – it is often too short to see clearly. Ultrasound is used to assess the anal sphincter muscle as well as to look for the fistula itself. Occasionally a contrast study (where X–Ray dye is placed in the rectum and x-rays taken to see if it leaks into the vagina) is necessary.
What treatment is available?
Treating a rectovaginal fistula can be very difficult. The cause of the fistula, its location and whether or not the anal sphincter is intact may influence the choice of treatment. When a fistula occurs straight after child birth, the first thing to do is wait. Many of these fistulas will simply heal up on their own without the need to resort to surgery. If the fistula persists, surgery may be necessary. A fistula caused by Crohn’s disease may be treated with Crohn’s medications in the first instance to try and encourage it to heal.
Surgery for rectovaginal fistula
Unfortunately, surgery for rectovaginal fistula is not always successful and many women face repeated operations before successful closure of the fistula is achieved. Around 75% of women will probably be successfully treated in the end. There are several different types of surgery performed, some through the abdomen and others by operating in the perineum (between the anus and vagina). Your surgeon will discuss the appropriate option for you in detail.
Will I need a stoma?
A stoma (ileostomy or colostomy) is where part of the bowel is brought to the surface of the skin of the abdomen so that the waste material (stool) empties into an airtight bag rather than passing through the rectum; it diverts the flow of faeces away from the site of the repair. The use of a stoma has not been shown (in research performed to date) to be beneficial in helping a rectovaginal fistula to heal. However, the research examining this question is not of a very high quality and probably does not answer the question with much confidence. Many experts suggest that women have a stoma created in order to improve the chances that their fistula will heal after surgery.
What happens if my fistula doesn’t heal?
Some women are never ‘cured’ of their fistula. This means that it never fully closes. However, surgery often shrinks the fistula to such a small size that further surgery is declined because an acceptable situation has been reached. Sometimes a surgical thread called a seton is placed through the fistula to help control drainage and again, symptoms are controlled such that no further surgery is required. Remember, however: the majority of women with a rectovaginal fistula will be healed by surgery, even if more than one attempt is necessary.
Delorme’s rectal advancement flap for rectovaginal fistula: why do I need this operation?
You have been diagnosed with a rectovaginal fistula. This is a tunnel which runs between the anus (or rectum) and the vagina. You may be experiencing symptoms such as the uncontrolled passage of wind or stool through the vagina, recurrent urinary tract infections, painful sex and smelly discharge from the vagina. The problem with your rectovaginal fistula may also be impacting many other aspects of your life, such as daily activities and your work life. To read in detail, please read our Information For Patients Document.
The Fistula Team
Mr Phil Tozer Consultant Colorectal Surgeon