A rectovaginal fistula is a medical condition where there is a fistula or abnormal opening between the rectum and the vagina. If this opening is located between colon and vagina, it is called colovaginal fistula; and anovaginal fistula if it is between vagina and anus. Patients suffer from serious health problems due to recurrent vaginal infections and significant restrictions in their social lives because of uncontrolled gas and/or stool flow from vagina. Complaints vary depending on the width and severity of the fistula between the rectum and vagina. Frequently recurring vaginal infections, vaginal flow with bad odor, gas or fecal flow and pain during sexual contact are among the main patient complaints.
CAUSES;
1. POST NATAL AND VAGINAL TRAUMAS;
These are the most common causes of rectovaginal fistula. It is reported in 0,1% after difficult births where tears develop.
2. INFLAMMATORY INTESTINAL DISEASES;
The frequency of the disease is high in inflammatory intestinal diseases like Crohn’s Disease.
3. RADIOTHERAPY;
Rectovaginal fistula and vesicovaginal fistula (fistula between vagina and bladder) frequency increases after radiotherapy application to this region for uterine cancer, cervical cancer, vaginal and rectum cancers.
4. PREVIOUS OPERATIONS;
Rectovaginal fistula can be seen after hemorrhoid, rectal prolapse, rectocele, uterine and rectum cancer operations. Fistula may also develop as a result of disease relapse after uterina, vaginal and rectum cancer surgeries.
5. INFECTIONS;
RVF can be seen after abscesses that develop in anus and genitalia Sigmoid colon or, as the patient?s age, bubbles called diverticle may develop in some individuals. In case of spontaneous perforation of these, diverticulitis and intra-abdominal abscess may develop. In women who have hysterectomy, this abscess is discharged into the vagina and colovaginal fistula develops.
DIAGNOSIS:
Although patient complaints lead to direct diagnosis, a detailed gynaecological, proctological examination and endoscopic evaluation is required. Medical history of the patient must be reviewed and radiological evaluations must be performed in order to reveal diseases that may cause fistula development. Evaluation of the muscles surrounding the anus and providing gas and stool continence is also very important. Correct treatment can only be selected by determining the fistula severity, size and cause through these evaluations.
TREATMENT:
Spontaneous healing of rectovaginal fistula is almost impossible except for some special conditions; therefore, main treatment is surgery. Surgical treatment decision vary depending on the development cause, location and size of the fistula.
Generally, torn anal muscles accompany this condition in patients suffering from RVF developed due to birth trauma. Primary treatment is the removal of the infection in this region. Then the fistula is closed via anus (transanal approach), vaginal rout (transvaginal approach) or from the region between anus and vagina (transperineal approach) and anal muscles are repaired.
Treatment of RVFs developed due to Crohn’s Disease is difficult and relapse rates are higher. First of all, infection must be removed, abscess must be discharged and colitis must be taken under control. Then, fistula can be closed by using recal or vaginal tissues (endorectal or transvaginal advancement flap methods). In RVFs relapsing due Crohn?s Disease, temporary removal of stool out (stoma) and advanced flap methods (rectal sleeve technique) may be used.
In RVFs developing due to radiotherapy, primarily, it must be proved that cancer is not relapsed. Local repairs generally fail because of the extensive damage on the rectum caused by radiotherapy. Therefore, closing the fistula by using muscle tissues (Gracilis muscle interposition and Martius flap methods) can be tried in such fistula types. However, successful results generally are obtained through abdominal route approach for such fistula patients. In this surgical technique (lower anterior resection and perianal pull-through coloanal anastomosis) radiotherapy-affected and diseased rectum is removed and large bowel is ligated back to the anus, providing intestinal continuity.
The most frequent fistula that are related to infections is colovaginal fistula and its treatment almost always requires surgery. Fistula may develop over time between the vagina and the sigmoid colon after abdominal diverticulitis episodes, which generally relapse in the sigmoid colon. The success rate is 100% with the removal of the diseased intestine via a laparoscopic method from the abdominal route and ensuring the continuity of the intestine.