Rectovaginal fistula

A rectovaginal fistula is a connection that should not exist between the lower part of the large intestine — the rectum or anus — and the vagina. Bowel contents can leak through the fistula, allowing gas or stool to pass through the vagina.

A rectovaginal fistula may result from:

• Injury during childbirth.
• Crohn's disease or other inflammatory bowel disease.
• Radiation treatment or cancer in the pelvic area.
• Complication after surgery in the pelvic area.
• Complication from diverticulitis, an infection of small, bulging pouches in the digestive tract.

The condition may cause gas and stool to leak out of the vagina. This may lead to emotional distress and physical discomfort for you, which may impact your self-esteem and intimacy.

Talk with your health care provider if you have symptoms of a rectovaginal fistula, even if it's embarrassing. Some rectovaginal fistulas may close on their own, but most need surgery to fix them.

The most common symptom of a rectovaginal fistula is passing gas or stool from the vagina. Depending on the fistula's size and location, you may have only minor symptoms. Or you may have significant problems with stool and gas leakage and keeping the area clean.

When to see a doctor

See your health care provider if you have any symptoms of a rectovaginal fistula.

A rectovaginal fistula may form as a result of:

• Injuries during childbirth. Delivery-related injuries are the most common cause of rectovaginal fistulas. Injuries include tears in the perineum — the skin between the vagina and the anus — that extend to the bowel or an infection. Fistulas caused by injuries during childbirth may involve injury to the anal sphincter — the rings of muscle at the end of the rectum that help hold in stool.
• Inflammatory bowel disease. The second most common cause of rectovaginal fistulas is Crohn's disease and, more rarely, ulcerative colitis. These inflammatory bowel diseases cause swelling and irritation of the tissues lining the digestive tract. Most people with Crohn's disease never develop a rectovaginal fistula, but having Crohn's disease does increase your risk of the condition.
• Cancer or radiation treatment in the pelvic area. A cancerous tumor in your rectum, cervix, vagina, uterus or anal canal can result in a rectovaginal fistula. Also, radiation therapy for cancers in these areas can put you at risk. A fistula caused by radiation can form at any time following radiation treatment, but most commonly forms within the first two years.
• Surgery involving the vagina, perineum, rectum or anus. In rare cases, prior surgery in your lower pelvic area, such as removing an infected Bartholin's gland, can cause a fistula to develop. Bartholin's glands are found on each side of the vaginal opening and help keep the vagina moist. The fistula may develop as a result of an injury during surgery or a leak or infection that develops afterward.
• Complication from diverticulitis. Infection of small, bulging pouches in your digestive tract, called diverticulitis, may cause the rectum or large intestine to stick to the vagina and may lead to a fistula.
• Other causes. Rarely, a rectovaginal fistula may develop following infections in the skin around the anus or vagina.

A rectovaginal fistula has no clear risk factors.

Complications of a rectovaginal fistula may include:

• Uncontrolled loss of stool, called fecal incontinence.
• Problems keeping the perineum clean.
• Recurrent vaginal or urinary tract infections.
• Irritation or inflammation of your vagina, perineum or the skin around your anus.
• Fistula recurrence.
• Issues with self-esteem and intimacy.

Among people with Crohn's disease who develop a fistula, the chances of complications are high. These can include poor healing, or another fistula forming later.

There are no steps you need to take to prevent a rectovaginal fistula.

To diagnose a rectovaginal fistula, your health care provider will likely talk to you about your symptoms and do a physical exam. Your provider may suggest certain tests depending on your needs.

Physical exam

Your health care provider does a physical exam to try to locate the rectovaginal fistula and check for a possible tumor, infection or abscess. The exam generally includes looking at your vagina, anus and the area between them, called the perineum, with a gloved hand. A tool specially designed to be inserted through a fistula may be used to find the fistula tunnel.

Unless the fistula is very low in the vagina and easy to see, your health care provider may use a speculum to hold the walls apart to see inside your vagina. A tool similar to a speculum, called a proctoscope, may be inserted into your anus and rectum.

In the rare case that your health care provider thinks the fistula may be due to cancer, the provider may take a small sample of tissue during the exam for testing. This is called a biopsy. The tissue sample is sent to a lab to look at the cells.

Tests for identifying fistulas

Most commonly, a rectovaginal fistula is easily seen during a pelvic exam. If a fistula is not found during the exam, you may need tests. These tests can help your medical team find and look at a rectovaginal fistula and can help plan for surgery, if needed.

• CT scan. A CT scan of your abdomen and pelvis gives more detail than does a standard X-ray. The CT scan can help locate a fistula and determine its cause.
• MRI. This test creates images of soft tissues in your body. MRI can show the location of a fistula, whether other pelvic organs are involved or whether you have a tumor.
• Other tests. If your health care provider thinks you have an inflammatory bowel disease, you may have a colonoscopy to look at the inside of your colon. During the procedure, small samples of tissue may be collected for lab analysis. Samples can help tell if you have Crohn's disease or other inflammatory bowel conditions.
• Exam under anesthesia. If other testing does not find a fistula, your surgeon may need to examine you in the operating room. This allows for a thorough look into the anus and rectum and can help locate the fistula and help plan surgery.

Treatment is often effective in repairing a rectovaginal fistula and relieving the symptoms. Treatment for the fistula depends on its cause, size, location and effect on surrounding tissues.

Your health care provider may have you wait 3 to 6 months after starting treatment before you have surgery. This helps make sure the surrounding tissue is healthy. It also gives time to see if the fistula closes on its own.

A surgeon may place a silk or latex string, called a draining seton, into the fistula to help drain any infection. This allows the tunnel to heal. This procedure may be combined with surgery.

Medicines

Your health care provider may suggest medicine to help treat the fistula or to get you ready for surgery:

• Antibiotics. If the area around your fistula is infected, you may be given a course of antibiotics before having surgery. You may take antibiotics if you have Crohn's disease and develop a fistula.
• Infliximab. Infliximab (Remicade) can help reduce inflammation and heal fistulas caused by Crohn's disease.

Surgery

In most cases, surgery is needed to close or repair a rectovaginal fistula. Before an operation can be done, the skin and other tissue around the fistula should be free of infection or inflammation.

Surgery to close a fistula may be done by a gynecological surgeon, a colorectal surgeon or both working as a team. The goal is to remove the fistula tunnel and close the opening by sewing together healthy tissue.

Surgical options include:

• Removing the fistula. The fistula tunnel is removed, and the anal and vaginal tissues are repaired.
• Using a tissue graft. The surgeon removes the fistula and creates a flap out of nearby healthy tissue. The flap is used to cover the repair. Several different procedures using tissue or muscle flaps from the vagina or the rectum are an option.
• Repairing the anal sphincter muscles. If these muscles have been damaged by the fistula, during vaginal delivery, or by scarring or tissue damage from radiation or Crohn's disease, they are repaired.

• Doing a colostomy before repairing a fistula in complex or recurrent cases. A procedure to divert stool through an opening in your belly instead of through your rectum is called a colostomy. A colostomy may be needed for a short time or, in very rare cases, it may be permanent. Most of the time, this surgery isn't needed.

  You may need a colostomy if you've had tissue damage or scarring from previous surgery or radiation treatment or from Crohn's disease. A colostomy may be needed if you have an ongoing infection or you have a large amount of stool passing through the fistula. A cancerous tumor, or an abscess also may require a colostomy.

  If a colostomy is needed, your surgeon may wait 3 to 6 months. Then if your provider is sure that your fistula has healed, the colostomy can be reversed so that stool again passes through the rectum.

Keeping the area around the rectovaginal fistula as clean as possible can help ease discomfort. It also can reduce the chance of vaginal or urinary tract infections while waiting for repair. These tips can help:

• Wash with water. Shower or gently wash your outer genital area with just warm water each time you have any vaginal discharge or pass stool.
• Don't use irritants. Soap can dry and irritate your skin, but you may sometimes need a gentle unscented soap. Don't use harsh or scented soap. Don't use scented tampons and pads. Vaginal douches can make an infection more likely, so they're not recommended.
• Dry thoroughly. Allow the area to air-dry after washing, or gently pat the area dry with a clean cloth or towel.
• Don't rub the area with dry toilet paper. Pre-moistened, alcohol-free, unscented towelettes or wipes or moistened cotton balls are a good option instead.
• Wear cotton underwear and loose clothing. Tight clothing can limit airflow and worsen skin problems. Change soiled underwear quickly. Products such as absorbent pads, disposable underwear or adult diapers can help if you're passing liquid or stool. Be sure they have an absorbent wicking layer on top to keep liquid away from your skin.
• Watch what you eat. Eat foods with fiber as part of your diet. Drink plenty of fluids to prevent constipation. Don't eat foods that give you diarrhea.

For best results, be sure to follow any other instructions from your health care team.

Your first appointment may be with your primary health care provider or gynecologist. After your initial evaluation, you may be referred to a surgeon to discuss treatment options. This may be a surgeon who specializes in procedures involving the female reproductive system, called a gynecological surgeon. Another option is a surgeon who specializes in treating conditions of the colon and rectum, called a colorectal surgeon.

What you can do

To prepare for your appointment:

• Ask about any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance to prepare for diagnostic tests.
• Make a list of symptoms you're experiencing. Include any that may seem unrelated to a rectovaginal fistula.
• Make a list of your key medical information. Include any other conditions you're treating, all past surgeries, and the names of any medicines, vitamins, herbs or other supplements you're taking, and the doses.
• Consider questions to ask your health care provider. Make a list, take it with you to your appointment, and make notes of answers to your questions.

Questions to ask your health care provider may include:

• What's causing these symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? What do I need to do to prepare for the tests?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you suggest?
• Are there any other options to your suggested treatment?
• Will I need surgery?
• Do you have any brochures or other printed material that I can have? What websites do you suggest?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or do they come and go?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, seems to worsen your symptoms?
• Are you able to have regular bowel movements?
• Do you have problems with stool leakage?
• Do you have difficulty with constipation that causes you to strain a lot during bowel movements?
• Have you given birth vaginally? Were there any complications?
• Have you ever had pelvic surgery?
• Have you had pelvic radiation therapy?
• Do you have any other medical conditions, such as Crohn's disease?