Rectovaginal Fistulas Secondary to Obstetrical Injury

Abstract

Rectovaginal fistula (RVF), defined as any abnormal connection between the rectum and the vagina, is a complex and debilitating condition. RVF can occur for a variety of reasons, but frequently develops following obstetric injury. Patients with suspected RVF require thorough evaluation, including history and physical examination, imaging, and objective evaluation of the anal sphincter complex. Prior to attempting repair, sepsis must be controlled and the tract allowed to mature over a period of 3 to 6 months. All repair techniques involve reestablishing a healthy, well-vascularized rectovaginal septum, either through reconstruction with local tissue or tissue transfer via a pedicled flap. The selection of a specific repair technique is determined by the level of the fistula tract and the status of the anal sphincter. Despite best efforts, recurrence is common and should be discussed with patients prior to repair. As the ultimate goal of RVF repair is to minimize symptoms and maximize quality of life, patients should help to direct their own care based on the risks and benefits of available treatment options.

Keywords: fistula repair; obstetric anal sphincter injury; obstetric trauma; rectovaginal fistula.

Fig. 1

Treatment algorithm for obstetric rectovaginal fistula. ERAF, endorectal advancement flap; EVAF, endovaginal advancement flap; LIFT, ligation of intersphincteric fistula tract; RVF, rectovaginal fistula.

Fig. 2

Endorectal advancement flap. ( A ) Fistula. ( B ) Flap raised, with fistula opening visible. ( C ) Fistula opening closed. ( D ) Flap advanced, and portion of flap with fistula opening excised. ( E ) Flap sutured in place, with fistula opening underneath flap. ( F ) Incorrect flap construction, with inadequate coverage of fistula opening. Reprinted with permission from Abcarian H, ed. Anal Fistula: Principles and Management. New York: Springer; 2014:98.

Fig. 3

Overlapping sphincteroplasty. ( A ) Incision over perineal body. ( B ) Division of scar. ( C ) Reapproximation of internal sphincter muscle, if separately identifiable. ( D ) Overlapping repair of external sphincter. ( E ) Partial closure of wound. Reprinted with permission from Abcarian H, ed. Anal Fistula: Principles and Management. New York, NY: Springer; 2014:153.