Download PDF
Clin Colon Rectal Surg 2021; 34(01): 028-039
DOI: 10.1055/s-0040-1714284
Review Article

Rectovaginal Fistulas Secondary to Obstetrical Injury

Aaron J. Dawes
1   Department of Surgery, University of Minnesota, Minneapolis, Minnesota
,
Christine C. Jensen
1   Department of Surgery, University of Minnesota, Minneapolis, Minnesota
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

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

rectovaginal fistula - obstetric trauma - obstetric anal sphincter injury - fistula repair


Publication History

Article published online:
22 September 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Pope R. Research in obstetric fistula: addressing gaps and unmet needs. Obstet Gynecol 2018; 131 (05) 863-870
    CrossrefPubMedSearch in Google Scholar
  • 2 Trovik J, Thornhill HF, Kiserud T. Incidence of obstetric fistula in Norway: a population-based prospective cohort study. Acta Obstet Gynecol Scand 2016; 95 (04) 405-410
    CrossrefPubMedSearch in Google Scholar
  • 3 Cowgill KD, Bishop J, Norgaard AK, Rubens CE, Gravett MG. Obstetric fistula in low-resource countries: an under-valued and under-studied problem--systematic review of its incidence, prevalence, and association with stillbirth. BMC Pregnancy Childbirth 2015; 15: 193
    CrossrefPubMedSearch in Google Scholar
  • 4 Adler AJ, Ronsmans C, Calvert C, Filippi V. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2013; 13: 246
    CrossrefPubMedSearch in Google Scholar
  • 5 Browning A, Whiteside S. Characteristics, management, and outcomes of repair of rectovaginal fistula among 1100 consecutive cases of female genital tract fistula in Ethiopia. Int J Gynaecol Obstet 2015; 131 (01) 70-73
    CrossrefPubMedSearch in Google Scholar
  • 6 Meister MR, Cahill AG, Conner SN, Woolfolk CL, Lowder JL. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol 2016; 215 (03) 310.e1-310.e7
    CrossrefPubMedSearch in Google Scholar
  • 7 Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E. Risk factors for obstetrical anal sphincter lacerations. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16 (04) 304-307
    CrossrefPubMedSearch in Google Scholar
  • 8 Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL. Risk factors for perineal injury during delivery. Am J Obstet Gynecol 2003; 189 (01) 255-260
    CrossrefPubMedSearch in Google Scholar
  • 9 Angioli R, Gómez-Marín O, Cantuaria G, O'sullivan MJ. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol 2000; 182 (05) 1083-1085
    CrossrefPubMedSearch in Google Scholar
  • 10 Venkatesh KS, Ramanujam PS, Larson DM, Haywood MA. Anorectal complications of vaginal delivery. Dis Colon Rectum 1989; 32 (12) 1039-1041
    CrossrefPubMedSearch in Google Scholar
  • 11 Meister MR, Rosenbloom JI, Lowder JL, Cahill AG. Techniques for repair of obstetric anal sphincter injuries. Obstet Gynecol Surv 2018; 73 (01) 33-39
    CrossrefPubMedSearch in Google Scholar
  • 12 Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2013; 12 (12) CD002866
    PubMedSearch in Google Scholar
  • 13 Tebeu PM, Fomulu JN, Khaddaj S, de Bernis L, Delvaux T, Rochat CH. Risk factors for obstetric fistula: a clinical review. Int Urogynecol J Pelvic Floor Dysfunct 2012; 23 (04) 387-394
    CrossrefPubMedSearch in Google Scholar
  • 14 McFadden E, Taleski SJ, Bocking A, Spitzer RF, Mabeya H. Retrospective review of predisposing factors and surgical outcomes in obstetric fistula patients at a single teaching hospital in Western Kenya. J Obstet Gynaecol Can 2011; 33 (01) 30-35
    CrossrefPubMedSearch in Google Scholar
  • 15 Muleta M, Rasmussen S, Kiserud T. Obstetric fistula in 14,928 Ethiopian women. Acta Obstet Gynecol Scand 2010; 89 (07) 945-951
    CrossrefPubMedSearch in Google Scholar
  • 16 Genadry RR, Creanga AA, Roenneburg ML, Wheeless CR. Complex obstetric fistulas. Int J Gynaecol Obstet 2007; 99 (Suppl. 01) S51-S56
    CrossrefPubMedSearch in Google Scholar
  • 17 Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308 (6933): 887-891
    CrossrefPubMedSearch in Google Scholar
  • 18 Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993; 329 (26) 1905-1911
    CrossrefPubMedSearch in Google Scholar
  • 19 Mazier WP, Senagore AJ, Schiesel EC. Operative repair of anovaginal and rectovaginal fistulas. Dis Colon Rectum 1995; 38 (01) 4-6
    CrossrefPubMedSearch in Google Scholar
  • 20 Lowry AC. Management of rectovaginal fistula. Semin Colon Rectal Surg 2016; 27: 64-68
    CrossrefPubMedSearch in Google Scholar
  • 21 Karp NE, Kobernik EK, Berger MB, Low CM, Fenner DE. Do the surgical outcomes of rectovaginal fistula repairs differ for obstetric and nonobstetric fistulas? a retrospective cohort study. Female Pelvic Med Reconstr Surg 2019; 25 (01) 36-40
    CrossrefPubMedSearch in Google Scholar
  • 22 Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD. Are there predictors of outcome following rectovaginal fistula repair?. Dis Colon Rectum 2010; 53 (09) 1240-1247
    CrossrefPubMedSearch in Google Scholar
  • 23 El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M. Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function. J Gastrointest Surg 2010; 14 (11) 1758-1763
    CrossrefPubMedSearch in Google Scholar
  • 24 Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol 2002; 178 (03) 737-741
    CrossrefPubMedSearch in Google Scholar
  • 25 VanBuren WM, Lightner AL, Kim ST. et al. Imaging and surgical management of anorectal vaginal fistulas. Radiographics 2018; 38 (05) 1385-1401
    CrossrefPubMedSearch in Google Scholar
  • 26 Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO. The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study. Dis Colon Rectum 2014; 57 (07) 888-898
    CrossrefPubMedSearch in Google Scholar
  • 27 Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y. Rectovaginal Fistula. Ann Surg 2015; 262 (05) 855-860 , discussion 860–861
    CrossrefPubMedSearch in Google Scholar
  • 28 Khanduja KS, Yamashita HJ, Wise Jr WE, Aguilar PS, Hartmann RF. Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach. Dis Colon Rectum 1994; 37 (04) 344-349
    CrossrefPubMedSearch in Google Scholar
  • 29 Ryoo S-B, Oh H-K, Ha H-K. et al. Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences. Ann Surg Treat Res 2019; 97 (03) 149-156
    CrossrefPubMedSearch in Google Scholar
  • 30 Oakley SH, Brown HW, Yurteri-Kaplan L. et al. Practice patterns regarding management of rectovaginal fistulae: a multicenter review from the Fellows' Pelvic Research Network. Female Pelvic Med Reconstr Surg 2015; 21 (03) 123-128
    CrossrefPubMedSearch in Google Scholar
  • 31 Lo TS, Huang YH, Dass AK, Karim N, Uy-Patrimonio MC. Rectovaginal fistula: Twenty years of rectovaginal repair. J Obstet Gynaecol Res 2016; 42 (10) 1361-1368
    CrossrefPubMedSearch in Google Scholar
  • 32 Norderval S, Lundby L, Hougaard H, Buntzen S, Weum S, de Weerd L. Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas. Tech Coloproctol 2018; 22 (01) 45-51
    CrossrefPubMedSearch in Google Scholar
  • 33 Gajsek U, McArthur DR, Sagar PM. Long-term efficacy of the button fistula plug in the treatment of Ileal pouch-vaginal and Crohn's-related rectovaginal fistulas. Dis Colon Rectum 2011; 54 (08) 999-1002
    CrossrefPubMedSearch in Google Scholar
  • 34 Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum 2008; 51 (07) 1084-1088
    CrossrefPubMedSearch in Google Scholar
  • 35 Ellis CN. Bioprosthetic plugs for complex anal fistulas: an early experience. J Surg Educ 2007; 64 (01) 36-40
    CrossrefPubMedSearch in Google Scholar
  • 36 Lightner AL, Dozois EJ, Dietz AB. et al. Matrix-delivered autologous mesenchymal stem cell therapy for refractory rectovaginal Crohn's fistulas. Inflamm Bowel Dis 2019; izz215
    PubMedSearch in Google Scholar
  • 37 Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas. Influence of previous repairs. Dis Colon Rectum 1988; 31 (09) 676-678
    CrossrefPubMedSearch in Google Scholar
  • 38 Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993; 114 (04) 682-689 , discussion 689–690
    PubMedSearch in Google Scholar
  • 39 Rothenberger DA, Christenson CE, Balcos EG. et al. Endorectal advancement flap for treatment of simple rectovaginal fistula. Dis Colon Rectum 1982; 25 (04) 297-300
    CrossrefPubMedSearch in Google Scholar
  • 40 Bhama AR, Schlussel AT. Evaluation and management of rectovaginal fistulas. Dis Colon Rectum 2018; 61 (01) 21-24
    CrossrefPubMedSearch in Google Scholar
  • 41 Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 2002; 45 (12) 1622-1628
    CrossrefPubMedSearch in Google Scholar
  • 42 Ozuner G, Hull TL, Cartmill J, Fazio VW. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 1996; 39 (01) 10-14
    CrossrefPubMedSearch in Google Scholar
  • 43 Kreis ME, Jehle EC, Ohlemann M, Becker HD, Starlinger MJ. Functional results after transanal rectal advancement flap repair of trans-sphincteric fistula. Br J Surg 1998; 85 (02) 240-242
    CrossrefPubMedSearch in Google Scholar
  • 44 Wise Jr WE, Aguilar PS, Padmanabhan A, Meesig DM, Arnold MW, Stewart WR. Surgical treatment of low rectovaginal fistulas. Dis Colon Rectum 1991; 34 (03) 271-274
    CrossrefPubMedSearch in Google Scholar
  • 45 Tsang CB, Madoff RD, Wong WD. et al. Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum 1998; 41 (09) 1141-1146
    CrossrefPubMedSearch in Google Scholar
  • 46 Nosti PA, Stahl TJ, Sokol AI. Surgical repair of rectovaginal fistulas in patients with Crohn's disease. Eur J Obstet Gynecol Reprod Biol 2013; 171 (01) 166-170
    CrossrefPubMedSearch in Google Scholar
  • 47 Devesa JM, Devesa M, Velasco GR. et al. Benign rectovaginal fistulas: management and results of a personal series. Tech Coloproctol 2007; 11 (02) 128-134
    CrossrefPubMedSearch in Google Scholar
  • 48 Sher ME, Bauer JJ, Gelernt I. Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach. Dis Colon Rectum 1991; 34 (08) 641-648
    CrossrefPubMedSearch in Google Scholar
  • 49 Bauer JJ, Sher ME, Jaffin H, Present D, Gelerent I. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease. Ann Surg 1991; 213 (02) 151-158
    CrossrefPubMedSearch in Google Scholar
  • 50 Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009; 13 (03) 237-240
    CrossrefPubMedSearch in Google Scholar
  • 51 Rahman MS, Al-Suleiman SA, El-Yahia AR, Rahman J. Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital. J Obstet Gynaecol 2003; 23 (06) 607-610
    CrossrefPubMedSearch in Google Scholar
  • 52 Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75 (04) 727-733
    PubMedSearch in Google Scholar
  • 53 Songne K, Scotté M, Lubrano J. et al. Treatment of anovaginal or rectovaginal fistulas with modified Martius graft. Colorectal Dis 2007; 9 (07) 653-656
    CrossrefPubMedSearch in Google Scholar
  • 54 Pitel S, Lefevre JH, Parc Y, Chafai N, Shields C, Tiret E. Martius advancement flap for low rectovaginal fistula: short- and long-term results. Colorectal Dis 2011; 13 (06) e112-e115
    CrossrefPubMedSearch in Google Scholar
  • 55 Zimmerman DD, Gosselink MP, Briel JW, Schouten WR. The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition. Tech Coloproctol 2002; 6 (01) 37-42
    CrossrefPubMedSearch in Google Scholar
  • 56 McNevin MS, Lee PY, Bax TW. Martius flap: an adjunct for repair of complex, low rectovaginal fistula. Am J Surg 2007; 193 (05) 597-599 , discussion 599
    CrossrefPubMedSearch in Google Scholar
  • 57 Hotouras A, Ribas Y, Zakeri S, Murphy J, Bhan C, Chan CL. Gracilis muscle interposition for rectovaginal and anovaginal fistula repair: a systematic literature review. Colorectal Dis 2015; 17 (02) 104-110
    CrossrefPubMedSearch in Google Scholar
  • 58 Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss EG, Zmora O. Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 2008; 248 (01) 39-43
    CrossrefPubMedSearch in Google Scholar
  • 59 Lefèvre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y. Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum 2009; 52 (07) 1290-1295
    CrossrefPubMedSearch in Google Scholar
  • 60 Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY. Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis 2017; 32 (07) 1029-1032
    CrossrefPubMedSearch in Google Scholar
  • 61 Schwandner O, Fuerst A, Kunstreich K, Scherer R. Innovative technique for the closure of rectovaginal fistula using Surgisis mesh. Tech Coloproctol 2009; 13 (02) 135-140
    CrossrefPubMedSearch in Google Scholar
  • 62 Göttgens KW, Heemskerk J, van Gemert W. et al. Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh. Tech Coloproctol 2014; 18 (09) 817-823
    PubMedSearch in Google Scholar
  • 63 Mege D, Frasson M, Maggiori L, Panis Y. Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula?. Colorectal Dis 2016; 18 (02) O61-O65
    CrossrefPubMedSearch in Google Scholar
  • 64 Khanduja KS, Padmanabhan A, Kerner BA, Wise WE, Aguilar PS. Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty. Dis Colon Rectum 1999; 42 (11) 1432-1437
    CrossrefPubMedSearch in Google Scholar
  • 65 Hull TL, Bartus C, Bast J, Floruta C, Lopez R. Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula. Dis Colon Rectum 2007; 50 (01) 97-101
    CrossrefPubMedSearch in Google Scholar
  • 66 Hull TL, El-Gazzaz G, Gurland B, Church J, Zutshi M. Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum 2011; 54 (01) 54-59
    CrossrefPubMedSearch in Google Scholar
  • 67 MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R. Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum 1995; 38 (09) 921-925
    CrossrefPubMedSearch in Google Scholar
  • 68 Halverson AL, Hull TL, Fazio VW, Church J, Hammel J, Floruta C. Repair of recurrent rectovaginal fistulas. Surgery 2001; 130 (04) 753-757 , discussion 757–758
    CrossrefPubMedSearch in Google Scholar
  • 69 Rodrigues FG, Chadi SA, Cracco AJ. et al. Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation. Colorectal Dis 2017; 19 (05) 456-461
    Search in Google Scholar
  • 70 Hasegawa H, Yoshioka K, Keighley MR. Randomized trial of fecal diversion for sphincter repair. Dis Colon Rectum 2000; 43 (07) 961-964 , discussion 964–965
    CrossrefPubMedSearch in Google Scholar
  • 71 Jones IT, Fazio UW, Jagelman DG. The use of transvaginal rectal aduancement flaps in the management of fistulas involving the Qnorectum. Dis Colon Rectum 1987; 30: 919-923
    CrossrefPubMedSearch in Google Scholar
  • 72 Hyman N. Endorectal advancemengt flap repair for complex anorectal fistulas. Am J Surg 1999; 178: 337-340
    CrossrefPubMedSearch in Google Scholar