Description

A rectovaginal fistula is a connection that should exist between the lower part of the large intestine — your 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.
  • The radiation treatment or cancer in the pelvic area.
  • Complication after surgery in the pelvic area.
  • Complications of diverticulitis, an infection of the small, bulging pouches in the digestive tract.

The condition can cause gas and feces out of the vagina. This can lead to emotional distress and physical discomfort, which can affect their self-esteem and intimacy.

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

Symptoms

The most common symptom of a rectovaginal fistula is the passage of gas or feces from the vagina. Depending on the fistula of the size and the location, you may have only minor symptoms. Or you may have significant problems with the stool and the loss of gas, and keep the area clean.

When to see a doctor

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

Causes

A rectovaginal fistula may form as a result of:

  • Injuries during childbirth. The delivery-related injuries are the most common cause of rectovaginal fistulas. The injuries include tears in the perineum, the skin between the vagina and the anus — stretching up to the intestine, or an infection. Fistulas caused by injury during childbirth may involve the anal sphincter — the ring of muscle at the end of the rectum that helps to retain feces.
  • The inflammatory bowel disease. The second most common cause of rectovaginal fistulas is the 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 have Crohn's disease increases your risk of disease.
  • Cancer or radiation treatment in the pelvic area. A cancerous tumor in his rectum, cervix, vagina, uterus, or of the anal canal can result in a rectovaginal fistula. In addition, radiation therapy for cancer in these areas can put you at risk. A fistula caused by radiation can be formed at any time after the radiation treatment, but more commonly within the first two years.
  • Surgery of the vagina, the perineum, the rectum or the anus. In rare cases, previous surgery in the lower part of the area of the pelvis, such as the elimination of infected Bartholin's gland, can cause a fistula to develop. Bartholin's glands are located on each side of the opening of the vagina and helps to keep the vagina moist. A fistula can develop as a result of injury during surgery or a leak or infection that develops after you.
  • Complications of diverticulitis. The infection of the small, bulging pouches in your digestive tract, it is called diverticulitis, can cause the rectum or large intestine stick in the vagina and can lead to a fistula.
  • Other causes. Rarely, a rectovaginal fistula can develop after infections on the skin around the anus or the vagina.

Risk factors

A rectovaginal fistula is not clear on the risk factors.

Complications

The complications of a rectovaginal fistula may include:

  • Uncontrolled loss of stool, is called fecal incontinence.
  • Problems to keep the perineum clean.
  • Recurrent vaginal or urinary tract infections.
  • Irritation or inflammation of the vagina, the perineum, or the skin around the anus.
  • Recurrence of the fistula.
  • Problems with self-esteem and intimacy.

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

Prevention

There are steps you need to take to prevent a rectovaginal fistula.

Diagnosis

For the diagnosis of a rectovaginal fistula, your healthcare provider will probably talk to you about your symptoms and do a physical exam. Your healthcare provider may suggest certain tests depending on your needs.

Physical examination

The doctor performs a physical examination to try to locate the rectovaginal fistula and check for a possible tumor, an infection or an abscess. The examination usually includes looking at your vagina, the anus and the area between them, called the perineum, with a gloved hand. A tool especially designed to be inserted through a fistula can be used to find the fistula tunnel.

Unless the fistula is very low in the vagina, and easy to see, your doctor may use a speculum to hold the walls apart to see the inside of her vagina. A tool similar to the one of a speculum, called a proctoscope, can be inserted in the anus and rectum.

In the rare case that your health care provider believes that the fistula may be due to a cancer, the doctor may take a small sample of tissue for examination to the test. This is called a biopsy. The tissue sample is sent to a laboratory for analysis of the cells.

Tests for the identification of fistulas

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

  • CTscan. A ct scan of the abdomen and pelvis gives more details of what makes a standard X-ray. The ct scan can help localize the fistula and to determine its cause.
  • The magnetic resonance imaging. This test creates images of soft tissue in your body. Magnetic resonance imaging can show the location of the fistula, if other organs of the pelvis, or if you have a tumor.
  • Other tests. If your doctor thinks that you have an inflammatory disease of the intestine, you can get a colonoscopy to see the inside of your colon. During the procedure, small samples of tissue can be collected for laboratory analysis. The samples can help you to know if you have Crohn's disease or other inflammatory bowel conditions.
  • Examination under anesthesia. If other tests do not find a fistula, your surgeon may need to examine you in the operating room. This allows an in-depth look at the anus and rectum, and can help locate the fistula and help plan surgery.

Treatment

The treatment is often effective in the repair of a rectovaginal fistula and the relief of symptoms. Treatment for the fistula depends on its cause, size, location and effect on surrounding tissues.

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

A surgeon may place a silk or latex chain, called seton drainage, within the shunt to help drain the infection. This allows the tunnel to heal. This procedure may be combined with surgery.

Medications

Your doctor may suggest medicines to help treat the fistula, or to prepare for surgery:

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

Surgery

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

Surgery to close the fistula can be performed by a gynecologic surgeon, a colorectal surgeon or both working as a team. The goal is to eliminate the fistula tunnel and close the opening by sewing the healthy tissue.

Surgical options include:

  • The removal of the fistula. The fistula tunnel is removed, and the anal and vaginal tissues are repaired.
  • The use of a tissue graft. The surgeon removes the fistula, and creates a flap of healthy tissue nearby. The flap is used to cover the repair. Different procedures using tissue or muscle flaps, of the vagina or the rectum are an option.
  • The repair of 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.
  • Making a colostomy before the repair of a fistula in the complex or recurrent cases.A procedure to divert the stool through an opening in the abdomen instead of through your rectum is called a colostomy. A colostomy may be needed for a short period of time or, in very rare cases, can be permanent. Most of the time, this surgery is not necessary. You may need a colostomy if you've had tissue damage or scarring from previous surgery or radiation treatment or Crohn's disease. A colostomy may be needed if you have an ongoing infection or you have a large amount of stool that passes through the fistula. A cancerous tumor, or abscess may also require a colostomy. If a colostomy is necessary, the surgeon can expect 3 to 6 months. Then, if your provider is sure that the fistula has healed, the colostomy can be reversed so that the stool again passes through the rectum.

Making a colostomy before the repair of a fistula in the complex or recurrent cases. A procedure to divert the stool through an opening in the abdomen instead of through your rectum is called a colostomy. A colostomy may be needed for a short period of time or, in very rare cases, can be permanent. Most of the time, this surgery is not necessary.

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

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

Lifestyle and home remedies

Keep the area around the rectovaginal fistula as clean as possible can help to relieve the discomfort. You can also reduce the likelihood of vaginal or urinary tract infections while waiting for the repair. These tips may help:

  • Wash with water. Shower or gently wash the outside of the genital area with warm water only every time you have vaginal discharge or passage of stool.
  • Do not use irritating substances. The soap can dry and irritate the skin, but sometimes you may need a mild neutral soap. Do not use harsh or perfumed soaps. Do not use scented tampons and pads. Douches can make an infection more likely, so it is not recommended.
  • Dry well. Allow the area to air dry after washing, or gently pat the area dry with a clean cloth or towel.
  • Do not rub the area with dry toilet paper. Pre-moistened, alcohol-free, fragrance-free wipes or a cloth or moistened cotton balls are a good option.
  • Wear cotton underwear and loose clothing. Tight clothing can restrict the flow of air and worsen skin problems. Change of underwear dirty quickly. Products such as absorbent pads, disposable underwear or diapers for adults can help you if you are going on a liquid or in the stool. Make sure that you have an absorbent wicking layer on top to keep the liquid away from your skin.
  • Careful with what you eat. Eat fiber-rich foods as part of your diet. Drink plenty of fluids to avoid constipation. Do not eat foods that give you diarrhea.

For best results, be sure to follow the instructions of your health care team.

Preparing for your appointment

Your first appointment can be with your family doctor or gynecologist. After your initial evaluation, you may be referred to a surgeon to discuss treatment options. This can be a surgeon who specializes in procedures related to the female reproductive system, called a gynecologic surgeon. Another option is a surgeon who specializes in the treatment of diseases 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 of making the appointment, ask if there's something you need to do in advance to prepare for the diagnostic tests.
  • Make a list of the symptoms that you are experiencing. Include any that may seem unrelated to a rectovaginal fistula.
  • Make a list of your key medical information. Include any other condition that is being treated, all of their surgeries, and the names of the medicines, vitamins, herbs, or other supplements you are taking and the dose.
  • Consider the possibility of questions to ask your health care provider. Make a list, take it with you to your appointment, and take notes of the answers to your questions.

Questions to ask your health care provider may include:

  • What is the cause of these symptoms?
  • There are other possible causes of the 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-term?
  • What treatments are available, and which do you suggest?
  • There are other options for treatment that is recommended?
  • I'm going to need surgery?
  • Do you have any brochures or other printed material I can have? What websites do you suggest?

Do not hesitate to ask questions during your appointment.

What to expect from your doctor

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

  • When did your symptoms begin?
  • The symptoms been continuous or come and go?
  • How severe are the symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • They are able to have regular bowel movements?
  • Do you have problems with the escape of stool?
  • Do you have difficulty with constipation that makes you work hard during your bowel movements?
  • You have given birth vaginally? Were there any complications?
  • Have you ever had a pelvic surgery?
  • You have had pelvic radiotherapy?
  • Do you have other medical conditions, such as Crohn's disease?
Symptoms and treatment of Rectovaginal fistula