What is Rectovaginal Fistula?
A fistula is an unnatural connection that forms between two layers of skin. This definition holds true for most types of fistulas, but not all. In understanding what a fistula is, it’s essential to distinguish it from other medical issues like abscesses, sinuses, or other unusual collections inside or outside the body.
A fistula forms a passage between two skin surfaces or spaces and usually follows the shortest and easiest route. For instance, a rectovaginal fistula starts in the rectum and travels to the vagina. This is not natural or healthy, indicating that there’s often an underlying disease, injury or prior surgical process.
Characteristics of a rectovaginal fistula, such as its location, size, length, activity, and symptoms, can differ. These factors depend on the root cause of the fistula, the person’s health, and the treatments they have received. This type of fistula can cause difficulty for both the patient and medical team. The root cause of the fistula dictates how it’s assessed, managed, and how the patient’s outcome is projected. This article discusses the rectovaginal fistula as part of the broader category of fistulas.
What Causes Rectovaginal Fistula?
A rectovaginal fistula (RVF) is an abnormal tunnel-like opening that forms between the rectum and vagina. This usually happens because of an underlying disease, an injury or surgery. Some conditions can make this more likely — the chances of it forming increase if there are health issues with the vagina or organs in the pelvic area.
There are various reasons that an RVF can form:
– Childbirth injuries: This is the most common reason why RVFs occur following a traumatic event; particularly after severe cuts during vaginal delivery.
– Surgery: Certain surgical procedures that unintentionally harm the vagina or rectum, lead to tissue thinning between the organs, or lower blood flow, can result in an opening and an RVF forming through the damaged tissue.
– Diverticular disease: This condition, where small bulging pouches develop in the digestive tract, often leads to an RVF forming. If the wall of a pouch becomes inflamed or forms an abscess, it can expand into and erode nearby organ walls, creating an RVF. Constant pressure and continued inflammation can maintain the RVF.
– Crohn’s disease: This chronic disease, which causes inflammation in the digestive tract, is known for causing abnormal connections between organs. Since it affects all layers of the bowel wall, it often extends to and involves nearby tissues and organs.
– Cancer: Cancers involving the bowel, or nearby organs, can lead to an RVF. Most commonly, this happens when vaginal, cervical or rectal cancer involves the complete wall thickness and extends to the vagina next to it.
– Radiation: Prolonged tissue inflammation from radiation with poor healing and repair processes can lead to fistula formation. It typically presents a while after radiation exposure.
– Non-surgical injuries and foreign bodies: In some cases, trauma or the presence of a foreign object could cause RVF.
Lastly, the acronym “FRIEND” — Foreign body, Radiation, Inflammation, Epithelization (the process of wound healing), Neoplasm (a new and abnormal growth of tissue), Distal obstruction — represents some known causes of non-healing in RVF. However, these are separate from the primary or underlying conditions that can lead to an RVF.
Risk Factors and Frequency for Rectovaginal Fistula
Rectovaginal fistulas, openings between the rectum and vagina, can vary. They are categorized based on cause, location, and size, which can affect the strategy for treatment and the outlook.
- There are two main locations for rectovaginal fistulas:
- Low rectovaginal fistulas are found in the lower areas of both the rectum and vagina, near the anus. This location is usually treated with a surgical approach that involves the area between the genitals and the anus (the perineum).
- High rectovaginal fistulas are situated between the middle section of the rectum and the back part of the vagina. These often need to be treated with a surgical approach that involves going through the abdomen.
- Usually, rectovaginal fistulas are less than 2 cm across, and we categorize them by size as:
- Small: Less than 0.5 cm across
- Medium-sized: Between 0.5 cm to 2.5 cm across
- Large: Over 2.5 cm across
Signs and Symptoms of Rectovaginal Fistula
Rectovaginal fistula (RVF) is a condition that occurs when there’s a passageway between the rectum and vagina, often due to an underlying disease or injury. Signs and symptoms can include unpleasant-smelling vaginal discharge, discomfort during sex, passing gas or even stool from the vagina, especially during diarrhea. There may also be bleeding from the vagina. At times, you might experience symptoms of related issues like cystitis (bladder inflammation) or vaginitis (vaginal inflammation). It’s also possible to experience symptoms of the underlying disease that led to the fistula, such as rectal cancer or diverticulosis.
During a physical exam, the doctor may find signs of irritation, redness, swelling, or discharge within the vagina. They might even find stool or an opening to the fistula. A closer look using a colposcope could reveal more about the condition of the vaginal lining and the fistula site itself. If the doctor performs a rectovaginal examination, they may find signs of the underlying condition such as a low-lying rectal tumor, tissue inflammation, Crohn’s disease, or tissue damage due to radiation treatment.
Testing for Rectovaginal Fistula
If your doctor suspects that you may have a rectovaginal fistula (RVF) – a condition where an unnatural channel is formed between the vagina and rectum – they’ll start various tests and checks. The goal here is not only to confirm the presence of RVF, but also to understand how serious the condition is and what could be the underlying cause.
Your doctor might ask about your medical history and perform a physical check. In addition, you might also undergo imaging tests and endoscopic examinations (where a small tube with a camera is inserted into your body) if needed.
Usually, your doctor will first order various lab tests to assess your overall health. These tests could provide information about your oxygen-carrying red blood cells (hematocrit), biochemistry of your body (such as blood sugar levels, electrolytes, etc.) and any infections. Depending on these results, further tests may be required.
Endoscopy is often performed to locate the fistula and understand the underlying disease. Special endoscopies such as colposcopy (to examine your cervix and vagina) and proctosigmoidoscopy (to examine your rectum and lower colon) may be done. These exams also help your doctor see if there are signs of other diseases like Crohn’s disease, diverticular disease, or rectal cancer. In addition, colposcopy can help detect cancers of the cervix or vagina if they are present.
Imaging tests, like a CT scan, are also commonly used to obtain detailed and objective information about the fistula, including its location and the surrounding areas. A rectal and intravenous contrast, which is a special dye that helps make the images more detailed, can show the path of the fistula and its related structures. If dye is observed in the vagina, it confirms the diagnosis of RVF, even if the fistula itself cannot be seen.
Your doctor may require further lab work to understand your general health condition, check for complications like infection or electrolyte imbalance, and identify the underlying cause. In cases where a lump or mass is found, a biopsy, where a small piece of tissue is taken for further study, is done to confirm whether it’s cancerous and to identify where it came from.
Treatment Options for Rectovaginal Fistula
Treating RVF (Rectovaginal Fistula) involves three main steps: treating the disease causing the fistula, healing the fistula itself, and managing any related complications. Understanding the cause of the fistula is key to planning its treatment. Several factors play a significant role in deciding the treatment approach, including the severity of the condition, symptoms, patient’s overall health, cause of the fistula, and any resulting complications.
In cases where the RVF is caused by diseases like Crohn’s disease, diverticular disease, or colorectal or gynecological cancers, it’s crucial to follow the standard treatment principles for these diseases. Treating the RVF involves managing the primary disease causing it. There isn’t just one way to treat a fistula with the intention to cure it completely. The American Society of Colon and Rectal Surgeons put together guidelines in 2016 on how to manage RVF.
One approach to treatment is the conservative or non-surgical treatment that addresses the symptoms and possible complications like urinary tract infection, irritation at the site, and infection. This method could be used in patients who are at high risk or have severe underlying conditions. Conservative treatment involves managing the infection and accompanying symptoms, maximizing medical treatment for the underlying disease like Crohn’s or diverticulitis, and supporting the patient’s overall health and well-being. Other non-surgical treatments involve procedures designed to close the fistula like fibrin glue or other closure methods. Unfortunately, these measures do not have a high success rate, but they can still be considered an option for high-risk patients who aren’t suitable candidates for surgery or have had unsuccessful surgery attempts in the past.
Through the surgical approach, multiple methods are used to treat an RVF, depending on complexity, recurrence, and the underlying disease. Simple measures, such as draining seton, may be used in recurrent or active infection to optimize the health of the local tissue and treat the infection.
The close proximity of the rectal and vaginal walls can make repairing the fistula a challenge. The principles of a successful repair involve removing the unhealthy fistula tissue, replacing it with healthy tissue with a good blood supply to promote healing, and ensuring there is plenty of tissue between the rectal and vaginal walls. Although these principles may not always be feasible, adhering to them can increase the chances of successful treatment.
Common surgical techniques include fistula debridement and flaps. Local endo-rectal flaps are often used in simple RVF cases, while gracilis regional myocutaneous flaps are utilized in more complicated cases. Proximal or high RVFs may require surgical excision of the rectal wall, a more radical surgical approach.
What else can Rectovaginal Fistula be?
If you’re experiencing abdominal discomfort, a lot of different conditions could be the reason. Here are some possibilities:
- Aortitis (inflammation of the aorta)
- Appendicitis (inflammation of the appendix)
- Blunt abdominal trauma (injury to the stomach area)
- Colon cancer
- Diverticulitis (inflammation of small pouches in the colon)
- Enterovesical fistula (abnormal connection between the intestinal and bladder)
- Inflammatory bowel disease (chronic inflammation of the digestive tract)
- Large bowel disease
- Malabsorption (issues with absorbing nutrients from food)
- Urinary tract infection and cystitis in females
Remember, if you’re feeling unwell, you should reach out to a healthcare professional to figure out the exact cause.
What to expect with Rectovaginal Fistula
Patients typically can get back to their regular activities one to two weeks after surgery, however, it may take several months for them to heal completely. Factors such as the size of the fistula, which is an abnormal connection between two body parts, and how extensive the surgery was, can influence this timeline.
Possible Complications When Diagnosed with Rectovaginal Fistula
Problems connected with a rectovaginal fistula, or an abnormal connection between the rectum and the vagina, include difficulty controlling bowel movements, cleanliness challenges, irritation of the vagina, area around the anus, or the anus itself, potential extremely serious abscess, and recurrence of the fistula.
- Difficulty with bowel movement control
- Hygiene issues
- Vaginal, perineal, or anal irritation
- Possibility of life-threatening abscess
- Recurrence of the fistula
Preventing Rectovaginal Fistula
After surgery, it’s important for patients to know how to reduce irritation and discomfort and help the healing process. Here are a few tips:
– Only clean the surgical area with water. If soap is necessary, make sure to use a mild, fragrance-free type.
– Stay away from perfumed tampons and vagina-cleaning products.
– Make sure the area is completely dry before covering it.
– Wear underwear and clothing that’s loose-fitting, ideally made from cotton, as it lets your skin breathe.
– Use unscented baby powder or creams that protect against moisture to keep the area dry.
