Rec To Vaginal Fistula

Surg Clin N Am 82 (2002) 1261–1272

Rectovaginal fistula Theodore J. Saclarides, MDa,b,* a

Rush Medical College, Rush University, 600 South Paulina Street, Chicago, IL 60612, USA b Rush-Presbyterian-Saint Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA

Diseases of the anorectal region and genitalia may be accompanied by significant psychosocial and sexual dysfunction. This is especially so for women who suffer from rectovaginal fistulas whereby the vaginal passage of gas and stool can not only cause physical symptoms of inflammation and irritation but also impact adversely on self esteem, intimacy, and long-term relationships. The focus of this article is on fistulas between the rectum and the vagina; it does not deal with enterovaginal or colovaginal fistulas. For those, laparotomy is frequently required and there is little opportunity for local attempts at fistula repair. This concern, however, is offset by the relative surplus of healthy tissue available to work with produced by mobilization of proximal colon. Thus, generally good results and low recurrence rates can be anticipated. This is certainly not the case with rectovaginal fistulas, where conservative, local attempts at repair must frequently take into consideration the fact that the tissue used for repair may not be completely normal or in its maximum state of health. The success of repair of rectovaginal fistulas depends upon the underlying etiology. For example, in inflammatory bowel disease, specifically Crohn’s disease, the health of the rectum and its ability to serve as a compliant reservoir for the storage of feces and gas must be taken into consideration, as well as the ability of the patient to withstand a potentially radical operation. These same concerns are echoed when dealing with radiation-induced rectovaginal fistulas. Classification Several classification schemes have been proposed for rectovaginal fistulas, although a scheme based on the underlying cause of the fistula is the * Rush-Presbyterian-Saint Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612. E-mail address: [email protected] 0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 5 5 - 5

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most useful for the treating physician. One other scheme is based on location, classifying fistulas as being in the low, mid, or high region of the rectum. This scheme pays special attention to the location of the fistula in relation to the underlying sphincter muscle. It is generally felt that fistulas originating from the upper rectum require a laparotomy. Such fistulas may not be readily apparent on physical examination or vaginal inspection and they may even be missed by endoscopy. They frequently require either rectal or vaginal contrast studies in order to delineate the anatomy. As stated above, however, a classification system based on the underlying cause of the fistula provides the best tool for the treating physician, as it takes into consideration integrity of the local tissue and the health of the patient. Obstetrical injuries Obstetrical injuries are the most common cause of rectovaginal fistulas, occurring in up to 88% of published series [1–4]. Such fistulas present either immediately postpartum from failed recognition of a fourth-degree injury or in 7 to 10 days following an apparently normal repair. In such instances, the fistulas occur either from infection of the wound or from breakdown of the repair. Approximately 5% of vaginal deliveries result in a third- or fourthdegree tear, which, when repaired promptly at the time of labor, heals satisfactorily in 90% to 95% of instances [5]. Some fistulas that occur following unsuccessful repair may heal spontaneously, lending support to the notion that a period of observation before attempting reoperation is worthwhile. Ultimately, approximately 1% to 2% of third- to fourth-degree perineal lacerations following labor will lead to a persistent rectovaginal fistula. Of paramount importance in these patients is an assessment of their degree of incontinence. If one takes into consideration the mechanism of injury, it should come as no surprise that the incidence of incontinence may be as high as 27% [6]. Before embarking on a repair of the fistula, therefore, a careful continence evaluation must be performed. Inflammatory bowel disease Inflammatory bowel disease, specifically Crohn’s disease, is the second most common cause of rectovaginal fistulas and should be suspected in any instance where a repair has failed. Because ulcerative colitis is not a transmural disease, it usually does not cause such problems. Prior anorectal surgery Prior anorectal surgery is also a frequent cause of rectovaginal fistula, which can occur especially after vaginal hysterectomy. Other types of procedures that predispose to rectovaginal fistulas include rectocele repair, hemorrhoidectomy, local excision of rectal tumors, low anterior resection, and restorative proctocolectomy with construction of an ileal J-pouch.

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Infections Infections of the anorectal region may also cause rectovaginal fistulas, the majority of which are cryptoglandular in origin; however, other causes must be considered, including tuberculosis, lymphogranuloma venereum, schistosomiasis, and diverticulitis. In the last, the fistula is usually located in the upper rectum. It may follow perforation of a complicated case, and it is usually found in women who have previously undergone a total abdominal hysterectomy. Cancers Cancers of the anorectal region may also cause fistulas, including tumors of the anal canal, rectum, and gynecologic organs. The neoadjuvant therapy used to treat some of these malignancies may also predispose toward fistula formation; in fact, radiation therapy can produce some of the more complex fistulas. Such fistulas usually occur within two years of completion of radiation, and warning signs include the passage of bright red blood per rectum, nonhealing rectal ulcerations, and anorectal pain. First and foremost in these situations, the physician must rule out recurrent cancer as the cause of the patients symptoms.

Evaluation The extent of patient assessment is disease specific. During the history taking process, it is important to determine if there is a prior history of anorectal surgery, complicated vaginal deliveries, radiation therapy, or inflammatory bowel disease. It is also important to determine the patient’s degree of continence. During the physical examination, the perineum should be inspected to determine the thickness of the perineal body and whether or not any postsurgical scarring is present in the posterior forchette or the perineal body. The anus should be inspected to determine whether or not it is patulous and able to close with squeezing. A bidigital examination should be performed to palpate the thickness of the perineal body, and during this maneuver, a rectovaginal fistula may frequently be appreciated. If the location of the fistula is not obvious with the above maneuvers, a vaginal speculum examination should be performed. Rigid proctoscopy may give helpful information regarding the compliance of the rectum, and the health of the mucosa; and when the vagina is filled with water, the site of the fistula can be identified by the escape of air bubbles. If a fistula still cannot be demonstrated, a vaginal tampon can be placed while methylene blue is instilled into the rectum. After 10 to 15 minutes, the tampon should be withdrawn and inspected for any blue staining. If the above maneuvers still do not demonstrate a fistula, the fistula may be located in the upper rectum and contrast studies are needed to establish

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the diagnosis. These include vaginography with a water soluble contrast medium; this has a sensitivity of 79% to 100% [7–9]. Alternatively, a barium enema can be performed and, although the fistula may not be identified in every patient, general information as to the health of the colon and rectum can be obtained. A computed tomography (CT) scan of the abdomen and pelvis using gastrointestinal contrast material is frequently helpful, especially when contrast is seen vaginally after the instillation of intestinal contrast. The presence of a phlegmon seen during CT may give insight into the underlying cause of the fistula and which portion of the gastrointestinal tract is responsible. Further testing may be performed with endoanal ultrasonography, anal manometry, and neurophysiologic testing, including pudendal nerve terminal motor latency testing. Ultrasound is especially important if the patient complains of incontinence or if the underlying cause of the fistula is obstetric trauma. Using ultrasound, the internal anal sphincter is seen as a uniform hypoechoic circle immediately underneath the submucosa of the anal canal. Defects in the internal anal sphincter are easy to identify sonographically and may herald the presence of an associated defect in the external anal sphincter. Defects in the external anal sphincter are more difficult to identify sonographically, as the fibers are hyperechoic, striated, and more loosely arranged in a circular pattern. Obstetrical injuries to the external sphincter include complete disruption of the sphincter muscle, attenuation or thinning out of the muscle within the perineal body, or shortened height of the high pressure zone of the anus. The normal thickness of the perineal body as measured from the anal mucosa to the posterior vaginal wall is 12 mm. Anorectal manometry has a selected role in the management of patients with rectovaginal fistulas and can provide useful information when the fistula is due to inflammatory bowel disease or radiation. Not only can the resting and squeeze pressures of the sphincter muscle be measured, but also the compliance of the rectum and its ability to function as a reservoir. If one finds that the rectum is highly noncompliant (ie, significant increases in intraluminal pressure are noted with small increases in rectal volume), then perhaps the rectum cannot function as a healthy and normal reservoir. Neurophysiologic testing with pudendal nerve terminal motor latency can be performed in selected instances; however, it probably does not have the prognostic value that it was once credited with. Certainly restorative surgery would not be withheld even if pudendal neuropathy was present.

Surgery for obstetrical rectovaginal fistulas Before undertaking repair, it is critical that an assessment be made regarding a patient’s degree of fecal incontinence. In a study from the University of Minnesota, the incidence of coexistent fecal incontinence was 48% [10]. Many, if not all, women with rectovaginal fistulas secondary to

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obstetrical trauma demonstrate sphincter injuries with endoanal ultrasound [11]. Ultrasound may not be necessary if the fistula and the onset of incontinence are directly temporally related to a complicated delivery and the physical examination and assessment of the perineum are consistent with sphincter disruption. Surgical options are categorized by approach: transanal, transperineal, or transvagjnal. The route chosen depends upon surgeon’s expertise, the presence of a sphincter defect, and whether or not prior attempts at surgical correction have failed. Whichever route is chosen, it is important to ensure that the health of the local tissues has been optimized and that inflammation and infection have resolved. A waiting period is justified, therefore, especially because some fistulas may heal spontaneously during this period. It is not necessary to subject a severely symptomatic patient to an unreasonably long waiting period, however. Before surgery, the patient should receive a full mechanical and antibiotic bowel preparation. The procedures may be carried out under local, regional or general anesthesia. Transanal approaches Transanal approaches are preferred by most colorectal surgeons, whereas gynecologists generally prefer the transvaginal approach. Choice is largely based on the surgeon’s familiarity with the approach; success has been noted with both types of operations. The transanal approach has the advantage of direct access to and repair of the rectal opening of the fistula, which most consider to be the high-pressure side of the rectovaginal fistula. Exposure, however, is limited compared with the transvaginal approach. The most common transanal procedure is the advancement flap. For this, the patient is placed in the prone jackknife position. Proctoscopy is recommended to irrigate the lower rectum and remove any residual from the preoperative bowel preparation. The perineum and vagina are cleansed with an antiseptic solution, after which retractors are placed within the rectum to visualize the rectal side of the fistula. Exposure may be improved by the placement of four effacement sutures at the anal verge, which are then tied to the perianal skin. A curvilinear incision is made commencing at the dentate line and comprising one third to one half of the circumference of the anal canal. The mucosa of this area may be infiltrated with a dilute epinephrine solution to aid in hemostasis and definition of the dissection planes. Most of the dissection can be carried out with the electrocautery. The flap should consist of mucosa, submucosa, and circular muscle. The flap is raised for a distance of 4 cm to 5 cm and the base of the flap should measure at least twice its width at the apex. The dissection is carried out in a cephalad direction until the entire flap can be easily advanced to cover the fistula tract without tension. Once this has been accomplished, the distal portion of the flap, which includes the fistula site itself, is excised. Dissection of the fistula tract is carried down deep into the rectovaginal septum; grasping the tissue with Allis

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clamps along the way helps to elevate the plane of dissection up into the wound. Once the dissection has been carried down into the vagina, the internal sphincter is mobilized from its lateral position and approximated over the vaginal closure. The flap is then advanced caudally and sutured over this muscle closure. The vaginal side is left open for drainage. If any tension is noted as the flap is being advanced, one can elevate the flap more cephalad. The flap is sutured in placed with interrupted sutures of a 3-0 long-lasting monofilament absorbable suture. Transanal advancement flaps are best suited for patients with low fistulas who do not have fecal incontinence or disruption of the sphincter muscle. The reported success rates vary in the literature, because a concomitant sphincter repair is frequently performed by many surgeons. Furthermore, some patients have failed previous attempts at repair, which impacts upon the likelihood of future success. Other patients may have undergone fecal diversion at the time of their advancement flaps, because of the complexity of the repair and the concern about the adequacy of local tissue integrity. When transanal advancement flaps are performed simultaneously with sphincteroplasty, success rates of up to 95% have been noted [3,12]. When advancement flaps have been performed for obstetrical injuries alone, success rates vary considerably in the literature, ranging from 41% to 100% [10,13]. An alternative to the advancement flap is the advancement rectal sleeve procedure. This involves a circumferential mobilization of the distal rectum and removal of the distal rectal mucosa. This is a more complex procedure and should be attempted only by those who are familiar with the technique. The patient is prepared in a manner similar to that for the advancement flap. A circumferential incision is made with the cutting current of the electrocautery beginning at the dentate line. This is carried down into the submucosal plane, which is then developed in a cephalad direction circumferentially. The internal sphincter is visible beneath the plane of dissection as the mucosectomy is performed. This dissection is continued until the anorectal ring has been passed and the dissection is above the level of the levator ani muscle. At the supralevator space, the rectum is mobilized until healthy tissue can be grasped and pulled downward to reach the dentate line without tension. This may require additional mobilization to the level of the anterior peritoneal reflection. The rectum is delivered to the anal canal, the diseased mucosa is amputated, and the rectum is then sutured to the dentate line where the mucosectomy began. This is done using interrupted sutures of long-lasting monofilament absorbable suture. A diverting stoma may be required, especially if one is dealing with Crohn’s disease. Transperineal approaches Transperineal approaches carry a higher risk of disability and functional impairment than do the transanal approaches; however, they have a definite role in selected instances.

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Fistulotomy alone, which consists of conversion of the fistula to a fourth degree perineal laceration, should not be performed as the primary operation. This approach would unnecessarily divide any remaining portions of the perineal body and sphincter complex and one should expect fecal incontinence to be the rule rather than the exception. Fistulotomy combined with perineoproctotomy, followed by a layered closure, is an approach that is ideally suited for women who have a coexisting sphincter defect and in those situations where previous transanal or transvaginal approaches have failed. This approach provides excellent exposure and permits complete identification of the fistula and all of its extensions, as well as a precise layer-by-layer closure of the perineal body. It is performed in a manner analogous to the primary closure commonly performed by gynecologists in the immediate postpartum period. After undergoing a mechanical and antibiotic bowel preparation, the patient is placed in the lithotomy position, the fistula tract is identified and the perineal bridge of skin, fat, sphincter muscle (if present), and rectal and vaginal walls is divided, thereby converting the fistula into a perineal cloaca. The fistula tract is then excised. The rectal and vaginal mucosal layers are then dissected away from the sphincter muscle and septum and repaired as separate layers, using a long-lasting absorbable monofilament suture. The rectal wall may then be imbricated even further by a second running suture, which helps to create a long length of the high pressure zone within the anal canal, thereby potentially improving continence. The external sphincter muscle is repaired in an overlapping fashion analogous to sphincteroplasty performed without the presence of a rectovaginal fistula. In doing the repair, it is important to mobilize the muscle from its lateral position within each ischiorectal fossa. This helps avoid tension on the repair, thereby improving the chance for success. Postoperatively, patients are hospitalized for two or three days, during which time analgesics are administered and wound care is provided. Reported success rates are excellent, ranging from 85% to 100% [14–17]. Exposure is generally excellent with this approach; however, it should be reserved for those women who have associated sphincter defects or who have undergone previous failed attempts that may limit exposure for repeat transanal approach. Transvaginal repairs For transvaginal repairs, patient preparation is similar to that for transanal repairs; however, the patient is positioned in the lithotomy position. The fistula tract is identified. The submucosal plane of the posterior vaginal wall is again infiltrated with a dilute epinephrine solution to aid in hemostasis and identification of the proper tissue planes. An incision is made in a circular fashion surrounding the site of the fistula on the posterior vaginal wall. The fistula tract is then excised down into the rectal vault, after which the vaginal mucosa is elevated off of the underlying rectovaginal septum. A

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series of concentric purse-string sutures are then placed transvaginally into the rectovaginal septum to imbricate the fistula opening into the rectal vault. Following this, the vaginal mucosa is then closed. Levatorplasty may be performed simultaneously with this approach; however, this does require lateral dissection. Closure of the levator muscle allows tissue to be interposed between the rectal and vaginal repairs and may add some strength to this. Proponents of the transvaginal approach cite its improved exposure compared with transanal methods; however, a randomized, prospective study comparing the two techniques has not been performed.

Radiation-induced rectovaginal fistulas Although radiation has assumed an important role in the treatment of most pelvic malignancies, it can cause severe gastrointestinal complications, such as hemorrhagic radiation proctitis, rectal ulcerations, rectal stenosis, radiation enteritis, and rectovaginal fistula. The incidence of gastrointestinal injury increases when the radiation dose exceeds 5,000 cGy. Associated medical comorbidities such as diabetes, cardiovascular disease, hypertension, advanced age, cigarette smoking, and prior pelvic surgery are risk factors for gastrointestinal complications [18–20]. All of these complications are equally complex and challenging from a treatment standpoint; however, recurrent cancer can produce similar symptoms independently of the radiation-induced complications mentioned above. With respect to rectovaginal fistulae, these symptoms include pelvic pain, rectal bleeding, and the passage of vaginal air, purulent material, or stool. It is important for the treating physician to evaluate the site of the fistula for any signs of possible tumor recurrence. This may be accomplished with computed tomography, magnetic resonance imaging, or an examination under anesthesia with biopsies of the site. When treating a fistula in the presence of cancer, it is important to determine if the cancer is resectable and at what cost. Once the fistula has been diagnosed and localized and recurrent tumor excluded, the extent of radiation damage to the remainder of the rectum must be determined. Endoscopy may prove helpful in this regard, because insufflation of air under direct visualization may give some indication as to the elasticity and compliance of the rectal wall. This information can also be obtained using manometry, whereby rectal compliance is measured. If the rectum is noncompliant and not able to serve as a storage reservoir, then a good result following any sort of local repair of the fistula may not be possible. Local attempts at repair of radiation-induced rectovaginal fistulas must take into consideration the health of the tissue, keeping in mind that it has been exposed to previous radiation and may therefore not heal. Furthermore, local repairs should probably be performed in conjunction with diverting colostomy, either initially or at the time of definitive local repair, in order to reduce local contamination and inflammation.

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Transanal approaches Transanal approaches can be performed in a manner analogous to transanal approaches to an obstetrical rectovaginal fistula. Transanal operations should be avoided in stenotic and noncompliant rectums, however. Transvaginal approaches Transvaginal approaches are considered by some to be preferable to transanal approaches because the vaginal tissue may be less affected by the radiation. Following closure of the rectal site of the fistula, anterior plication of the levator ani muscle may help to separate the rectal and the vaginal suture lines. To improve healing and the success of the operation, transposition of healthy, well-vascularized and nonirradiated tissue may be performed in conjunction with local repairs. The Sartorius and the Gracilis muscles have been used in such repairs. The blood supply to the Gracilis muscle is based on the obturator artery and vein, which enter the muscle on its undersurface approximately 5 cm to 8 cm from the groin crease. The Gracilis muscle is especially attractive because harvesting this muscle for pelvic surgeries does not cause any disability with ambulation or any cosmetic problems. The muscle is flexible and its long length allows it to be used at sites remote from its origin. A transperineal incision is made and dissection is undertaken underneath the vaginal mucosa. A tunnel is created to accommodate the muscle as it is advanced toward the perineum. After the fistula is debrided and the rectum closed, the gracilis muscle is placed over the closure and is anchored to the contralateral ischial tuberosity [21]. The Martius technique incorporates subcutaneous tissue and the bulbocavernosus muscle from one of the labia majora. The bulbocavernosus muscle is vascularized by the perineal branches of the pudendal artery. After the vaginal mucosa is elevated, the rectal side of the fistula is debrided and, if possible, the rectum is closed. The bulbocavernosus muscle and its fat pad are then isolated, and a tunnel is created underneath the vaginal mucosa, after which the muscle is sutured to the rectal wall. The vaginal mucosa is then closed. Again, strong consideration should be given to performing fecal diversion, either as an initial operation or in conjunction with local repairs, with or without the tissue transposition techniques described above [22]. Transabdominal operations Transabdominal operations are best suited for those cases where the rectum is ulcerated or is stenotic over a long segment. These approaches are performed either after an initial transverse colostomy has been fashioned or simultaneously with fecal diversion, usually in the form of a loop ileostomy. At the time of laparotomy, the splenic flexure, left colon, and sigmoid colon are fully mobilized. A full rectal mobilization is then performed down to the levator hiatus, after which the diseased segment is resected. A colonic

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reservoir is then created, either in the form of a J-pouch or a coloplasty. The reservoirs thus created help to improve bowel function in the postoperative period. A hand-sewn anastomosis between the proximal colon and the dentate line is preferable to the stapled technique if one takes into consideration that the distal rectum may not heal well or accommodate surgical staplers. Following a period of satisfactory healing, as demonstrated using endoscopic or radiographic techniques, the stoma may then be closed at another surgical setting. Nonresectional on-lay techniques employ the use of proximal colon, which is mobilized, divided, and the distal end sutured to the exposed, debrided, rectal fistula opening. The proximal colon is sutured to the pelvic loop of bowel. This technique, known as the Bricker-Johnston colonic patch, does not mandate resection of the diseased rectum and helps to create an internal reservoir, which serves to increase the storage capability of the rectum and thereby improve function. It’s main disadvantage is that irradiated tissue is left in place, and from a technical standpoint, it may be just as demanding as a low anterior resection, especially for those fistulas located deep in the pelvis in the lower portion of the rectum. For this reason, it has been relegated to the arsenal of esoteric and rarely used operations. The surgeon should always keep in his armamentarium colostomy alone as a means of treating radiation-induced rectovaginal fistulas. This is especially suitable for the elderly patient or those with multiple comorbid conditions that render a radical operation hazardous. Although the patient will still experience mucoid discharge from the vagina, the absence of the passage of gas or stool vaginally will provide significant amelioration of her previous symptoms. Rectovaginal fistulas and Crohn’s disease The therapy for Crohn’s-related rectovaginal fistulas is based on disease activity, the extent of Crohn’s disease, and its impact on lifestyle. For example, a woman with pan-colonic Crohn’s disease who experiences only the passage of air through the vagina may not be ready either emotionally or physically for total proctocolectomy. This is certainly the case if the rectovaginal fistula is not affecting intimacy. These fistulas should be approached in a step-wise fashion. First, local sepsis should be treated with surgical drainage and placement of a noncutting Seton suture. This suture may be left in place indefinitely and may be all that is required to treat the patient’s symptoms. Fibrin glue has been considered and may be appropriate for those fistulas that have a long tract. Overall however, disappointing results have been noted for Crohn’s-related rectovaginal fistulas where the tract is typically short. Next, medical therapy should be maximized, and at some point, removal of the Seton should be considered to see if the fistula will close spontaneously. One should not be overly optimistic in this regard. For the persistent, symptomatic rectovaginal fistula, fecal diversion may be considered as a

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definitive procedure; however, again the results have been disappointing and one should not ever consider closure of the stoma until healing of the fistula has been verified either radiographically, endoscopically, or during an examination under anesthesia. Fecal diversion may also be considered as an initial operation, either before or simultaneous with local attempts at repair or proctocolectomy. The choice of the operation is dictated by the extent of rectal disease. For the woman who has severe involvement of the rectum, proctectomy is considered the operation of choice. Delayed perineal healing may be expected in at least one third of patients, however. If the rectum is minimally involved by Crohn’s disease, one may consider performing a curvilinear advancement flap, advancement sleeve flaps, or episioproctotomy. The curvilinear flap is performed in a manner analogous to that performed for obstetrical fistulas, and healing can be expected in almost 70% of patients [23,24]. Its chief advantage lies in its avoidance of traumatizing the sphincter muscle, and hence continence should not change from the patient’s preoperative status. Sleeve advancement flaps involve circumferential mobilization of the mucosa or the submucosa beginning at the dentate line and proceeding in a cephalad fashion until the rectal side of the fistula opening has been mobilized and sufficient tissue can be advanced to the dentate line. Following this, the fistula is cored out down to the vaginal opening, the rectovaginal septum and rectal wall is closed, and the sleeve of normal, healthy proximal mucosa is advanced and sutured to the dentate line. Episioproctotomy may be considered as well and is performed similar to fourth-degree perineal laceration repairs. This operation should not be considered unless there is a preexisting sphincter abnormality, however.

Summary Rectovaginal fistulas present a distressing problem for the patient and a challenge for the treating physician. Successful management must take into consideration the etiology of the fistula and the health of both the rectum and the patient. Obstetrical fistulas can be treated successfully by local approaches transanally or transvaginally. Episioproctotomy may be considered if there is an associated sphincter defect. Crohn’s related fistulas usually require proctectomy if the rectum is severely involved. Local repair can be considered in instances where the rectum is relatively healthy and local sepsis has been controlled. Radiation-induced fistulas may be secondary to cancer recurrence, which must be excluded. If the patient is not a candidate for a radical resectional approach, fecal diversion alone should be performed.

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[2] Hibbard LT. Surgical management of rectovaginal fistulas and complete perineal tears. Am J Obstet Gynecol 1978;130:139–41. [3] Lowry AC, Thorson AG, Rothenberger DA, et al. Repair of simple rectovaginal fistula. Influence of previous repairs. Dis Colon Rectum 1988;31:676–8. [4] Russell TR, Gallagher DM. Low rectovaginal fistulas: approach and treatment. M J Surg 1977;134:13–8. [5] Venkatesh KS, Ramanujum PS, Larson DM, et al. Anorectal complications of vaginal delivery. Dis Colon Rectum 1989;32:1039–41. [6] Wise WE, Aguilar PS, Padmanabtan A, et al. Surgical treatment of low rectal vaginal fistulas. Dis Colon Rectum 1991;34:271–4. [7] Arnold MW, Aguilar PS, Stewart WRC. Vaginography: an easy and safe technique for diagnosis of colovaginal fistulas. Dis Colon Rectum 1990;33:344–5. [8] Bird D, Taylor D, Lee P. Vaginography: the investigation of choice for vaginal fistulae? Aust N Z J Surg 1993;63:894–6. [9] Giordano P, Drew PJ, Taylor D, et al. Vaginography-investigation of choice for clinically suspected vaginal fistulas. Dis Colon Rectum 1996;39:568–72. [10] Tsang CBS, Madoff RD, Wong WD, et al. Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum 1998;41:1141–6. [11] Yee LF, Birnbaum EH, Read TE, et al. Use of endoanal ultrasound in patients with rectovaginal fistulas. Dis Colon Rectum 1999;42:1057–64. [12] Lowry AC, Goldberg SM. Simple rectovaginal fistulas. In: Cameron JL, editor. Current surgical therapy. 4th edition. Philadelphia: BC Decker; 1992. p. 244–9. [13] Khanduja KS, Yamashita HJ, Wise WE Jr, et al. Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach. Dis Colon Rectum 1994;37:344–9. [14] Mazier WP, Senagore AJ, Schiesel EC. Operative repair of anovaginal and rectovaginal fistulas. Dis Colon Rectum 1995;38:4–6. [15] Pepe F, Panella M, Arikan S, et al. Low rectovaginal fistulas. Aust NZJ Obstet Gynecol 1987;27:61–3. [16] Tancer ML, Lasser D, Rosenblum N. Rectovaginal fistula or perineal and anal sphincter disruption or both after vaginal delivery. Surg Gynecol Obstet 1990;171:43–6. [17] Watson SJ, Phillips RKS. Non-inflammatory rectovaginal fistula. Br J Surg 1995;82: 1641–3. [18] DeCosse JJ, Rhodes RS, Wentz W, et al. The natural history and management of radiation injury of the gastrointestinal tract. Ann Surg 1969;170:369–84. [19] Van Nagell. Parker JC, Maruyama Y, et al. Bladder or rectal injury following radiation therapy for cervical cancer. Am J Obstet Gynecol 1974;199:727–32. [20] Wall JA, Collins VP, Hudgins PT, et al. Carcinoma of the cervix. Review of clinical experience during a 20 year period (1946–1965). Am J Obstet Gynecol 1966;96:57–63. [21] Ward MW, Morgan BG, Clark CG. Treatment of persistent perineal sinus with vagina fistula following proctocolectomy in Crohn’s disease. Br J Surg 1982;6:228–9. [22] Martius J. Operations for urinary incontinence. In: McCall M, Bolten KA, editors. Operative gynecology. Boston: Little, Brown; 1956. p. 318–27. [23] Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn’s disease. A Am J Surg 1997;173:95–8. [24] Kodner IJ, Mazor A, Shemesh EI, et al. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993;114:682.