Rectovaginal Fistula: Symptoms, Causes, Treatment

What are the symptoms of a rectovaginal fistula?

A rectovaginal fistula is an abnormal connection between the rectum and the vagina. This condition can cause a variety of symptoms, which can vary depending on the size of the fistula and the underlying cause. Common symptoms of a rectovaginal fistula include:

Passage of Gas or Stool Through the Vagina: One of the most noticeable symptoms is the passage of gas, stool, or both from the rectum into the vagina. This can occur during bowel movements or even without any bowel movement.
Vaginal Discharge: Women with a rectovaginal fistula may experience a persistent foul-smelling discharge from the vagina. This discharge may contain stool or pus.
Recurrent Infections: Frequent urinary tract infections (UTIs) or vaginal infections can occur due to the contamination of the vaginal area with stool.
Irritation and Discomfort: The presence of stool or gas in the vagina can cause irritation, inflammation, and discomfort in the vaginal and perineal areas. Women may experience pain, itching, or burning sensations.
Foul Odor: Due to the passage of stool into the vagina, there may be a persistent unpleasant odor.
Pain During Intercourse: Women with a rectovaginal fistula may experience pain or discomfort during sexual intercourse (dyspareunia).
Bowel Movement Issues: There may be difficulties with bowel movements, including the sensation of incomplete evacuation or discomfort during defecation.
Leakage of Stool: Some women may experience fecal incontinence or the leakage of liquid stool, especially if the fistula is large.

These symptoms can significantly impact a woman’s quality of life and may lead to embarrassment or social isolation. If any of these symptoms are present, it is important to seek medical evaluation for proper diagnosis and treatment.

What are the causes of a rectovaginal fistula?

A rectovaginal fistula can develop due to various causes, most of which involve trauma, disease, or complications from medical procedures. The primary causes include:

Childbirth Trauma: One of the most common causes of rectovaginal fistula is trauma during childbirth. Prolonged labor, the use of forceps, episiotomy (a surgical cut made at the opening of the vagina during childbirth), or a tear that extends from the vagina to the rectum can result in the formation of a fistula. The risk is higher in women who have had multiple vaginal deliveries or large babies.
Surgical Complications: Rectovaginal fistulas can occur as a complication of pelvic surgeries, particularly surgeries involving the rectum, vagina, or uterus. Surgeries such as hysterectomy (removal of the uterus) or procedures to treat rectal prolapse or vaginal prolapse can sometimes lead to accidental damage to the tissue between the rectum and vagina, resulting in a fistula.
Radiation Therapy: Radiation treatment for pelvic cancers, such as cervical cancer, uterine cancer, or rectal cancer, can damage the tissues in the pelvic region, leading to the development of a fistula. The damage from radiation may not become apparent until months or years after treatment.
Inflammatory Bowel Disease (IBD): Conditions such as Crohn’s disease or ulcerative colitis, which cause chronic inflammation of the digestive tract, can lead to the formation of fistulas. Crohn’s disease, in particular, is a common cause of rectovaginal fistulas due to its tendency to cause deep ulcers and abscesses in the intestines and surrounding tissues.
Infections: Severe infections in the pelvic region, such as an abscess or a deep perineal infection, can erode the tissue between the rectum and vagina, creating a fistula.
Cancer: Tumors in the rectum, vagina, or surrounding tissues can erode through the tissue separating the rectum and vagina, leading to the formation of a fistula.
Traumatic Injury: Trauma to the pelvic region, such as that resulting from an accident, sexual assault, or penetrating injury, can cause a rectovaginal fistula.
Foreign Bodies or Medical Devices: In rare cases, the presence of foreign bodies or the improper use of medical devices in the rectal or vaginal areas can lead to the formation of a fistula.
Previous Radiation Therapy: Radiation therapy for pelvic cancers can weaken tissues and increase the risk of developing a rectovaginal fistula, either immediately or years after treatment.

The causes of rectovaginal fistula are diverse and often related to damage or weakening of the tissues between the rectum and vagina. Addressing the underlying cause is an important part of managing and treating the condition.

What is the treatment for a rectovaginal fistula?

Treatment for a rectovaginal fistula depends on the cause, severity, and symptoms of the condition. Options range from conservative management to surgical intervention. Here’s an overview of the treatment approaches:

Non-Surgical Treatments

Conservative Management: In some cases, small or asymptomatic fistulas may close on their own with conservative treatment. This may include avoiding activities that could exacerbate the condition and ensuring good hygiene to prevent infection.
Nutritional Support: Maintaining a healthy diet and managing bowel movements are crucial. For instance, a diet high in fiber can help prevent constipation and reduce the strain on the affected area.
Fecal Management: Using stool softeners or laxatives to manage bowel movements can help reduce irritation and the risk of further damage. Keeping the area clean and dry is important to prevent infection and irritation.
Antibiotics: If there is an associated infection, antibiotics may be prescribed to address it and reduce the risk of complications.

Surgical Treatments

Surgical intervention is often required to repair the fistula, especially if conservative measures are ineffective or the fistula is causing significant symptoms. The type of surgery depends on the location and complexity of the fistula:

Fistula Repair Surgery: The primary surgical treatment involves repairing the fistula by closing the abnormal connection between the rectum and vagina. The surgery typically involves removing any damaged or infected tissue and reconstructing the affected area. This procedure is usually done under general anesthesia.
Flap Repair: In cases where the fistula is complex or does not respond to simple closure techniques, a flap repair might be used. This involves using a piece of tissue from another part of the body (often from the vaginal wall) to cover and close the fistula.
Seton Placement: In some cases, especially with complex fistulas or when there is surrounding inflammation, a seton (a type of surgical stitch) may be placed to help drain the area and promote healing before definitive repair.
Vaginal Reconstruction: For large or complicated fistulas, additional procedures might be required to reconstruct the vaginal wall and ensure proper closure.

Post-Surgical Care

Recovery and Follow-Up: After surgery, patients typically need a period of recovery during which they should avoid activities that could stress the repair site. Follow-up appointments are crucial to monitor healing and ensure that the fistula has been properly closed.
Physical Therapy: Pelvic floor physical therapy may be recommended to strengthen the muscles and support structures in the pelvic area, which can aid in recovery and reduce the risk of recurrence.
Ongoing Management: Managing bowel movements and maintaining good hygiene continue to be important to prevent complications and support healing.

The choice of treatment should be tailored to the individual patient’s needs and circumstances. Consulting with a healthcare provider, such as a colorectal or gynecological surgeon, is essential for determining the most appropriate treatment plan based on the specifics of the rectovaginal fistula.