World J Gastrointest Surg 2015 August 27; 7(8): 133-137

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DOI: 10.4240/wjgs.v7.i8.133

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MINIREVIEWS

Operative considerations for rectovaginal fistulas

Kevin R Kniery, Eric K Johnson, Scott R Steele
40% when considering all of the surgical options. At
present, surgical options range from collagen plugs and
endorectal advancement flaps to sphincter repairs or
resection with colo-anal reconstruction. There are general
principles that will allow the best chance for resolution of
the fistula with the least morbidity to the patient. These
principles include: resolving the sepsis, identifying the
anatomy, starting with least invasive surgical options,
and interposing healthy tissue for complex or recurrent
fistulas.

Kevin R Kniery, Eric K Johnson, Scott R Steele, Department

of Surgery, Division of Colorectal Surgery, Madigan Army
Medical Center, Tacoma, WA 98431, United States
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest statement: The authors do not have any
conflicts-of-interest to disclose.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/

Key words: Rectovaginal fistulas; Anovaginal fistulas

The Author(s) 2015. Published by Baishideng Publishing
Group Inc. All rights reserved.

Core tip: There are general principles that will allow

the best chance for resolution of a rectovaginal fistula
with the least morbidity to the patient. Identifying and
addressing the disease process that caused the fistula
is critical, including medical management for Crohns, and
resolving inflammation or sepsis with a seton. Then
the exact anatomy of the fistula should be defined
to determine operative approaches. The operative
algorithm should begin with fistula plugs and local
advancement flaps, if these fail more invasive options
such as diversion, and interposition of healthy tissue
should be pursued for complex and recurrent fistulas.

Correspondence to: Kevin R Kniery, MD, General Surgery

Resident, Department of Surgery, Division of Colorectal
Surgery, Madigan Army Medical Center, 9040 Jackson Ave,
Tacoma, WA 98431, United States. [email protected]
Telephone: +1-504-6554276
Received: April 29, 2015
Peer-review started: April 29, 2015
First decision: May 14, 2015
Revised: May 26, 2015
Accepted: June 30, 2015
Article in press: July 2, 2015
Published online: August 27, 2015

Kniery KR, Johnson EK, Steele SR. Operative considerations

for rectovaginal fistulas. World J Gastrointest Surg 2015;
7(8): 133-137 Available from: URL: http://www.wjgnet.
com/1948-9366/full/v7/i8/133.htm DOI: http://dx.doi.
org/10.4240/wjgs.v7.i8.133

Abstract
To describe the etiology, anatomy and pathophysiology of
rectovaginal fistulas (RVFs); and to describe a systematic
surgical approach to help achieve optimal outcomes.
A current review of the literature was performed to
identify the most up-to-date techniques and outcomes
for repair of RVFs. RVFs present a difficult problem that
is frustrating for patients and surgeons alike. Multiple
trips to the operating room are generally needed to
resolve the fistula, and the recurrence rate approaches

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INTRODUCTION
Rectovaginal fistula (RVF) is an epithelial lined tract
between the rectum and vagina, and generally presents
with passage of air, stool or even purulent discharge from

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Kniery KR et al . Rectovaginal fistula review

dystocia, operative vaginal delivery and prolonged and
obstructed labor still occur and remain the highest risk
[3]
for causing a RVF .
Outside of delivery complications, hysterectomy
and rectal surgery are the highest risk procedures for
causing RVFs. Use of stapling devices (specifically the
double-stapled technique) and placement of perineal or
vaginal mesh also have been shown to be associated
[3]
with an increase in the likelihood of RVF formation . The
incidence of RVF after a resection for low rectal cancer
is widely variable (0.9% to 10%), likely reflecting the
heterogeneity in both the individual tumor and operating
surgeon. Another possibility is that an anastomotic
leak and the resulting pelvic sepsis may lead to the
development of a RVF. To avoid the inciting event (i.e.,
leak), fecal diversion is commonly utilized following a
proctectomy and low-lying anastomosis to protect
it and minimize the clinical consequence of a leak.
Although proximal diversion may play a role in improving
outcomes (and is itself used in the management of
RVFs), fecal diversion does not completely eliminate
the risks of RVF, with up to 11% of patients after a
proctocolectomy developing RVFs despite complete
[2]
enteric diversion .
Another setting where RVFs can occur is in the
setting of malignancy. Anal cancer, rectal cancer and
pelvic cancer can all cause RVFs by various mechanisms.
First, the lesion itself can be locally destructive, resulting
in direct erosion between the two luminal surfaces.
Another potential source of the RVF is from the adjuvant
radiation therapy that is commonly used to help treat
these pelvic malignancies. In this situation, the radiation
is cytotoxic, leading to obliterative endarteritis, chronic
inflammation and ischemia, and eventually resulting
[2]
in a fistula between the two anatomical structures .
With regards to inflammatory bowel disease, RVFs are
most commonly seen in Crohns disease and rarely in
ulcerative colitis. While still relatively infrequent, women
with Crohns disease have a reported cumulative 10%
lifetime risk of developing a RVF. Of these, Crohns
patients who have a significant disease burden in their
[2]
colon are the most likely to be affected by RVFs .
While ulcerative colitis patients, especially following
total proctocolectomy and ileal-anal pouch procedures,
may still develop a RVF, this should be a red flag to
providers to re-evaluate the patient for the possibility of
a misdiagnosis of Crohns disease.

Figure 1 Clamp passing through the rectovaginal fistula. Note that the skin
bridge courses across the vaginal introitus.

the vagina (Figure 1). This can result in recurrent urinary

tract or vaginal infections, but also creates a serious
[1]
psychosocial burden for the patient . They are well
known to dramatically lower a females self-esteem and
prevent successful intimate relationships. Unfortunately,
they are also notoriously difficult to manage, despite
the numerous surgical options presently described, and
may even require fecal diversion to aid closure. When
choosing the optimal method to surgically manage
these fistulas, the available literature is limited and there
currently are no large prospective trials comparing the
numerous surgical options. While the paucity of data
is driven in part by the relatively low incidence of RVFs
and the complex anatomical differences between indivi
dual patients, it remains one of the more challenging
conditions that surgeons caring for colorectal disease
encounter. In this manuscript we will describe the scope
and pathophysiology of RVFs, as well as a systematic
approach to treating these patients and determining the
most suitable operative approach.

RVF ETIOLOGY
RVFs account for approximately 5% of all perirectal
fistulas, most commonly occurring as a result of obstetric
trauma (85%) and pelvic surgery (5%-7%); while
inflammatory bowel disease, malignancy, and radiation
therapy encompass the majority of the remaining
[1]
etiologies . Although obstetric trauma causes the vast
majority of RVFs, they are still relatively uncommon in
this population, occurring in only approximately 0.1%
[2]
of vaginal deliveries in Western countries . In contrast,
RVFs are considered almost endemic in sub-Saharan
Africa and South Asia secondary to obstetrical trauma,
with an estimated incidence of 50000 to 100000 new
[2]
cases annually . With a prevalence of two million, RVFs
in developing nations are related to prolonged labors that
cause necrosis of the rectovaginal septum. Overall, the
past quarter century has seen the rates of episiotomy
and operative vaginal delivery decrease dramatically,
and with it the number of RVFs. Yet, vaginal deliveries
associated with severe perineal lacerations, shoulder

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CLASSIFYING RVFS
Although several classifications of RVFs exist, most RVF
are generally broken down into low vs high fistulas and
simple vs complex fistulas. These basic categorizations
are extremely helpful in selecting the optimal surgical
procedure for the patient. Low fistulas are generally
located through or distal to the sphincter complex,
but proximal to the dentate line. Due primarily to their
location, they may be approached via anal, perineal or

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Kniery KR et al . Rectovaginal fistula review

Table 1 Reported outcomes with various rectovaginal fistula repairs
Published number of cases

Success rate

Complications

Fistula anatomy

515[10,11]
72[12,13]
99[14,15]
49
49[16,17]
48[10,18]
104[7,19]

68%
64%-100%
43%-100%
45.9%
95%-100%
71%-81%
65%-100%

Incontinence, Recurrence, Larger Fistula

Incontinence, Sexual dysfunction, Wound Dehiscence
Sexual dysfunction, Cosmesis, Wound dehiscence
Recurrence, Cost
Bleeding, Intraperitoneal Rectal injuries
Recurrence, Larger fistula, Cost
Sexual Function, Cosemsis

Low
Low
Low + High
Low
High
Low + High
Low

Advancement flaps
Transperineal/sphincteroplasty
Gracilis muscle flap
Plugs
Transabdominal ligation1
Mesh repair
Martius flap
1

For high fistula only.

vaginal routes. Anovaginal fistulas have a rectal opening

distal to the dentate line and are generally approached
the same as a low fistula. High fistulas are proximal to
the sphincteric complex, with a vaginal opening near the
cervix, and generally require an abdominal approach for
repair.
The other classification (simple vs complex) primarily
differentiates the RVF on whether it will be amenable to
a local repair vs a more complicated underlying patho
genesis that will require resection, interposition grafts,
and/or diversion. A simple fistula is one that is smaller
in size (< approximately 2.5 cm), more distally located
along rectovaginal septum, and generally occurred a
result of trauma or a cryptograndular infection. Complex
fistulas are typically a result of inflammatory bowel
disease, radiation or invasive cancer. Fistulas that have
failed prior attempts at repair are also included in the
category. Complex fistulas are commonly more proximal
on the rectovaginal septum and are not amenable to
primary repair, though may occur anywhere due to the
underlying etiology.

complex repair that includes diversion may be recom

mended at the initial operation (Table 1).

LOW FISTULAS
Plugs

The plugs currently available are composed of synthetic

material or made from porcine small intestine sub
mucosa. Regardless of the composition, the tract is
debrided, and the plug is brought through the RVF
fistula in an attempt to form a biologic seal. In some
cases, surgeons will perform a concomitant endorectal
advancement flap with plug placement to improve
outcomes. Fistula plugs have shown some benefit in
perianal fistulas of cryptoglandular origin; yet, the limited
data for RVFs has shown only a 20%-50% closure rate.
The length of the tract, which is almost always very
short, likely plays a role in the high failure rate of this
procedure, as has been seen with anal fistulas having
[4]
short tracts .

Advancement flaps

Advancement flaps may be performed by raising either

rectal or vaginal mucosa and using it to cover the
fistulous tract. This is performed in conjunction with
debridement/excision of the fistula tract and primary
closure. Healthy surrounding tissue is mobilized along
a wide pedicle to ensure adequate blood supply and
brought distally to cover the RVF. Different opinions exist
as to the best approach. Those that favor an endorectal
flap feel it is easier to mobilize and approximate the
rectal mucosa when compared with vaginal mucosa,
and that the repair is performed from the high-pressure
side. Proponents of the vaginal side feel it is better
vascularized, less likely to result in a larger fistula, and
an easier recovery. In either instance, the reported
success rates of this repair are reported between
60%-90%. In general, this is the procedure of choice
for low-lying/simple traumatic RVFs without a history of
[4]
incontinence .

PREOPERATIVE CONSIDERATIONS
To optimize outcomes, it is important to ensure that
any associated perineal sepsis has resolved completely
before attempting an operative repair. This should
be achieved primarily by addressing the underlying
cause of the fistula (e.g., medical therapy for Crohns
disease, removal of a foreign body such as a staple, or
drainage of an abscess). Once this has been addressed,
adjunctive measures such as fecal diversion or a drai
ning seton will help resolve the active inflammation and
allow the tissues to soften and be more amenable to
operative repair.

SURGICAL OPTIONS
The anatomy of the individual patient and the fistula
itself are the foremost factors in determining which
procedure to perform. In general, our approach has
been to recommend an attempt at less invasive proce
dures first, and if those fail, to then try more complex
and potentially morbid procedures. However, depending
on the underlying disease state of the patient, individual
co-morbidities and the anatomy of the fistula, a more

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Transperineal

A transperineal repair is accomplished by approaching

the fistula tract through the perineum, making an
incision at the perineal body and dissecting in the
rectovaginal septum above the level of the fistula. The

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Kniery KR et al . Rectovaginal fistula review

tract is then excised, and closure is performed in multiple
layers on both the sides. The benefit of this approach is
that an overlapping sphincteroplasty can be performed
simultaneously for those patients that have associated
defects or in those patients in which the fistula can be
incorporated into the sphincter repair. This is best used in
women with preexisting incontinence, or those a history
[2]
of failed transanal or transvaginal approach . Success
rates are reported to be 64.7%-100%; however, this
procedure is often more technically challenging, results
in higher morbidity rates, and normally is not a first-line
[4]
procedure .

when the RVF is high (i.e., vaginal cuff), and may be

performed via a minimally invasive or open approach.
The common bond to these fistulas is often the presence
of a prior hysterectomy and an inflammatory condition
that resulted in pelvic sepsis that eroded through the
vaginal cuff (e.g., Crohns diverticulitis, anastomotic leak).
In this procedure, the offending bowel is resected along
with division of the fistula tract. It is often helpful to
place a piece of omentum in between the rectum and
vagina to avoid recurrence. Some gynecologists prefer
to debride and re-close the vaginal cuff, although this
is widely variable. Success rates are 95%-100%, and
normally this is the preferred treatment for the patient
[4]
has a high fistula tract .

Martius flap

In 1928 Dr. Heinrich Martius, a professor of gynecology

in Gottingen, described using the bulbocavernosus
muscle and labial fat pad for vaginal wall defects due
to its proximity which allows for a single operative
[5]
field . The Martius flap was first used in cysto- and
urethral-vaginal fistulas. Only later was it adapted to
its present use in RVFs. In sum, it is ideally suited for
RVF repair, providing a local well-vascularized pedicle
of adipose/muscular tissue that is mobile and results in
low morbidity. It is most suited for complex, recurrent,
[6]
or recalcitrant RVFs . The Martius flap is best able to
treat low and mid-level fistulas up to approximately 5 cm
proximal to the vaginal introitus, but in reality is only
limited by the reach of the bulbocavernosus pedicle.
There are approximately 104 cases reported in the
retrospective literature with a success rate ranging from
[4]
65%-100% . Dyspareunia has been reported in as
many as 30% of females at six weeks post operatively
when they are allowed to resume vaginal intercourse,
but it appears to improve with time. The only other
more common complication reported in the literature
are labial wound issues (< 10%), which largely resolve
[7]
with local wound care .

Mesh repair

A mesh repair is essentially the same as transabdominal

ligation. However, rather than placing omentum between
the rectum and vagina, various biologic meshes have
been utilized as an interposition graft between the two
structures to prevent re-fistulization. The largest study
used porcine small intestine submucosa and showed
a success rate of 71%-81% in 48 patients. Other
biologic meshes such as acellular porcine dermal graft
and acellular human dermal matrix have also been
[4]
successful in small studies and case reports . Biological
mesh placement has also been described following
perineal approaches, although this is less well described.

CONCLUSION
RVFs are a disease process that is a significant burden
on women that are afflicted, and a difficult problem
for surgeons from whom they seek help. The diverse
disease pathology has prevented prospective trials,
and consensus guidelines on the management of
these patients. With a clear understanding of the
anatomy, ensuring resolution of the sepsis, and large
armentarium of surgical approaches these patients can
be treated successfully.

Gracilis muscle transposition

In this procedure, the gracilis muscle is harvested from

the leg, mobilized on a proximal pedicle, and used as
an interposition graft between the rectum and vagina.
Success rates are reported from 60%-100%, but there
is increased morbidity associated with the harvest site
and there appears to be a prolonged decrease in sexual
[4]
function . Dyspareunia is reported in up to 57% of
patients undergoing this operation and the decreased
sexual desire has been felt to be, in part, related to
[8]
the relatively large burden of perineal scarring .
Furthermore, when the gracilis is harvested for use in
other procedures (e.g., plastic surgery free flaps), a
short-term decrease in functionality of that leg has been
reported for approximately 6 mo in 26% of the patients,
[9]
and 6% of patients have long-term difficulties .

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P- Reviewer: Coskun A, Wong KKY
S- Editor: Ji FF L- Editor: A E- Editor: Jiao XK

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