Women with rectovaginal fistula report uncontrolled passage of gas or stool through their vagina, foul-smelling discharge and painful sex. The condition may also cause recurrent urinary tract infections and pelvic pain.
Your health care provider will talk with you about your symptoms and do a physical exam. They will use a special tool to examine the area around your rectum and anus, as well as the area between your rectum and anus (the perineum). They will look for signs of a fistula tunnel.
Symptoms
A rectovaginal fistula is an abnormal connection between your bowel and the vagina. This connection allows stool and gas to leak from your bowel into the vagina. This condition can cause discomfort and distress, particularly during sexual activity and childbirth. It can also affect your self-esteem and intimacy. Rectovaginal fistulas develop from complications of surgery in your pelvic area, especially surgery to remove your uterus (hysterectomy). They can also occur as a result of an injury during childbirth. This can include tears in the perineum or an infection of a surgical cut in your perineum (episiotomy). They may also occur due to complications from prior surgeries to treat other conditions, such as cancer and radiation therapy in the pelvic area.
In addition to a feeling of fullness in the pelvic area, symptoms of a rectovaginal fistula vary by the location of the fistula and its size. You may experience leaking urine and foul-smelling discharge from your vagina or vulva, which can be painful. You can also have pain, swelling and itching in the area between your vagina and anus, called the perineum.
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To diagnose a rectovaginal fistula, your doctor will do a physical exam and ask you about your symptoms. He or she will also perform a bowel evaluation and check for signs of an infection in your bladder and rectum. You may have a complete blood count, urinalysis or a dye test to look for fistulas. An X-ray, pelvic CT scan or flexible sigmoidoscopy can show the number and size of your fistulas.
If you have a rectovaginal fistula, he or she will likely recommend a temporary colostomy procedure to prevent further damage from fistulas. A colostomy diverts poop away from your anus and rectum to another surgical opening in your abdomen called a stoma. Stool leaves your body through this opening and collects in a bag that you change regularly. Later, you will have a surgery to reconnect your rectum and colon to close the stoma and repair the fistula. This is a more complicated surgery, but it can help prevent further problems from the rectovaginal fistula.
Diagnosis
To diagnose a rectovaginal fistula, your health care provider will talk to you about your symptoms and do a physical exam. The doctor may also do a test to see if you have a leakage from the abnormal passage between your anus and vagina. During this test, the health care provider puts a gloved hand in your anus and vagina or the area between them, called the perineum. Then he or she squeezes and feels the area to find out if there is a fistula tunnel.
Your doctor may also do a pelvic ultrasound to check for a rectovaginal fistula or other abnormal opening in your pelvic tissue. These ultrasounds use a tool similar to a speculum but have a small probe with a light on the end. The probe sends sound waves to help your doctor see your rectum, anus and the space between them. These ultrasounds can also look for disruption of your internal and external anal sphincter muscles.
Other tests may include a blood test to see if you have an infection in your rectum, vagina or both. The test will look for a certain kind of white blood cell that can be an indication that you have an infection. The test is also used to check for the presence of a tumor or abscess in your pelvic area.
Some rectovaginal fistulas close up on their own without treatment, but most need surgery to repair them. During the surgery, the doctor closes the passage between your anus and vagina by using tissue from another part of your body.
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Fistulas may develop due to complications from previous surgery in your lower pelvic area. They can also form from infected Bartholin’s glands, which are found on each side of your anus and help keep your vagina moist. Fistulas may also be caused by inflammatory bowel disease, such as Crohn’s or ulcerative colitis. Rarely, a rectovaginal fistula can develop from the infection of small bulging pouches in your digestive tract called diverticulitis.
Some fistulas are very difficult to locate and diagnose. If this is the case, your doctor can try to detect the fistula by filling your rectum and vagina with liquid while inhaling air. You will then feel bubbling or a leak at the site of the fistula.
Treatment
Fistulas form due to trauma or injury to the vaginal tissue. This can occur from prolonged labor or when the healthcare provider makes a cut during childbirth (episiotomy). Fistulas can also develop due to long-standing use of pessaries. Sometimes a fistula forms spontaneously. However, most of the time a rectovaginal fistula will need to be treated by surgery.
If you have a recto-vaginal fistula, your healthcare provider may recommend that you take antibiotics or immunosuppressants to help prevent infection. They will do a pelvic exam to check your vagina, perineum, and anus. They will also ask you about your symptoms. A complete blood count and urinalysis will be done to look for infections. You may have a dye test using a blue-colored liquid to see if your rectovaginal fistula is leaky. You may also have a flexible sigmoidoscopy to view the area between your rectum and large intestine (colon).
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A surgical procedure called posterior sagittal anorectoplasty can be used to treat RVF. During the procedure, the abnormal fistula between the rectum and vagina is disconnected. The anal opening is connected to a newly created anal sac in the rectum, and a sphincter muscle complex is formed to control the flow of stool through the anal opening. Depending on the nature of your fistula, it may be possible to restore bowel control and a normal vaginal vestibule, but in some cases the sphincter muscles cannot be controlled, so a colostomy may be needed.
Other options for treatment include occlusive measures like fibrin glue or other occlusive agents, and a rectovaginal anastomosis (RVA). The RVA approach involves creating a new anal opening in the rectum. It is often more successful in restoring bowel control than a sphincter muscle repair. However, the success rate of a RVA is lower than with a sagittal anorectoplasty.
Another option is to have a stoma (an airtight bag) placed in the abdomen instead of having a surgical procedure to close your rectovaginal fistula. The research on this is not very strong, but some people find that having a stoma helps their fistula heal and improves their symptom symptoms.
Prevention
A fistula starts when some kind of damage stops blood flow to tissue. Over days or years, the tissue breaks down and creates an opening that connects two organs. Fistulas can form between the bladder and urethra, or the colon and rectum. The majority of obstetric fistulas are formed between the urinary tract and the vagina. A few are between the rectum and the small bowel.
Fistulas can start due to injury during childbirth, including tears in the vagina or uterus or if your healthcare provider makes a cut (incision) to help you deliver your baby (episiotomy). They may also develop because of prolonged labor, a ruptured pelvic fracture, surgical trauma from other health problems like cancer or surgery, and infections. They can even happen because of complications from radiation to the pelvic area. Fistulas can also be congenital, meaning you are born with them.
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When you have a rectovaginal fistula, you will likely have a painful leak of gas or stool from the area of your abdomen and lower back. It is important to see your healthcare provider, as this is a very serious problem that needs to be treated.
Your healthcare provider will check your symptoms and history and do a physical exam. They will also assess your perineum (the skin between the vagina and anus) and the rectum. They will apply pressure to the rectum, which will help them find your fistula. They may use a tool like a speculum to help them look into your vagina.
Other tests you may need include a complete blood count, urinalysis, and a fistulogram X-ray. A dye test with a blue-colored liquid or charcoal tablets is used to confirm a fistula.
If you have a fistula, you will need to wear a sanitary pad all the time to prevent it from being exposed to germs that cause infections. You can also keep your fistula clean by washing it and the surrounding skin with warm water each time you pass urine or stool. Then, wipe your rectum with a cloth that is specially made for fistulas.
