Rectovaginal fistula
An abnormal epithelialized communication between the rectum and vagina that presents with passage of flatus or stool through the vagina, most often from breakdown of an inadequately repaired fourth-degree obstetric laceration or from fistulizing Crohn disease, confirmed on exam and treated according to the underlying cause.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Defining lesion: rectovaginal fistula is an abnormal epithelialized tract connecting the rectum or anal canal to the vagina, allowing flatus, stool, or purulent discharge to pass through the vagina.
- Epidemiology
Obstetric injury is a recognized driver: fourth-degree perineal laceration, which breaches the anal sphincter and rectal mucosa, complicates about 3.8% of vaginal deliveries, and rectovaginal fistula…
- Risk factors
Fourth-degree perineal laceration with inadequate or dehisced repair: the leading obstetric risk factor; midline episiotomy is more likely than mediolateral episiotomy to extend into the anal sphincter or rectum, see perineal lacerations.
- Pathophysiology
Obstetric mechanism: a fourth-degree laceration already breaches the rectal mucosa and anal sphincter into the vagina at the moment of injury; if the repair breaks down or heals with infection, the…
- Clinical features
Passage of flatus or stool through the vagina: the hallmark, most specific symptom, present regardless of cause.
- Differential diagnosis
Vesicovaginal fistula: continuous, painless urine leakage through the vagina rather than stool or flatus, from a urinary rather than rectal tract, see vesicovaginal fistula.
- Diagnosis
How the diagnosis is made: rectovaginal fistula is a clinical diagnosis confirmed by direct visualization or palpation of an epithelialized tract connecting the rectum or anal canal to the vagina on…
- Management
First, treat active infection or inflammation before attempting repair: a fistula with active perineal wound infection, perianal abscess, or active Crohn inflammation is not repaired until the…
- Complications
Recurrent vaginitis and urinary tract infection: from chronic fecal contamination of the vagina and lower urinary tract.
- Prognosis
Outcome depends on cause and control of the driving process: an obstetric fistula repaired after infection has resolved closes more reliably than one repaired through active inflammation or infection.
- Prevention
Prevent the antecedent obstetric injury: avoid routine episiotomy, and prefer mediolateral over midline episiotomy when one is indicated, since midline episiotomy is more likely to extend into the…
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Vesicovaginal fistula
Vesicovaginal fistula is an abnormal epithelialized tract between the bladder and vagina that produces continuous, painless leakage of urine from the vagina, most often after pelvic surgery (especially hysterectomy) in resource-rich settings or prolonged obstructed labor in resource-limited settings. Small fistulas found early may heal with prolonged bladder (Foley) catheter drainage; established fistulas require surgical closure, timed to let inflammation resolve.
- Anal fissure
Anal fissure is a longitudinal tear of the anoderm distal to the dentate line that causes severe pain during and after defecation with bright-red bleeding, most often from hard stool passage and high internal sphincter tone. Diagnosis is clinical on gentle inspection, a posterior midline location is typical, and treatment steps from fiber and topical vasodilators to botulinum toxin and lateral internal sphincterotomy for disease refractory to medical therapy.
- Hemorrhoids
Hemorrhoids are symptomatic engorgement and prolapse of the normal anal vascular cushions, internal above the dentate line causing painless bright-red bleeding and prolapse and external below the dentate line causing pain, especially with thrombosis. Diagnosis is clinical by inspection and anoscopy, and treatment escalates from fiber and topical measures through office procedures such as rubber band ligation to hemorrhoidectomy for advanced or refractory disease.
- Fecal incontinence
Fecal incontinence is the recurrent, involuntary passage of fecal material for at least three months, most often from a combination of obstetric or surgical sphincter injury, altered stool consistency, and impaired rectal sensation. Diagnosis rests on history and digital rectal exam followed by anorectal manometry and anal endosonography, and treatment moves stepwise from correcting stool consistency and reversible causes to pelvic floor therapy, biofeedback, and, for refractory or structural disease, bulking agents, sacral nerve stimulation, or sphincteroplasty.
- Colorectal cancer
Colorectal cancer is an adenocarcinoma that arises through the adenoma-carcinoma sequence and presents differently by location, with right-sided tumors causing occult bleeding and iron-deficiency anemia and left-sided tumors causing obstruction and hematochezia. Colonoscopy with biopsy confirms the diagnosis, TNM staging on CT chest/abdomen/pelvis with CEA guides treatment, and management ranges from surgical resection alone for localized disease to adjuvant FOLFOX for node-positive colon cancer, neoadjuvant chemoradiation for rectal cancer, and molecularly targeted systemic therapy for metastatic disease.
- Pelvic organ prolapse
Pelvic organ prolapse is descent of the anterior or posterior vaginal wall, the uterus, or the vaginal cuff into or beyond the vaginal introitus from loss of pelvic floor support. It is a clinical diagnosis made on Valsalva examination; treatment is a vaginal pessary for most patients and compartment-specific reconstructive or obliterative surgery for those who fail or decline conservative care.