Rectovaginal fistula

Specialty: Gynecology and breast.

• Passage of feces through the vagina
• vaginal gas emission
• colon-vaginal fistula

Why it occurs

• Undiagnosed or incorrectly sutured third or fourth degree obstetric injury during childbirth
• Crohn's disease with fistulizing perineal involvement
• Post-surgical complication of previous pelvic or perineal surgeries
• Late sequel to pelvic radiotherapy for the treatment of cervical or rectal cancer
• Advanced infiltrating colorectal, cervical or vaginal carcinoma

Initial workup

Direct visual examination of the vagina and rectum using speculum and rectoscope. Injection of diluted methylene blue into the rectum while gauze is placed in the vagina to confirm the fistulous tract (gauze stain). Pelvic MRI with contrast or high-resolution endoanal ultrasound to assess the course of the fistula and the status of the anal sphincters.

Standard management

• Metronidazole 500 mg orally every 8 hours associated with Ciprofloxacin 500 mg every 12 hours if there are signs of active infection or local cellulitis, or in the context of active Crohn's disease
• Infliximab (anti-TNF antibody) as an intravenous infusion regimen if the fistula is secondary to active Crohn's disease. Definitive treatment of the established fistulous tract is usually surgical through a transvaginal, transperineal or transanal approach (note: ensure meticulous perineal hygiene and the use of barrier creams to avoid severe fecal contact dermatitis).