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Rectovaginal fistula

Key sources
The following summarized guidelines for the evaluation and management of rectovaginal fistula are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2022), the American College of Radiology (ACR 2021), the British Society of Gastroenterology (BSG 2019), the American College of Gastroenterology (ACG 2018), and the Association of Gynecologists in Germany (BVF/BCD/DGAV/DDG/DGVS/DGGG/BDC/DGU/DGK/AGUB/CACP 2012).
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Guidelines

1.Screening and diagnosis

Etiology
Recognize that the majority of rectovaginal fistulas are caused by obstetric trauma (postpartum rectovaginal fistula), and other less common causes include chronic IBD (particularly Crohn's disease), low anterior rectal resection, hemorrhoid or pelvic floor surgery, particularly when using staplers or foreign materials, local infections, particularly cryptoglandular infections and Bartholin gland abscesses, foreign body erosion.
Recognize that preoperative and postoperative radiochemotherapies are risk factors for the development of postoperative fistulas.
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2.Classification and risk stratification

Classification: recognize that there is no generally accepted classification of rectovaginal fistulas.
E
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3.Diagnostic investigations

Clinical assessment
Elicit patient history and perform clinical examination for the diagnosis of rectovaginal fistula. Recognize that patients typically report air, mucus, and possibly stool discharge through the vagina.
E
Assess for any perineal defects for treatment planning.
E

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4.Medical management

Nonoperative management: as per ASCRS 2022 guidelines, offering nonoperative management for the initial care of patients with obstetrical rectovaginal fistula, and consider offering in patients with other benign and minimally symptomatic fistulas.
B

5.Surgical interventions

Endorectal repair: perform endorectal advancement flap repair, with or without sphincteroplasty, as the procedure of choice in most patients with rectovaginal fistulas.
B

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  • Transabdominal repair

  • Tissue interposition

  • Seton placement