Rectovaginal fistula

Date Updated: 12/05/2020

Overview

A rectovaginal fistula is an abnormal connection between the lower portion of your large intestine — your rectum — and your vagina. Bowel contents can leak through the fistula, allowing gas or stool to pass through your vagina.

A rectovaginal fistula may result from:

Injury during childbirth
Crohn's disease or other inflammatory bowel disease
Radiation treatment or cancer in the pelvic area
Complication following surgery in the pelvic area

The condition may cause emotional distress and physical discomfort, which can impact self-esteem and intimacy.

Talk with your doctor if you have signs and symptoms of a rectovaginal fistula, even if it's embarrassing. Some rectovaginal fistulas may close on their own, but most need surgical repair.

Symptoms

Depending on the fistula's size and location, you may have minor symptoms or significant problems with continence and hygiene. Signs and symptoms of a rectovaginal fistula may include:

Passage of gas, stool or pus from your vagina
Foul-smelling vaginal discharge
Recurrent vaginal or urinary tract infections
Irritation or pain in the vulva, vagina and the area between your vagina and anus (perineum)
Pain during sexual intercourse

When to see a doctor

See your doctor if you experience any signs or symptoms of a rectovaginal fistula. A fistula may be the first warning of a more serious problem, such as an infected, pus-filled area (abscess) or cancer. Identifying the cause of the fistula can help your doctor determine a treatment plan.

Causes

A rectovaginal fistula may form as a result of:

Injuries during childbirth. Delivery-related injuries are the most common cause of rectovaginal fistulas. This includes tears in the perineum that extend to the bowel, or an infection of an episiotomy — a surgical incision to enlarge the perineum during vaginal delivery. These may happen following a long, difficult, or obstructed labor. These types of fistulas may also involve injury to your anal sphincter, the rings of muscle at the end of the rectum that help you hold in stool.
Crohn's disease. The second most common cause of rectovaginal fistulas, Crohn's disease is an inflammatory bowel disease in which the digestive tract lining is inflamed. Most women with Crohn's disease never develop a rectovaginal fistula, but having Crohn's disease does increase your risk of the condition.
Cancer or radiation treatment in your pelvic area. A cancerous tumor in your rectum, cervix, vagina, uterus or anal canal can result in a rectovaginal fistula. Radiation therapy for cancers in these areas can also put you at risk. A fistula caused by radiation usually forms within six months to two years after treatment.
Surgery involving your vagina, perineum, rectum or anus. Prior surgery in your lower pelvic region, such as removal of your uterus (hysterectomy), in rare cases can lead to development of a fistula. The fistula may develop as a result of an injury during surgery or a leak or infection that develops afterward.
Other causes. Rarely, a rectovaginal fistula may be caused by infections in your anus or rectum; infections of small, bulging pouches in your digestive tract (diverticulitis); long-term inflammation of your colon and rectum (ulcerative colitis); dry, hard stool that gets stuck in the rectum (fecal impaction); or vaginal injury unrelated to childbirth.

Complications

Physical complications of a rectovaginal fistula may include:

Uncontrolled loss of stool (fecal incontinence)
Hygiene problems
Recurrent vaginal or urinary tract infections
Irritation or inflammation of your vagina, perineum or the skin around your anus
An infected fistula that forms an abscess, a problem that can become life-threatening if not treated
Fistula recurrence

Among women with Crohn's disease who develop a fistula, the chances of complications are high. These can include poor healing, or another fistula forming later.

Diagnosis

You can expect a physical exam and certain tests, depending on your needs.

Physical exam

Your doctor will perform a physical exam to try to locate the rectovaginal fistula and check for a possible tumor mass, infection or abscess. The doctor's exam includes inspecting your vagina, anus and the area between them (perineum) with a gloved hand.

Unless the fistula is very low in the vagina and readily visible, your doctor may use a speculum to see inside your vagina. An instrument similar to a speculum, called a proctoscope, may be inserted into your anus and rectum to check for problems.

Your doctor may take a sample of tissue for lab analysis (biopsy) during the procedure.

Tests for identifying fistulas

Your doctor may not find a fistula during the physical exam. Other tests may be needed to locate and evaluate a rectovaginal fistula. These tests can also help your medical team in planning for surgery.

Contrast tests. A vaginogram or a barium enema can help identify a fistula located in the upper rectum. These tests use a contrast material to show the vagina or the bowel on an X-ray image.
Blue dye test. This test involves placing a tampon into your vagina, then injecting blue dye into your rectum. Blue staining on the tampon indicates a fistula.
Computerized tomography (CT) scan. A CT scan of your abdomen and pelvis provides more detail than does a standard X-ray. The CT scan can help locate a fistula and determine its cause.
Magnetic resonance imaging (MRI). This test creates images of soft tissues in your body. MRI can show the location of a fistula, whether other pelvic organs are involved or whether you have a tumor.
Anorectal ultrasound. This procedure uses sound waves to produce a video image of your anus and rectum. Your doctor inserts a narrow, wand-like instrument into your anus and rectum. This test can evaluate the structure of your anal sphincter and may show childbirth-related injury.
Anorectal manometry. This test measures the sensitivity and function of your rectum and can give information about the rectal sphincter and your ability to control stool passage. This test does not locate fistulas, but may help in planning the fistula repair.
Other tests. If your doctor suspects you have inflammatory bowel disease, he or she may order a colonoscopy to view your colon. During the procedure, your doctor can take small samples of tissue (biopsy) for lab analysis, which can help confirm Crohn's disease.

Treatment

Symptoms of a rectovaginal fistula can be distressing, but treatment is often effective. Treatment for the fistula depends on its cause, size, location and effect on surrounding tissues.

Medications

Your doctor may recommend a medication to help treat the fistula or prepare you for surgery:

Antibiotics. If the area around your fistula is infected, you may be given a course of antibiotics before surgery. Antibiotics may also be recommended for women with Crohn's disease who develop a fistula.
Infliximab. Infliximab (Remicade) can help reduce inflammation and heal fistulas in women with Crohn's disease.

Surgery

Most people need surgery to close or repair a rectovaginal fistula.

Before an operation can be done, the skin and other tissue around the fistula must be healthy, without infection or inflammation. Your doctor may recommend waiting three to six months before having surgery to ensure the surrounding tissue is healthy and see if the fistula closes on its own.

Surgery to close a fistula may be done by a gynecologic surgeon, a colorectal surgeon or both working as a team. The goal is to remove the fistula tract and close the opening by sewing together healthy tissue. Surgical options include:

Sewing an anal fistula plug or patch of biologic tissue into the fistula to allow your tissue to grow into the patch and heal the fistula.
Using a tissue graft taken from a nearby part of your body or folding a flap of healthy tissue over the fistula opening.
Repairing the anal sphincter muscles if they've been damaged by the fistula or by scarring or tissue damage from radiation or Crohn's disease.
Performing a colostomy before repairing a fistula in complex or recurrent cases to divert stool through an opening in your abdomen instead of through your rectum. Most of the time, this surgery isn't needed. But you may need this if you've had tissue damage or scarring from previous surgery or radiation treatment, an ongoing infection or significant fecal contamination, a cancerous tumor, or an abscess. If a colostomy is needed, your surgeon may wait eight to 12 weeks before repairing the fistula. Usually after about three to six months and confirmation that your fistula has healed, the colostomy can be reversed and normal bowel function restored.

Lifestyle and home remedies

Good hygiene can help ease discomfort and reduce the chance of vaginal or urinary tract infections while waiting for repair. Other home remedies for people living with a rectovaginal fistula include:

Wash with water. Shower or gently wash your outer genital area with just warm water each time you experience vaginal discharge or passage of stool.
Avoid irritants. Soap can dry and irritate your skin, but you may need a gentle unscented soap in moderation. Avoid harsh or scented soap and scented tampons and pads. Vaginal douches can increase your chance of infection.
Dry thoroughly. Allow the area to air-dry after washing, or gently pat the area dry with a clean cloth or towel.
Avoid rubbing with dry toilet paper. Pre-moistened, alcohol-free, unscented towelettes or wipes or moistened cotton balls are a good alternative.
Apply a cream or powder. Moisture-barrier creams protect irritated skin from liquid or stool. Nonmedicated talcum powder or cornstarch also may help relieve discomfort. Ask your doctor to recommend a product. Be sure the area is clean and dry before you apply any cream or powder.
Wear cotton underwear and loose clothing. Tight clothing can restrict airflow and worsen skin problems. Change soiled underwear quickly. Products such as absorbent pads, disposable underwear or adult diapers can help if you're passing liquid or stool, but be sure they have an absorbent wicking layer on top.

For best results, be sure to follow any other recommendations from your health care team.

Preparing for an appointment

Your first appointment may be with your family doctor, primary care provider or gynecologist. After your initial evaluation, you may be referred to a surgeon who specializes in procedures involving the female reproductive system (gynecologic surgeon) or one who specializes in treating conditions of the colon and rectum (colorectal surgeon) to discuss treatment options.

What you can do

To prepare for your appointment:

Ask about any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance to prepare for diagnostic tests.
Make a list of symptoms you're experiencing. Include any that may seem unrelated to a rectovaginal fistula.
Make a list of your key medical information. Include any other conditions you're treating, all past surgeries, and the names of any medications, vitamins, herbal remedies or supplements you're taking.
Consider questions to ask your doctor. Make a list, take it with you to your appointment, and make notes as your doctor answers your questions.

For a rectovaginal fistula, some basic questions to ask your doctor include:

What's causing these symptoms?
Are there other possible causes for my symptoms?
What kinds of tests do I need? Do these tests require any special preparation?
Is this condition temporary or long lasting?
What treatments are available, and which do you recommend?
Are there any alternatives to your recommended treatment?
Will I need surgery?
Do you have any brochures or other printed material that I can take with me? What websites do you recommend?

Don't hesitate to ask questions during your appointment anytime you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

When did your symptoms begin?
Have your symptoms been continuous or occasional?
How severe are your symptoms?
What, if anything, seems to improve your symptoms?
What, if anything, appears to worsen your symptoms?
Are you able to have regular bowel movements?
Do you experience uncontrolled loss of stool, also called fecal incontinence?
Do you have difficulty with constipation that causes you to strain a lot during bowel movements?
Have you given birth vaginally? Were there any complications?
Have you ever had pelvic surgery?
Have you ever been treated for a gynecologic cancer?
Have you had pelvic radiation therapy?
Do you have any other medical conditions, such as Crohn's disease?