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What Are Rectovaginal Fistulas?

Rectovaginal fistulas are any pathological communications between rectum and vagina. They can be congenital or caused by different factors during life. Symptoms of this disorder can be very disturbing for patients. In an addition, surgery often fails to provide a permanent solution, so repeated procedures are needed. Here we address possible causes of rectovaginal fistula, as well as modern treatment options.

Causes Of Rectovaginal Fistulas

The most common causes of rectovaginal fistulas are injuries during childbirth. If the labor is complicated, prolonged pressure is being put on vaginal walls, which can cause necrosis (death due to lack of oxygen) of some parts of the vaginal wall. The back wall of the vagina and the front wall of the rectum are very close, so this can lead to development of fistulas between lumens of the two organs.

Due to the closeness between the vagina and rectum, infections of one organ can spread to the other, which can lead to development of rectovaginal fistula. This is common in purulent infections, where there is a pressure on the rectovaginal wall caused by large amounts of pus. Tuberculosis of the rectum and vagina can also cause fistulas.

Malign tumors of the rectum, vagina, or surrounding structures may cause the development of rectovaginal fistulas, especially if they are locally destructive. Radiation therapy of pelvic malignancies can cause tissue damage, leading to necrosis and subsequent fistulas.

Chronic inflammatory diseases of the bowels which affect the rectum, such as ulcerous colitis and Crohn's disease, cause rectovaginal fistulas through a similar mechanism as infectious diseases.

Symptoms And Diagnosis Of Rectovaginal Fistulas

The most common symptom of rectovaginal fistula is appearance of stool in vagina. That is a certain sign of pathological communication between the rectum and vagina. Urinary and genital infections are common, as some bacteria that are normally present in the rectum can cause infections of the urogenital system.

Detailed anamnestic data from the patient and a physical examination are usually enough to make the diagnosis. Further examinations, such as transrectal ultrasound imaging, are performed in order to plan surgical intervention.

Treatment Of Rectovaginal Fistulas

A limited number of women can benefit from conservative treatment, which includes treating the cause and regulating bowel movements and eating habits. In some of these cases, rectovaginal fistulas might heal without surgical intervention.

In most cases, surgery is necessary in order to close the pathological communication. There are several different approaches that colorectal surgeons prefer today. 

Advancement flaps are most commonly used. The procedure consists of the removal and closure of the rectal part of the fistula and coverage of the higher pressure part with a mucosal flap. Biprostethic fistula plug and LIFT (ligation of intersphincteric fistula tract) are novel procedures used for treatment of simple rectovaginal fistulas. They are constantly being improved and have an increasing efficacy.

Unfortunately, current treatment options provide a permanent solution of the problem in only about 50 percent of cases, while the remaining 50 percent require additional interventions. Scientists are working on developing new methods which are expected to increase the success rate of these interventions. Dealing with rectovaginal fistulas is a big challenge, given their complexity and unpleasant symptoms which produce physical, social, and psychological consequences.

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