Diseases & Conditions

Rectovaginal fistula

A rectovaginal fistula is an abnormal connection between the lower portion of your large intestine — your rectum — and your vagina. Contents of your bowel can leak from the fistula, meaning you might pass gas or stool through your vagina.

A rectovaginal fistula may result from an injury during childbirth, a complication following surgery, cancer or inflammatory bowel disease, such as Crohn's disease. An estimated 0.1 percent of vaginal births lead to a rectovaginal fistula.

The symptoms of a rectovaginal fistula often cause emotional distress as well as physical discomfort. Though bringing up the subject with your doctor may be difficult, it's important to have a rectovaginal fistula evaluated. Some rectovaginal fistulas may close on their own, but most need to be repaired surgically.

Don't shy away from seeing a doctor if you experience any signs or symptoms of rectovaginal fistula. A fistula may be the first indication of a more serious problem, such as an area of infection where pus has collected (abscess), or cancer. It's important that your doctor identify the cause of the fistula and determine whether and when it should be repaired. Depending on the cause of your fistula, your doctor may refer you to a colorectal or gynecologic surgeon.

Physical complications of rectovaginal fistula may include incontinence, problems with hygiene, and irritation or inflammation of your vagina, perineum or the skin around your anus. In some cases, a fistula may become infected and form an abscess, a problem that can become life-threatening if not treated. Among women with Crohn's disease who develop a fistula, the chance of another fistula forming later is high.

Treatment for a rectovaginal fistula depends on its cause, size, location and effect on surrounding tissues. Sometimes fistulas heal on their own, but most people need surgery to close or repair the abnormal connection. Before an operation can be done, the skin and other tissue around the fistula must be healthy, with no signs of infection or inflammation. Your doctor may advise a waiting period of up to three months before surgery to ensure the surrounding tissue is healthy and see if the fistula closes on its own.

Medications
If the area around your fistula is infected, you'll take a course of antibiotics before surgery. Antibiotics may also be recommended for women with Crohn's disease who develop a fistula. Another medication that may help heal a fistula in women with Crohn's disease is infliximab (Remicade). This drug blocks the action of an immune system protein called tumor necrosis factor-alpha (TNF-alpha), which causes inflammation. Side effects may include chest pain, chills, fever, flushing, hives, itching and troubled breathing.

Surgery
An operation to close a fistula may be done by a gynecologist or a colorectal surgeon. The goal is to remove the fistula tract and close the opening by sewing together healthy tissue around it. The repair may require using a tissue graft taken from an adjacent part of the body, or folding a flap of healthy tissue over the fistula opening. More complicated operations may be needed if the anal sphincter muscles are also damaged or if there's scarring or tissue damage from radiation or Crohn's disease.

To clean out your bowel before the operation, you may take laxatives or follow a liquid diet for several days. This may be followed by an enema shortly before surgery. You'll also be given an antibiotic medication before surgery.

In some cases, the surgeon may do a colostomy before repairing a fistula. A colostomy is an operation that diverts stool through an opening in your abdomen instead of through your rectum. This may be needed 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.

After an operation to close a fistula, you'll be on a liquid diet for about three days, followed by a low-fiber diet for several weeks. A low-fiber diet reduces the frequency and volume of stools. Your care team may recommend that you take sitz baths two to three times a day and dry off with a blow dryer to keep the area clean and dry.

Some doctors suggest that a woman who's had surgery to repair a fistula consider having a Caesarean delivery for the next pregnancy.

Good hygiene can help ease discomfort and reduce the chance of vaginal or urinary tract infections:

• Wash with water. Gently wash your outer genital area with warm water each time you experience vaginal discharge or passage of stool. Soap can dry and irritate your skin but may be necessary in moderation. Avoid rubbing with dry toilet paper. Premoistened, alcohol-free towelettes or wipes or moistened cotton balls may be a good alternative for cleaning the area.
• Dry thoroughly. Allow the area to air-dry after washing, or gently pat the area dry with toilet paper or a clean washcloth.
• Avoid irritants. These include harsh or scented soap and scented tampons and pads.
• Use a cold compress. Apply a cold compress, such as a washcloth, to the labial area.
• Apply a cream or powder. Moisture-barrier creams help keep irritated skin from having direct contact with fecal matter. Ask your doctor to recommend a product. Be sure the area is clean and dry before you apply any cream. Nonmedicated talcum powder or cornstarch also may help relieve discomfort.
• Wear cotton underwear and loose clothing. Tight clothing can restrict airflow, making skin problems worse. Change soiled underwear quickly. Products such as absorbent pads and disposable underwear can help if you're passing liquid or stool. If you use pads or adult diapers, be sure they have an absorbent wicking layer on top.
• Don't douche. Douching can increase your risk of infection.

Symptoms of a rectovaginal fistula can be very distressing, but treatment generally offers good results.