An Overview of Rectovaginal Fistula

A rectovaginal fistula is a hole between the vagina and the rectum. A fistula is defined as an abnormal opening between a hollow organ and either another hollow organ or the outside of the body. The term rectovaginal describes the two organs that the opening lies between—the rectum and the vagina. This can cause gas, mucus, and stool to leak into the vagina and lead to unpleasant odors, infection, and other concerns.

A rectovaginal fistula is one type of obstetric fistula or urogenital fistula. These are terms that describe all such openings between the genital organs and the urinary and intestinal tract. Another type of obstetric fistula is a vesicovaginal fistula. This is an opening between the vagina and the bladder. It can cause urine to leak into the vagina.

For some women, rectovaginal fistula can be emotionally devastating. Women with rectovaginal fistula often report difficulties with self-esteem and intimate relationships. Fortunately, this condition is relatively rare and rectovaginal fistulas can often be repaired. Furthermore, the risk of rectovaginal fistula is particularly low in countries where there is well-trained support around labor and delivery during childbirth.

Body Systems Affected

In order to understand how rectovaginal fistula can occur, it is helpful to understand the anatomy of the pelvis. The rectum is a mucus-lined tube that makes up the end of the intestinal tract. When the colon becomes full of stool, that stool gets pushed into the rectum. It is at that point that people have the urge to move their bowels. During a bowel movement, stool gets pushed out of the rectum through the anus.

The vagina is also lined with mucus. It lies in between the rectum and the bladder. During non-cesarean childbirth, the baby passes through the vagina. This can put pressure on the rectum. It can sometimes even lead to tears.

Symptoms

The primary symptom of rectovaginal fistula is abnormal vaginal discharge and odor. More specifically, people may complain of stool in their vagina. They may also complain about gas coming from their vagina or particularly smelly mucus. These symptoms are very similar to fecal incontinence.

As such, without physical examination, the two may be confused by a healthcare provider. Some women with rectovaginal fistula may also experience pain during sex or recurring vaginal infections.

Causes

There are a number of potential causes of a rectovaginal fistula. What all these causes have in common is the potential to weaken or stress the tissues between the vagina and rectum. The most common causes include:

• Obstetrical or vaginal trauma, including prolonged delivery
• Inflammatory bowel disease, particularly Fistulizing Crohn's
• Radiation therapy of the pelvis
• Certain types of cancer, including anorectal, perineal, and pelvic
• Complications of surgery (very rare causes)

With respect to obstetric trauma, fistulas occur in approximately one in 1,000 vaginal deliveries in the Western world. Women are more at risk if it is their first pregnancy, they have a very large baby, forceps are used, or a midline episiotomy is performed.

In some areas of the developing world, rectovaginal fistulas from obstetrical trauma are far more common. They are often the result of prolonged, obstructed labor. Vaginal trauma leading to rectovaginal fistula can also be caused by retrained foreign bodies. In rare cases, sexual intercourse can lead to fistula.

Fistulizing Crohn's disease is the second leading cause of rectovaginal fistulas. They may occur in as many as 10% of women with Crohn's disease. The risk is thought to be related to the severity and frequency of inflammatory events. Other inflammatory disorders affecting the pelvic region may also increase the risk of rectovaginal fistula.

Finally, the third major cause of rectovaginal fistula is cancer and its treatment. Pelvic radiation can cause inflammation and breakdown of the tissues between the vagina and the rectum. In addition, certain pelvic tumors can actually erode into these tissues, leading to fistula formation.

Diagnosis

In order to diagnose rectovaginal fistula, your healthcare provider will want to hear your medical and surgical history. During the medical history, healthcare providers will likely ask a number of questions about pregnancy and labor. They will also ask about any history with cancer treatment or inflammatory bowel disease. If you have had any pelvic surgeries, your healthcare provider may ask for you to forward those medical records as well as records from any recent gynecologic exams or colonoscopies.

At this point, your healthcare provider may ask you if you've ever had any fecal incontinence. They may also want to know about other issues with emptying your bowels. They may look for symptoms of inflammatory bowel disease or a history of reproductive problems.

The next step in diagnosing rectovaginal fistula is a physical exam. Your perineal region (the outside of your genitals) will be inspected to look for signs of inflammation or infection. Then, your healthcare provider may insert a speculum into your vagina. This will be used to look for signs of inflammation and other problems with your vulva, vagina, and cervix. At this point, your healthcare provider may or may not see a fistula if one is present. Sometimes small fistulas can cause significant symptoms but not be visible to the naked eye.

After the speculum exam, your healthcare provider will perform a bi-manual recto-vaginal exam. This involves inserting a finger or two in the rectum as well as in the vagina.

Your healthcare provider will also be checking to see if your anal sphincter appears intact and healthy.

Finally, if a rectovaginal fistula is suspected, you will likely be sent for an anoscopy, proctoscopy, or colonoscopy. These procedures allow the healthcare provider to see inside your rectum. If those tests still aren't conclusive, but your healthcare provider thinks it is highly likely you have a rectovaginal fistula, they may also want to do an examination under anesthesia.

Some healthcare providers prefer to use diagnostic imaging to look for rectovaginal fistula rather than a visual or manual exam. This usually involves either an endoanal ultrasound or magnetic resonance imaging (MRI.) These tests are thought to be highly accurate for diagnosing fistula. A CT scan may also be performed if there are no clear, non-malignant causes for a suspected fistula.

Treatment

The best treatment option for rectovaginal fistula depends on a number of factors including the cause of the fistula, the severity of symptoms, and a person's overall health. For example, at least one study has found that half of small fistulas caused by obstetrical trauma heal on their own within six to nine months. Therefore, for women with manageable symptoms, watchful waiting may be the best choice. However, this only works for women with minimal symptoms that are easy to manage.

As such, your healthcare provider may treat you with antibiotics. They may also insert a tube called a seton to allow your fistula to drain safely and reduce inflammation. The seton is usually removed at the time of fistula repair.

Once inflammation and/or infection have resolved, there are a number of options for surgical repair of a rectovaginal fistula. The surgical procedure that is the best choice for you will depend on a number of factors, including whether you have previously undergone a repair. Repair can either be performed on the rectal side of the fistula or the vaginal side of the hole.

In some cases, temporary fecal diversion through a stoma may be part of surgical fistula repair and healing. There are also more experimental procedures for rectovaginal fistula repair. These include the use of fibrin glue and fistula plugs. Fistula plugs are, however, more often used for repairing other types of fistula.

Coping

It can be difficult to cope with a rectovaginal fistula. In severe cases, constant fecal and urinary leakage can lead to issues with odor as well as damage to the vulva and thighs. Some women, particularly in the developing world, have reported being socially ostracized. Rectovaginal fistula can also cause problems in intimate relationships.

Due to all of these factors, and other potential concerns associated with rectovaginal fistula, depression is common both before and after diagnosis.

Fortunately, in the Western world, there are numerous options for fistula treatment and repair. However, because of the intimate nature of this problem, it's still a good idea to seek support. You may want to find a support group of other women who have experienced similar conditions. It may also be helpful to find an individual therapist with whom you can share your concerns.

Finally, sex and relationship therapy may be a good option for women who have experienced intimacy problems after a rectovaginal fistula or repair. These problems can be difficult to talk about with a partner, and it never hurts to have help.

A Word From Verywell

If you have been diagnosed with a rectovaginal fistula, or are afraid you might have one, there is help available. The most important step is finding a healthcare provider with whom you feel comfortable sharing your symptoms. The more open and honest you are with your healthcare provider, the closer you will be toward healing and recovery.