What Is Rectovaginal Fistula

Introduction

A fistula can be defined as an abnormal connection between two hollow structures in the body.¹ A rectovaginal fistula (RVF) refers to an abnormal passageway which has formed between the rectum and the vagina. The most common cause of an RVF is physical trauma caused by childbirth.² Since these two structures are typically separated and serve very different functions, a connection between the two can cause health complications, functional impairment and severe emotional distress for those assigned female at birth (AFAB) who experience it.³

Awareness and understanding of RVF is crucial in destigmatising this experience and empowering people AFAB around the world to seek help and share their experiences, which can help foster a sense of community. Due to the distressing nature of this condition, RVFs are associated with high rates of mental health burden.⁴ This burden is multiplied in underdeveloped countries wherein a person's AFAB’s value in society is highly reliant on their reproductive health, and issues such as RVF serve only to ostracise, degrade, and devalue a person's AFAB.⁵

Anatomy and location

The rectum is the final part of the digestive system found at the end of the large intestine and just above the anus. The rectum is responsible for storing faeces until your body receives the signal to release them.⁶ The vagina is a vital, muscular, tube-like organ in the female reproductive system which forms a passageway between the uterus and the outside of the body, through the external genitalia. This passageway enables various important functions, particularly menstruation, sexual intercourse, and childbirth.⁷

The front-facing part of the rectum and the posterior wall of the vagina are separated by a thin layer of tissue known as the rectovaginal septum.² A rectovaginal fistula occurs when, due to various mechanisms usually traumatic in nature, a hole develops in this septum; this creates an abnormal passage between the rectum and vagina.² This enables the flow of rectal contents into the vagina, causing the distressing symptoms characteristic of RVF.

Causes

The various causes of RVF can be grouped as either traumatic in nature or non-traumatic. The vast majority of RVF cases are caused by trauma, more specifically, injury sustained due to prolonged, obstructed labour.^2,8 Other traumatic causes include surgical errors and, more rarely, injury sustained via forceful sexual intercourse.

Non-traumatic causes are associated with inflammation in and surrounding the rectum and vagina, causing weakening of the rectovaginal septum and leading to the development of a fistula. Some of these causes include:²

• Inflammatory bowel disease (particularly Crohn’s disease)
• Cancer in surrounding areas
• Local injury from radiation
• Local infection

Symptoms

Symptoms resulting from an RVF can be extremely distressing, and are predominantly caused by the abnormal flow of gas or faecal matter from the rectum into the vaginal cavity. Symptoms include:⁴

• Pain and discomfort
• Foul-smelling vaginal discharge
• Faecal incontinence through the vagina (i.e. an inability to control when you empty your bowels)
• Pain during sexual intercourse
• Chronic, recurrent vaginal and bladder infections

An additional complication to consider is the significant mental burden of this diagnosis, and the impact it can have on a person AFAB’s self-esteem and confidence to engage meaningfully with their activities of daily living.

Diagnosis

Diagnosing RVF requires a three-step approach:⁴

1. Identifying a patient’s symptoms
2. Physical exam
3. Imaging and diagnostic testing

If a person with AFAB has symptoms suggestive of an RVF, this will prompt a physical examination of the vagina. This will be done using a speculum, which is a tool used to widen the opening of the vaginal canal, making the lower part of the internal aspect of the vagina easier to visualise with the naked eye. Signs that may be visible during the physical exam include:⁴

• Redness due to irritation
• Swelling
• Presence of stool
• The presence of a fistula (depending on the size and location of the fistula)

Blood tests may be done to identify complications of an RVF, for example, the presence of infection.² Furthermore, biopsies (tissue samples) may be taken from the area if inflammatory bowel disease or cancer is suspected as an underlying cause.² Imaging studies may be used to confirm the presence of a fistula and potentially identify its underlying cause.⁴ Imaging techniques used may include:²

• CT scans
• Ultrasound (endorectal and transvaginal)
• MRI scans
• Endoscopy to confirm inflammatory bowel disease as an underlying cause

While investigating the presence of a rectovaginal fistula (RVF), clinicians aim to rule out alternative conditions which may produce similar symptoms. Examples of these alternative diagnoses include:⁴

• UTI
• Cystitis (bladder inflammation)
• Inflammatory bowel disease
• Enterovesical fistula - this is an abnormal connection between the bladder and the bowels. This leads to the flow of bowel contents, such as gas and faeces, into the bladder
• Colon cancer

Treatment options

Although the gold standard of treatment is surgical repair,² the course of treatment for RVF is greatly dependent on the underlying cause and its present complications.⁴

If infection is present, antibiotics and supportive care will be offered to treat this complication. If the cause is related to a pre-existing disease, such as inflammatory bowel disease or cancer, appropriate treatment will be provided in order to treat the underlying condition and improve the likelihood of fistula healing.⁴

Some traumatic fistulas will heal entirely on their own. However, if the fistula is too big or the symptoms are too impairing, surgical repair under general anaesthetic is advised.⁹

Prognosis and outcomes

Although multiple attempts of surgery may be necessary, the success rate of fistula repair is around 75%, resulting in a dramatic improvement in quality of life.¹⁰ Although complete healing may take several months, patients can usually return to their daily routines within a week or two of surgery.⁴ This depends on the severity of the fistula, the success of the surgery, and the presence of post-surgical complications. For the remaining patients in whom surgical repair only succeeded in shrinking the fistula rather than closing the fistula, a surgical thread known as a seton can be threaded through the fistula. This thread allows control of drainage through the fistula and can help to control symptoms.¹¹

Prevention

When it comes to preventing rectovaginal fistulas, it is important to consider how to prevent them from happening in the first place (primary prevention), and how to prevent recurrence (secondary prevention). 

Methods of primary prevention include:

• Delaying the age of first pregnancy (especially in vulnerable young girls)¹²
• Family planning:
  • Planning around risks
  • Leaving adequate space between births to enable sufficient healing
• Opting for C-section delivery if at high risk of RVF
• Immediate urinary catheterisation during labour if at high risk of RVF¹³

Methods of secondary prevention aim to promote fistula healing and reduce the likelihood of recurrence by preventing infection and irritation. The following methods are all part of healthy feminine hygiene, and are recommended even in the absence of RVF:

• Washing intimate areas with water or mild soap
• Avoiding scented products
• Keeping the rectovaginal area dry
• Wearing cotton, loose-fitted underwear¹⁴

Emotional and psychological impact

Before rounding this article off, it is important to acknowledge the emotional and psychological impact RVF can have. In societies where a person's AFAB’s value is intrinsically tied to their reproductive health and sexual desirability, a diagnosis of RVF can be physically, mentally, and societally devastating. Such a diagnosis may jeopardise a person AFAB’s marriage prospects and ostracise them from wider society due to the nature of their symptoms. For those in intimate relationships, sexual intercourse can be a particularly burdensome experience due to the pain experiences, fear of defecating during intercourse, and fear of dissatisfying their partners.⁵ In certain societies, this may put those living with RVF at risk of intimate partner violence¹⁴ and the social instability that comes with separation and divorce.⁵

Summary

A rectovaginal fistula (RVF) is an abnormal connection between the rectum and the vagina, often caused by trauma during childbirth or underlying conditions. RVF can lead to distressing symptoms, including pain, foul-smelling discharge, faecal incontinence, and mental health burdens. Diagnosing RVF involves physical examinations and imaging, with a focus on ruling out alternative conditions with similar symptoms. Treatment options include surgical repair and therapy for underlying causes and complications. Successful repair can significantly improve a person's AFABs quality of life. Primary prevention methods include family planning and C-section delivery, while secondary prevention involves hygiene practices. The emotional and psychological impact of RVF can be devastating, affecting a person's AFAB’s self-esteem, relationships, and societal standing, emphasising the need for prompt medical attention and destigmatization. Giving those AFABs the space to share their experiences can provide empowerment to people lacking a voice, creating a spirit of advocacy and sisterhood. This can dispel the social isolation which may otherwise be experienced by those living with RVF.

FAQs

What is a rectovaginal fistula?

A rectovaginal fistula (RVF) is an abnormal passageway that forms between the rectum and the vagina. This condition arises as a result of various mechanisms, most commonly due to physical trauma during childbirth.

What causes rectovaginal fistulas?

RVFs can be caused by traumatic or non-traumatic factors. Traumatic causes include injuries sustained during prolonged and obstructed labour, surgical errors, or, less frequently, forceful sexual intercourse. Non-traumatic causes may result from inflammatory bowel diseases such as Crohn's disease, cancer in the surrounding areas, local injury from radiation, or local infection.

What are the symptoms of a rectovaginal fistula?

RVF symptoms are distressing and often involve the abnormal flow of gas or faecal matter from the rectum into the vaginal cavity. Common symptoms include:

• Pain and discomfort
• Foul-smelling vaginal discharge
• Faecal incontinence through the vagina
• Pain during sexual intercourse
• Chronic recurrent vaginal and/or bladder infections 
• Significant mental and emotional burden

How is a rectovaginal fistula diagnosed?

Diagnosis of RVF involves a three-step approach: identifying the patient's symptoms, a physical examination of the vagina using a speculum, and imaging and diagnostic testing. This may include blood tests, biopsies, and imaging studies, including  CT scans, ultrasounds, MRI scans, and endoscopies. The goal is to rule out alternative conditions with similar symptoms.

Can rectovaginal fistulas heal on their own?

While some traumatic fistulas may heal on their own, larger or more severe cases often require surgical repair under general anaesthesia.

What are the treatment options for rectovaginal fistulas?

Surgical repair is considered the gold standard for treating RVFs. However, the course of treatment depends on the underlying cause. Infections may be treated with antibiotics and supportive care, whilst underlying diseases such as inflammatory bowel disease or cancer require appropriate treatment and therapy.

What should I expect during treatment and recovery?

Following surgery, the success rate for RVF repair is around 75%. Complete healing can take several months, but most patients can return to their daily routines within a week or two of surgery, depending on the severity of the fistula and the success of the procedure.

Can rectovaginal fistulas recur?

In some cases, surgical repair may only shrink the fistula rather than closing it entirely. In such instances, a surgical thread known as a seton may be used to control drainage and manage symptoms.

How can rectovaginal fistulas be prevented?

Preventing RVFs involves primary and secondary prevention methods. Primary prevention includes delaying the first age of pregnancy, family planning, and opting for a C-section delivery if at high risk. Secondary prevention focuses on promoting fistula healing and reducing the likelihood of recurrence through healthy feminine hygiene practices.

What is the emotional and psychological impact of RVFs?

RVFs can have a profound emotional and psychological impact, particularly in societies where the value of those AFAB is closely tied to their reproductive health and sexual desirability. In certain societies, this may put those living with RVF at risk of intimate partner violence and social instability.