What Is a Rectovaginal Fistula and How’s It Treated?

Rectovaginal fistulas can cause a variety of symptoms:

• passing stool or gas from your vagina
• trouble controlling bowel movements
• smelly discharge from your vagina
• repeated vaginal infections
• pain in the vagina or the area between your vagina and anus (perineum)
• pain during sex

If you have any of these symptoms, see your doctor.

The most common causes of a rectovaginal fistula include:

• Complications during childbirth. During a long or difficult delivery, the perineum can tear, or your doctor might make a cut in the perineum (episiotomy) to deliver the baby.
• Inflammatory bowel disease (IBD). Crohn’s disease and ulcerative colitis are types of IBD. They cause inflammation in the digestive tract. In rare cases, these conditions can increase your risk of developing a fistula.
• Cancer or radiation to the pelvis. Cancer in your vagina, cervix, rectum, uterus, or anus can cause a rectovaginal fistula. Radiation to treat these cancers can also create a fistula.
• Surgery. Having surgery on your vagina, rectum, perineum, or anus can cause an injury or infection that leads to an abnormal opening.

Other possible causes include:

• an infection in your anus or rectum
• infected pouches in your intestines (diverticulitis)
• stool stuck in your rectum (fecal impaction)
• infections due to HIV
• sexual assault

You are more likely to get a rectovaginal fistula if:

• you had a long and difficult labor
• your perineum or vagina ripped or was cut with an episiotomy during labor
• you have Crohn’s disease or ulcerative colitis
• you have an infection such as an abscess or diverticulitis
• you’ve had cancer of the vagina, cervix, rectum, uterus, or anus, or radiation to treat these cancers
• you had a hysterectomy or other surgery to the pelvic area

About 0.5 percent of women who have vaginal deliveries worldwide get this condition. However, it’s much less common in developed countries like the United States. Up to 10 percent of people with Crohn’s disease develop rectovaginal fistula.

Rectovaginal fistula can be difficult to talk about. Yet it’s important to tell your doctor about your symptoms so you can get treated.

Your doctor will first ask about your symptoms and perform a physical exam. With a gloved hand, the doctor will check your vagina, anus, and perineum. A device called a speculum may be inserted into your vagina to open it up so your doctor can see the area more clearly. A proctoscope can help your doctor see into your anus and rectum.

Tests your doctor might use to help diagnose rectovaginal fistula include:

• Anorectal or transvaginal ultrasound. During this test, a wand-like instrument is inserted into your anus and rectum, or into your vagina. An ultrasound uses sound waves to create a picture from inside your pelvis.
• Methylene enema. A tampon is inserted into your vagina. Then, a blue dye is injected into your rectum. After 15 to 20 minutes, if the tampon turns blue, you have a fistula.
• Barium enema. You will get a contrast dye that helps your doctor see the fistula on an X-ray.
• Computerized tomography (CT) scan. This test uses powerful X-rays to make detailed pictures inside your pelvis.
• Magnetic resonance imaging (MRI). This test uses strong magnets and radio waves to make pictures from inside your pelvis. It can show a fistula or other problems with your organs, such as a tumor.

The main treatment for a fistula is surgery to close the abnormal opening. However, you can’t have surgery if you have an infection or inflammation. The tissues around the fistula need to heal first.

Your doctor might suggest that you wait for three to six months for an infection to heal, and to see if the fistula closes on its own. You’ll get antibiotics to treat an infection or infliximab (Remicade) to bring down inflammation if you have Crohn’s disease.

Rectovaginal fistula surgery can be done through your abdomen, vagina, or perineum. During the surgery, your doctor will take a piece of tissue from somewhere else in your body and make a flap or plug to close the opening. The surgeon will also fix the anal sphincter muscles if they’re damaged.

Some women will need a colostomy. This surgery creates an opening called a stoma in your belly wall. The end of your large intestine is put through the opening. A bag collects wastes until the fistula heals.

You may be able to go home on the same day as your surgery. For some types of surgery, you’ll need to stay overnight in the hospital.

Possible risks from the surgery include:

• bleeding
• infection
• damage to the bladder, ureters, or bowel
• blood clot in the legs or lung
• blockage in the bowel
• scarring

Rectovaginal fistula can affect your sex life. Other complications include:

• trouble controlling the passage of stool (fecal incontinence)
• repeated urinary tract or vaginal infections
• inflammation of your vagina or perineum
• a pus-filled sore (abscess) in the fistula
• another fistula after the first one is treated

While you wait to have surgery, follow these tips to help yourself feel better:

• Take the antibiotics or other medications your doctor prescribed.
• Keep the area clean. Wash your vagina gently with warm water if you pass stool or a foul-smelling discharge. Use only gentle, unscented soap. Pat the area dry.
• Use unscented wipes instead of toilet paper when you use the bathroom.
• Apply talcum powder or a moisture-barrier cream to prevent irritation in your vagina and rectum.
• Wear loose, breathable clothing made from cotton or other natural fabrics.
• If you’re leaking stool, wear disposable underwear or an adult diaper to keep the feces away from your skin.

Sometimes a rectovaginal fistula closes up on its own. Most of the time, surgery is needed to correct the problem.

The odds of surgery success depend on what type of procedure you have. Abdominal surgery has the highest rate of success, at 95 percent. Surgery through the vagina or rectum has about a 55 percent success rate. If the first surgery doesn’t work, you will need another procedure.