Rectovaginal Fistula
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Rectovaginal Fistula- Key Concepts
- Etiology of Rectovaginal Fistula
- Obstetrical
- Crohn’s Disease
- Cryptoglandular
- Anastomotic and Other Surgical Complications
- Radiation Injury
- Evaluation of Patient with RVF
- Surgical Techniques
- Conclusion
- References
Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula (2022)
Anorectal Disease- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 36-year-old woman has a history of obstetric injury and low rectovaginal fistula. Magnetic resonance imaging shows a 45 degree anterior sphincter defect. The patient reports weekly fecal incontinence. What is the recommended treatment?
- A 52-year-old woman presents with a distal recurrent rectovaginal fistula after 2 failed endorectal advancement flap repairs. She had normal findings on colonoscopy and endorectal ultrasonography confirmed a rectovaginal fistula in the very distal rectum with an intact sphincter complex and seton in place. What is the best next surgical treatment?
- A 27-year-old woman presents with a grade 4 perineal laceration 2 weeks after vaginal delivery. At the time of delivery, a repair was attempted. She presents today reporting passage of flatus and stool from the vagina. On examination under anesthesia, the patient is found to have a low rectovaginal fistula. What is the next step in management?
- A 27-year-old woman with no previous medical problems presents 1 day after prolonged vaginal delivery with passage of stool from the vagina. On physical examination, she has a 2-cm rectovaginal fistula approximately 3.5 cm from the anal verge with no sign of infection. She has no significant gastrointestinal history and no family history of gastrointestinal disorders. What is the best next step for this patient?
- A 55-year-old man presents with malaise, fatigue, inability to urinate, temperature of 102°F (38.8°C) and a heart rate of 115 beats/min 4 days after undergoing rubber band ligation for bleeding internal hemorrhoids. What is the next step in management?
Anorectal Disease- A 53-year-old woman, gravida 3, para 3, with a BMI of 38 and diabetes, and who is an active smoker presents to your office with a draining seton placed for recurrent fistula in ano. Magnetic resonance imaging (MRI) shows a right anterolateral transsphincteric fistula with an anterior sphincter defect. Which factor places her at the highest risk for anal advancement flap failure?
- A 36-year-old patient with quiescent Crohn’s disease involving the ileum and rectum presents to your clinic to discuss treatment for a symptomatic rectovaginal fistula. She is maintained on biologic therapy with excellent control. Recent colonoscopy has demonstrated no active proctitis. The best approach for this patient is management with
- A 29-year-old patient presents with an anovaginal fistula following a vaginal delivery 2 years ago and which was complicated by a fourth-degree perineal laceration. She reports incontinence to gas and liquid stool. Digital rectal examination demonstrates diminished sphincter tone, and anoscopy reveals a 1-cm internal fistula opening in the anterior midline at the dentate line. The most next appropriate step is
- A 55-year-old woman presents with persistent feculent drainage from the vagina despite prior transanal and transvaginal repairs. What is the best next step?
- A 24-year-old woman reports feculent vaginal discharge 8 months after spontaneous vaginal delivery complicated by a 4th-degree perineal laceration, which was previously repaired. Physical examination reveals a 3-mm rectovaginal fistula 2 cm proximal to the anal verge with significant thinning of the perineal body and a palpable sphincter defect anteriorly. Endoanal ultrasound confirms a 90° defect of the external sphincter at the anterior midline. The best next step in management is
- A 29-year-old female patient presents 3 weeks postpartum following a vaginal delivery. She has incontinence to flatus and flatus per vagina. Examination shows an intact perineum, adequate resting anal tone, and a 5-mm anterior defect in the upper anal canal. What is the most appropriate next step in her management?
- A 38-year-old patient presents with symptomatic grade 3 internal hemorrhoids. Which of the following is a contraindication to stapled hemorrhoidopexy?
- Benign Disease
- A 24-year-old patient underwent penile inversion vaginoplasty 5 days ago. You notice feculent drainage on the vaginal packing. The patient has no signs of sepsis. The speculum examination does not show an obvious rectovaginal fistula. The patient has minimal fecal discharge per her vagina over the past few days. The best next step in management is
- A 54-year-old woman with a history of endometriosis is referred to you for worsening constipation, bloating, and pelvic pain. She previously underwent a laparoscopic-assisted hysterectomy with bilateral salpingo-oophorectomy. You perform a colonoscopy and identify a stricture at the rectosigmoid; the rest of her colon was normal. Pelvic magenetic resonance imaging (MRI) shows irregular thickness with three large spiculated nodules that were hypointense on T1- and T2-weighted images, encasing 70% of the wall of the rectosigmoid, consistent with endometriosis. What is the best surgical option for this patient?
- A 39-year-old woman with a history of long-standing ulcerative colitis (UC) undergoes an elective total proctocolectomy and ileoanal pouch anal anastomosis (IPAA). Two months postoperatively, she reports a persistent low-grade fever, dyspareunia, vaginal air, and mucopurulent rectal drainage. A gastrografin pouch study demonstrates a pouch vaginal fistula. What is the most likely etiology?
- Pelvic Floor
- Anorectal Crohn’s Disease
- Radiation, Microscopic, and Ischemic Colitis
Complex Anterior Anorectal Fistulae in Women- Common Tests for the Pelvic Floor
Local Excision- Fecal Incontinence: Evaluation and Treatment
- Treatment of Difficult/Obstructive Defecation
Ligation of Intersphincteric Fistula Tract for Perianal Fistula: Long-term Results, Functional Outcomes, and Predictors of Failure- About ASCRS Textbook of Colon and Rectal Surgery
- Rectourethral and Complex Fistulas: Evaluation and Management
- Crohn’s Disease: Surgical Management
- Cryptoglandular Abscess and Fistula
- Treatment of Rectal Prolapse (2017)
- Rectal Cancer: Local Excision
- Hemorrhoids
- Endoscopy
- Endometriosis
- Treatment of Chronic Radiation Proctitis (2018)
- Ulcerative Colitis: Surgical Management
- Management of Hemorrhoids (2024)
- Anatomy and Embryology of the Colon, Rectum, and Anus
- Surgical Management of Crohn's Disease (2020)
- Evaluation and Management of Chronic Constipation (2024)