They are usually caused by errors in surgical technique, where the posterior vaginal wall is also caught in the stapler.Īnother suspected cause of the rising incidence of rectovaginal fistula is the introduction of the more technically challenging STARR (Stapled Trans Anal Rectal Resection) and TRANSTAR (Transanal Stapled Resection) procedures, ,, ,. While rectovaginal fistulas are an absolute rarity after conventional hemorrhoid surgery, cases of postoperative fistulas have been increasingly reported since the introduction of stapler hemorrhoidopexy, ,.
Procedures include transanal tumor resection (anterior rectal wall), hemorrhoid surgery using staplers, and procedures for pelvic floor disorders (descent, rectal prolapse, rectocele, incontinence) using staplers or mesh implantation. With the increase of reconstructive procedures in the pelvic floor region, the number of publications on fistula formation between the rectum and vagina has risen as well. Strength of consensus: Strong consensus.Recommendation level: Point of clinical consensus (PCC).The assessment of any perineal defects is also important for treatment planning. Fistulas in the central third are very rare due to the location and the characteristics of the vaginal wall for high fistulas, there is no sharp distinction to colovaginal fistulas, which typically occur secondary to hysterectomy and terminate in the vaginal cuff, which represents a weak point. Some publications describe anovaginal fistulas that terminate directly at the introitus without contact to the vaginal tube and typically arise from the anal canal. Low fistulas are those that can be reconstructed via an anal, perineal, or vaginal access, while high fistulas require an abdominal approach. In view of the surgical procedure, it makes sense to distinguish between low and high rectovaginal fistulas. Since the vast majority of fistulas are of traumatic origin, no natural relationships are available as a basis for classification. Most classifications are based on size, localization, and etiology. No generally accepted classification of rectovaginal fistulas exists. Rectovaginal fistula, surgery, incontinence, postpartal trauma, rectal cancer, German guideline Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature. Given the low evidence level, this guideline is to be considered of descriptive character only. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient.Ĭonclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany.
Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. In higher fistulas, abdominal approaches are used as well. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. The most common procedure involves a transrectal approach with endorectal suture.
Various surgical procedures have been described. Persistent rectovaginal fistulas generally require surgical treatment. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Other pathologies should be ruled out by endoscopy, endosonography or tomography. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Methods: A systematic review of the literature was undertaken. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. The most common causes are obstetric trauma, local infection, and rectal surgery. Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin.