Vaginal perineal fistula. Treatment and prevention of fistula in the vagina. Treatment of rectovaginal fistula

– pathological anastomosis (fistulas) connecting the vagina with the intestines or urinary organs (bladder, ureter, urethra). Through the fistulous tracts, the contents of the intestines and urinary tract (feces, gases, urine) enter the vaginal lumen. Vaginal fistula is diagnosed based on the results of a gynecological examination, endoscopic and x-ray examinations of the pelvic organs. Treatment of fistulas is surgical, aimed at eliminating the pathological communication of the vagina with other organs.

General information

Vaginal fistulas are a serious complication, often encountered in obstetrics and gynecology. The vaginal wall is in direct contact with the walls of the rectum and urinary organs, therefore, when a pathological communication occurs between them, a fistula defect is formed.

Among vaginal fistulas, vesicovaginal, uretero-vaginal, urethrovaginal, rectovaginal, colon-vaginal, and enteric-vaginal fistulas are distinguished. Based on their location, vaginal fistulas are divided into low (in the lower third of the vagina), medium (in the middle third) and high (in the upper third of the vagina). Most vaginal fistulas are acquired, and the developmental features and clinical signs of the disease depend on the reasons for the formation of the defect.

Causes of vaginal fistula formation

The most common - traumatic vaginal fistulas occur as a result of damage to the intestinal wall, urinary tract and vagina during invasive manipulations and operations in urology, proctology, obstetrics and gynecology. Urogenital fistulas are usually a complication of reconstructive operations for urethral diverticula, stress urinary incontinence, prolapse of the anterior wall and vaginal cysts, radical hysterectomy, supravaginal amputation of the uterus, etc.

Rectovaginal fistulas are most often formed as a result of obstetric trauma or trophic disorders during pathological childbirth. Trauma or rupture of the birth canal if it does not correspond to the size of the fetus, breech presentation of the fetus, or operative delivery may be accompanied by damage to the walls of the vagina, rectum and its ligamentous-muscular apparatus. The development of vaginal fistulas may be based on prolonged ischemia and necrosis of soft tissues due to compression between the fetal head and pelvic bones during prolonged labor and a long anhydrous interval.

Fistulas of an inflammatory nature are usually formed as a result of opening of abscesses into the vaginal lumen or perforation of acute paraproctitis or diverticulitis. Less commonly, the causes of vaginal fistulas can be burns (chemical, electrical), domestic trauma to the rectovaginal septum, ectopia of the ureter, Crohn's disease, irradiation of the pelvic organs during radiation therapy, tumor diseases of the pelvic organs.

Symptoms of vaginal fistula

The course of vaginal fistulas, as a rule, has a chronic, recurrent nature. With genitourinary fistulas, patients are bothered by involuntary partial or complete urinary incontinence due to leakage from the vagina, and frequent urinary tract infections. There is maceration of the epidermis in the perineum and thighs, swelling and hyperemia of the vaginal mucosa.

Urine leakage with continued urination usually indicates pinpoint or high-lying fistulas. When urethro-vaginal fistulas are located in the middle or proximal urethra, urine cannot be retained in either the vertical or horizontal position of the patient. As the pathology progresses, pain in the vagina and bladder is observed. Intestinal-vaginal fistulas are characterized by complaints of incontinence of gases (with point fistulas) and feces (with large fistulas), discharge of gases and feces through the vagina, burning and itching of the genitals due to irritation of the mucous membrane around the fistula.

Constant infection of the vagina from the rectum is manifested by frequent exacerbations of colpitis, vulvitis, provoking pain in the perineum at rest and during sexual intercourse. Rectovaginal fistulas are often accompanied by severe cicatricial deformation of the posterior wall of the vagina and perineum, failure of the pelvic floor muscles and a defect in the rectal sphincter.

With vaginal fistulas of purulent-inflammatory origin, there may be a deterioration in the general condition, fever, pain in the lower abdomen and pubic region, radiating to the rectum or lower back, purulent leucorrhoea, loose stools with an abundance of mucus and pus in the feces, dysuria, pyuria, and sometimes menouria. Symptoms of vaginal fistula cause physical discomfort and are often accompanied by psycho-emotional disorders.

Diagnosis of vaginal fistulas

Diagnosis of any vaginal fistula begins with a thorough collection of medical history and gynecological examination of the patient. In the case of low-lying vaginal fistulas, when examined in the speculum, you can see a retracted scar (ostium), from which urine or intestinal contents are released. The height and direction of the fistula tract is determined using probing with a button probe. To clarify the localization of urovaginal fistulas, urethrocystoscopy and chromocystoscopy with indigo carmine are performed.

In the diagnosis of vaginal fistulas of inflammatory origin, ultrasound of the pelvis and ultrasound of the kidneys, laboratory tests of blood and urine are indicated. For difficult to diagnose high and pinpoint urovaginal fistulas, excretory and retrograde urography, renography, cystography, and, if necessary, vaginography are additionally performed. In the case of rectogenital fistulas, a rectovaginal examination is performed to determine the size, consistency of the fistula, the volume of scar damage to surrounding tissues, the degree of anal sphincter insufficiency, the presence of infiltrate, and the possibility of developing an abscess.

Mandatory endoscopic examination, clarifying the location of fistulas of the vagina and intestines, is sigmoidoscopy, if necessary, differentiation of the diagnosis - colonoscopy. For complex fistulas, contrast radiographic studies are performed: irrigoscopy, fistulography, which help to see the branches and leaks of the fistula tract.

Diagnosis of vaginal fistulas may include cytological or histological examination of affected tissue taken during biopsy, CT scan. The rectoanal reflex is assessed using instrumental methods - sphincterometry, electromyography, anorectal manometry.

Treatment of vaginal fistulas

The treatment tactics for vaginal fistulas depend on the main characteristics of the fistula, the condition of the surrounding tissues, the pelvic floor muscles and the rectal sphincter. Small cystovaginal fistulas may heal on their own after conservative treatment; punctate fistulas of the urethra and bladder can be closed with electrocoagulation.

For most genitourinary fistulas, 3 to 6 months after the injury, when the inflammatory processes subside, surgical excision of the scar lesion in the fistula area is indicated, followed by separate suturing of defects in the vaginal wall, bladder or urethra using patchwork. In the case of ureterovaginal fistula, ureterocystoneostomy is performed. Acute rectovaginal injuries are urgently eliminated within the first 18 hours: after preliminary treatment of the edges of the wound, non-viable tissue around the fistula is excised and the levators, rectal and vaginal walls are sutured in layers.

Surgical intervention for formed fistulas of the vagina and rectum is determined by the specific situation and is carried out through vaginal, perineal or rectal approaches; in case of significant scarring - laparotomy. After excision of scar tissue and the fistula opening, anterior levatoroplasty is performed; if necessary, it is combined with vaginoplasty; in case of a sphincter defect, sphincteroplasty is performed, followed by suturing of the intestinal and vaginal defects. In case of cicatricial or purulent process in the area of the fistula, a colostomy is first applied for 2-3 months to divert feces from the area of future surgery.

Prognosis and prevention of vaginal fistulas

Serious postoperative complications of vaginal fistulas are failure of intestinal sutures and recurrence of the fistula, requiring repeated radical surgery. The prognosis for ability to work and quality of life after elimination of vaginal fistulas is relatively favorable. After closure of vaginal fistulas, women are recommended to deliver their next pregnancy by cesarean section no earlier than 2-3 years after the operation.

Prevention of vaginal fistulas consists of preventing obstetric injuries, qualified management of obstetric and gynecological operations, and timely treatment of genital inflammation.

In gynecology, the concept of “rectovaginal fistula,” which is also called a fistula, refers to pathological changes that do not exist normally. Rarely, a fistula is congenital, but in most cases, a fistula is classified as an acquired disease with a variety of causes and the only treatment method is surgery.

Rectovaginal fistula: what is it?

From the point of view of medical terminology, a fistula is a canal in the septum connecting the cavities of organs to each other or to the external environment. In gynecology, a narrow canal opened from the inside by the epithelium is a damage to the rectovaginal septum. The result of the development of the pathological condition is the formation of a passage from the vagina into the rectal space.

The consequence of the unnatural lumen between the chambers is the passage of feces with mucus and gases through the vagina.

The disease is accompanied by pain in the perineal area, pain during sexual intercourse, and dysuric disorders.

What is known about congenital pathology

The description of the disease is included in the 10th version of the ICD, which is a list of the International Classification of Diseases. The description of congenital rectovaginal fistula is included in the chain of classes of congenital anomalies of the female genital organs - position 5, number Q52.2. The protocol contains complete information for medical professionals about the disease of the female genital area.

Factors provoking the appearance of the disease

The discovery of rectovaginal fistulas in adults is considered a rather rare occurrence; in ICD-10 its code is N82.3. Congenital defects in female children are successfully eliminated surgically in childhood.

The causes of acquired pathology are as follows:

birth injuries - mechanical rupture of the septum due to the passage of a large fetus, some obstetric manipulations;
a protracted labor process with the death of soft tissues due to the baby’s head being pressed against the pelvic bone, which leads to a lack of nutrition and moisture;
inflammation of infected wounds as a result of postpartum tears, even with proper stitching, which slows down the healing of defects after childbirth;
injury to the rectum due to damage to the septum during tumor resection operations or during anal sexual intercourse;
inflammatory diseases of the intestines and genitourinary organs, breakthrough of purulent masses in the vagina, complications after Crohn's disease, as well as diverticulosis.

The postpartum type of rectovaginal fistula often has a simple structure - the location of the defects in the rectum and vagina is similar. Fistulas of a traumatic nature, formed due to colitis or due to an acute form of paraproctitis, have a more complex form. In this case, the opening of the inflamed tissue of the rectum occurs in the vagina, causing damage to the barrier by a fistula of a branched structure with chambers of purulent exudate.

The photo shows a rectovaginal fistula

Conditions for the formation of the fistula mouth

In light of the structure of the organs (vagina and rectum), their adjacent walls are in close contact with each other along an extended trajectory. Intravaginal pressure is significantly less than intraintestinal pressure. This leads to prolapse of the mucous membrane of the walls of the rectum into the vaginal cavity through the rectovaginal communication, which arises for any reason.

The result of intestinal ectropion is the release of intestinal contents into the vaginal space.

A temporarily formed fistula after 7-8 days turns into a permanent problem, resulting in fusion of the mucous membranes of the rectum with the walls of the vagina at the site of the defect.

Classification

The types of rectovaginal canals in the interstitial septum are usually classified according to the location of the fistula tube in the space of the rectum relative to the linea pectinea (anus):

high type - the mouth of the fistula is 60 mm or more above the anus;
medium type - the fistula channel is localized 60 mm above the anus, but not lower than 30 mm;
low type - the entrance to the tube is found below 30 mm under the anus.

Most of the defects have a lip-like structure. The openings of classical types of fistulas coincide in both cavities, having a short and straight channel. Branched fistulas that form in the rectal area have a different topographic-anatomical picture. Fistulas of a tubular structure are surrounded by purulent bags or streaks that infect the surrounding tissue.

Symptoms of the pathological condition

The severity of signs signaling the formation of a rectovaginal fistula depends on the size and location of the interstitial canal. The main and most unpleasant symptom of female pathology is the evacuation of stool with pus from the rectum through the vagina. The most common sign of the disease is uncontrolled vaginal discharge of gases (intestinal).

Other symptoms of rectovaginal fistula are:

inflammation bothers a woman with pain in the perineal area, especially during intimacy, forcing her to refuse sexual contacts;
the appearance of an accompanying fistula () causes the vagina to fill with urine, causing great inconvenience to the patient;
no less debilitating are dysuric disorders along with the unpleasant odor of feces, even with good hygiene.

For young women, such symptoms bring physical and moral suffering, worsening intimate life and family relationships, and the development of psychoneurological disorders. The presence of a constant source of infection in the vaginal cavity increases the frequency of exacerbations of inflammatory processes in the female genital tract (colpitis), as well as diseases of the urinary system.

Features of diagnostic methods

If the gynecologist suspects the formation of a rectovaginal fistula, during the interview with the patient, the doctor finds out the development of the clinical picture, specifying the number and type of diseases, the number of births, and the presence of operations.

To diagnose fistula pathology, a complex of informative examinations will be required:

Examination on a gynecological chair using a speculum system allows visualization of the posterior wall of the vagina to locate the canal. During the manual examination, the fistula itself and the scars in its surroundings are identified.
The method of two-handed examination of the vaginal and rectal space complements the gynecological examination. This is the possibility of detecting an anastomosis in the plane of the anterior rectal wall, connecting the intestine to the vagina.
Using sigmoidoscopy, a detailed examination of the mucous membrane inside the rectum is continued in search of a rectovaginal fistula. The use of an endoscope allows you to determine the diameter and direction of the tube and take a biopsy sample.
Fistulography is considered the most informative, especially in the formation of tubular fistulas. By saturating the fistula with a contrast agent, it is possible to detect the exact number of tubes, as well as leaks and cavities, in the images.

In the case of branching fistula tracts with severe tissue scarring, the results of additional diagnostic techniques may be required. During a rectal ultrasound examination, the likelihood of external or internal damage to the colon is determined. Modern diagnostics using colonoscopy makes it possible to assess the condition of the large intestine along its entire length; the pressure in its lumen is measured during manometry.

If the doctor suspects that the cause of the rectovaginal fistula could be concomitant pathologies (Crohn's disease, tumor, diverticulosis, etc.), it is necessary to conduct a differential diagnosis together with a proctologist and oncologist.

How to treat pathology?

The only way to get rid of a rectovaginal fistula is through surgery. If no more than 18 hours have passed since the damage to the rectal-vaginal septum, the integrity of the septum is restored by suturing the wound while simultaneously excision of its edges. Treatment of fully formed fistulas is quite difficult.

With many developed techniques, the following operations most often eliminate tissue defects:

Name of surgery	Brief information about the essence of the surgical process
Allotransplantation	The scar tissue is excised along with the fistula. The patient’s own tissue or a collagen analogue is used as a patch.
Using traffic jams	The mouth of the fistula canal is closed with an obturator made of collagen fibers. The biological plug is fixed with sutures in the lumen of the rectum.
Application of titanium clips	Focusing on advanced technologies, the walls of the fistula in the rectovaginal septum are compressed using a titanium clip that does not cause pain.

In case of existing purulent inflammation, surgical intervention is postponed for 2-3 months to allow the inflammatory process to subside. To remove feces, a colostomy is placed on the anterior abdominal wall, surgically forming an artificial anus. Thus, the lower intestines are switched off, local inflammation is cured, and fistulas often resolve on their own without surgery.

What is the danger

As with any surgery, there may be complications after surgery to remove a rectovaginal fistula. Depending on the type of manipulation, the incidence of recurrent fistula ranges from 10-30%. It takes 3-4 months to wait for a lasting result; otherwise, repeated radical intervention is necessary. If a positive result is achieved, the woman can plan a pregnancy by preparing for a caesarean section.

Preventive measures to protect against rectovaginal fistulas are simple - it is important to promptly and completely cure gynecological diseases identified during regular examinations. You should also pay special attention to the treatment of inflamed intestines under the supervision of a proctologist. The absence of fistulas in the thickness of the rectovaginal septum excludes the appearance of purulent foci.
Treatment of rectovaginal fistula by installing a plug:

Practical activities:

Rectovaginal fistulas

Rectovaginal fistulas are a relatively rare, but extremely serious disease for patients. Without presenting an immediate threat to life, the main manifestations of these fistulas - involuntary release of gases and feces from the vagina - lead to a sharp change in the usual lifestyle, self-isolation, change of place of work, force patients to give up intimate life, and lead to the breakup of families. Rectovaginal (or rectovaginal fistulas) are the most common type of enterovaginal fistula. In this case, a pathological communication (anastomosis, fistula) occurs between the rectum and vagina.

What are the types of rectovaginal fistulas?

Rectovaginal fistulas are traditionally divided into congenital and acquired. Congenital rectovaginal fistula is a rare disease that is usually combined with other anorectal anomalies (anal atresia, etc.). Typically, anorectal developmental anomalies require correction in childhood, and are the responsibility of pediatric surgeons.

Why do rectovaginal fistulas occur?

In most cases, rectovaginal fistulas are acquired in nature and are divided into traumatic, inflammatory, oncological and radiation.

The most difficult group of patients with rectovaginal fistulas are cancer patients. One of the reasons for the formation of fistulas in such patients is the local spread of the tumor in the pelvis. By growing into adjacent organs, malignant tumors of the bladder, female genital organs, rectum or anal canal can lead to the formation of intestinal fistulas. In the absence of distant metastases, the only chance to save the patient from cancer and fistula may be to perform pelvic exenteration. But more often, a fistula in an oncology patient is not a consequence of progression of the underlying disease, but a complication of antitumor treatment, mainly radiation therapy. Sometimes patients who have been cured of cervical cancer through surgery and radiation therapy “pay” for recovery from the malignant disease by the formation of rectovaginal fistulas. This occurs because radiation therapy damages not only tumor cells, but also normal tissues. The rectum is most sensitive to radiation exposure.

The cause of rectovaginal fistulas of inflammatory origin may be the so-called “anterior” acute purulent paraproctitis, opened in the vagina. Crohn's disease of the large intestine can also lead to the formation of abscesses (pus cavities) in the tissue between the vagina and rectum, and then to the rupture of pus into the vagina and rectum, followed by the formation of a fistula (pathological communication) between them.

There are frequent cases of rectal injury during various gynecological operations. Surgical interventions with an increased risk of rectal injury are operations for rectocele using synthetic prostheses, colpoperineolevatoplasty (plasty of the posterior wall of the vagina and perineum), removal of retrocervical endometrioid infiltrate, removal of the peritoneum of the rectouterine cavity for ovarian cancer, and others.

Often, rectovaginal fistulas are formed as a result of suppuration of the perineal wound after suturing a third-degree perineal rupture during childbirth.

An everyday injury to the rectum is also possible during masturbation with the use of dildos, or when the perineal area falls on sharp objects.

What examination is needed?

Diagnosis of enterovaginal fistulas usually does not present any particular difficulties. Constant uncontrolled release of gases and feces from the vagina are the main symptoms of these fistulas. The patient is examined on a gynecological chair. In this case, you can detect scars in the perineal area, visualize a fistula in the vagina, determine the lack of closure of the anal sphincter, involuntary release of gases and feces. During examination, the integrity of the anal reflex is assessed. To do this, make stroke movements in the area of the anus, labia majora and buttocks, and evaluate the contraction of the external anal sphincter. With a digital examination of the anal canal and rectum, the doctor can determine the level of the fistula on the side of the rectum, assess the condition of the rectal mucosa, the presence of an anal sphincter defect and its tone, and the condition of the pelvic floor muscles. Further, the examination is complemented by instrumental research methods. Anoscopy allows you to visually assess the condition of the mucous membrane of the anal canal and distal rectum. To exclude concomitant pathology of the large intestine, all patients must undergo colonoscopy or irrigoscopy with double contrast. Transanal ultrasound (US) and magnetic resonance imaging (MRI) allow more accurate visualization of the extent of the anal sphincter defect. It is also sometimes necessary to assess the condition of the closure apparatus (sphincter) of the rectum before surgery. For this purpose, functional methods of instrumental diagnostics are used. Sphincterometry, anal profilometry and electromyography provide the most complete picture of the functional state of the internal and external anal sphincters.

What treatment is possible for rectovaginal fistulas?

Conservative treatment of rectovaginal fistulas is ineffective; the main role is given to surgical treatment. At the first stage of treatment, most patients are given a colostomy, that is, a section of the large intestine located above the fistula area is brought out onto the skin of the anterior abdominal wall. Thanks to this operation, the area of the rectovaginal fistula is “switched off” and isolated from feces. Firstly, it relieves patients from such painful symptoms of the disease as the constant release of gases and feces from the vagina, and an unpleasant odor. Secondly, it helps relieve inflammation in the fistula area. The second stage of surgical treatment is the actual operation to close the intestinal-vaginal fistula. You can refrain from forming a colostomy only for small, low traumatic fistulas. Usually the operation is performed several months after the formation of the fistula. This time is necessary for the inflammation in the fistula area to completely subside and for the formation of favorable conditions for surgery. With post-radiation fistulas, the time before surgery can extend to 6–12 months. Surgery to close a fistula can be performed using an approach through the abdomen, vagina, or rectum. The access option depends on the location and size of the fistula, and the experience of the surgeon. The purpose of the operation is to separate the vagina and rectum and suturing them separately.

If the cause of the formation of a fistula is acute paraproctitis, then only rectal access is used, since it allows not only to separate the rectovaginal fistula, but also to excise the infected crypt at the border of the anal canal and rectum, which caused the formation of the fistula. For other low rectal-vaginal fistulas, the operation of choice is to disconnect the fistula and lower the rectal mucomuscular flap to “cover” the fistula area.

Operations for mid-level fistulas are performed primarily through vaginal access. With large fistulas and post-radiation fistulas, it may be necessary to use various flaps from surrounding tissues for more reliable closure of the fistula.

The greatest difficulties arise when suturing high rectovaginal fistulas. For this purpose, vaginal or abdominal access is used. A few months after the fistula has healed, you can proceed to the third stage of surgical treatment - closing the colostomy and restoring the passage of intestinal contents. In this case, complete medical and social rehabilitation of patients is achieved.

Often women face a variety of complications after childbirth. One of them is the formation of a fistula tract, a pathological canal that connects two hollow organs or cavities. The main problem of the disease is that abnormal contents, getting, for example, into the vagina or even the uterus, can cause the development of serious diseases. And this is not to mention the impossibility of sexual intercourse and the psychological discomfort that arises in a young girl.

Why do fistulas form, what are the main symptoms of the disease and methods to combat them?

Read in this article

Causes of fistulas after childbirth

Postpartum fistulas usually connect the vagina (much less often the uterus) with some other structures - the rectum, other parts of the intestines, bladder, etc.

The peculiarities of the anatomy of the pelvic organs are such that all organs here border on each other without additional restrictions or special fatty layers. The rectum is located directly behind the vagina, separated from it only by a thin layer of tissue. And in front lies the bladder. All these organs can be easily palpated through the vagina.

Their development does not always require any serious trauma or, especially, surgical interventions during childbirth. All tissues inside the small pelvis are so close to each other that even with prolonged compression, for example, by the head or other part of the fetus, necrosis subsequently occurs and fistulas are formed.

The main causes of postpartum fistulas are as follows:

Prolonged labor, during which parts of the fetus can press the pelvic organs against the walls of the bones. This is especially dangerous during a long period without water. The fact is that the amniotic sac provides a kind of “cushion” role, preventing excessive exposure. There is a disruption in blood supply and tissue nutrition. If the compression was critical, a fistula subsequently forms in this place.
Large or giant fruit. Moreover, even with careful adherence to all recommendations and manuals, the likelihood of ruptures of the perineum, vagina and other structures is high. And the slightest errors in subsequent sutures or improper care can lead to failure of the ligatures and, as a result, fistula.
3rd and 4th degree ruptures of the perineum, which are accompanied by a violation of the integrity of the rectal mucosa and anal sphincter. If such wounds are not properly sutured, a woman may experience gas and fecal incontinence already on the first day after childbirth.
Primary and secondary weakness of the birth process, as well as rapid labor, increase the risk of developing fistula tracts in the future.
Any obstetric manipulations, such as the application of obstetric forceps, a vacuum extractor, etc. In this case, healthy tissue can accidentally get between the jaws of the instrument and be damaged.

Forms of formation of postpartum fistulas

There are several classifications of postpartum fistulas in women. According to the development mechanism, the following can be distinguished:

independent, which arise during natural childbirth due to ischemia and tissue necrosis;
violent, as a result of poor tissue healing after various surgical interventions (dissection of the perineum, etc.).

According to the organs involved, the following fistulas are distinguished:

Vesicogenital, in which the bladder is connected by pathological fistulas to the uterine appendages, cavity, cervical canal or vagina.
Ureterogenital, in which the ureters (drain urine from the kidneys to the bladder) have fistulous passages with the uterine cavity or vagina. They are rare.
Urethro-vaginal, connects the urethra and vagina. They can form throughout the entire length of the urethra.
Intestinal-genital, in which the rectum, sigmoid, small or large intestine communicates with the vagina and perineum simultaneously or separately.

Depending on the distance at which the entrance/exit hole in the vagina is located, fistulas can be distinguished:

low, if less than 3 cm to the vestibule;
medium, at a distance of 3 - 5 cm;
high when the hole is located close to the cervix, more than 5 cm from the vestibule.

Symptoms of a fistula after the birth of a child

As a rule, it takes several weeks for a full-fledged fistula to form. But already on the second or third day a woman may suspect some kind of violation. The most significant complaint is incontinence of feces and gases. If this is the case, it means that the integrity of the rectal sphincter is compromised and more serious complications are possible.

Sometimes the doctor warns immediately about significant ruptures and injuries. He can also advise how long it will take to see you for a more in-depth examination to rule out complications.

When fistulas form, a woman most often complains about the following:

Discharge of gases from the vagina with a characteristic sound, but sometimes they may not be present. In this case, air can escape not only during stress, but even in a calm state.
The woman will also notice the appearance of atypical leucorrhoea with admixtures of feces. Their number depends on the defect in the wall between the intestines and the vagina.
If a fistula has formed between the urinary system and the reproductive system, then vaginal discharge can be liquid and quite abundant. In this case, a woman may urinate rarely or as usual, it all depends on where the hole is located (in the bladder, in the urethra, etc.) and whether urine will accumulate.
Constant heavy exposure will irritate the skin and mucous membranes of the external genitalia, perineum, thighs, etc. This will ultimately lead to the formation of macerations, possibly causing infection. Taken together, this will bring significant discomfort to the woman.
Permanent atypical flora in the vagina will provoke recurrent cervicitis, and more serious inflammation, including the fallopian tubes and ovaries.
If a fistula connects the genital organs and the urinary system, this can exacerbate infectious processes in the kidneys and other parts of it. Permanent urethritis, etc. occur. The clinical picture is largely determined by the location of the fistula tract.
In addition to everything described, if a woman initially had grade 3-4 perineal injuries, fecal and air incontinence may occur.
As a result of all the above processes, the girl is forced to limit intimate relationships. This can lead to misunderstandings in the family and even a breakdown in relationships.

As a result, most women have psychological trauma to varying degrees of severity; they often require the help of specialists in this field.

Watch the video about vaginal-rectal fistula:

Diagnosis of obstetric fistulas

Diagnostic measures largely depend on in which organs the fistula tracts open. The most commonly used are the following:

General gynecological examination, during which you can see the opening of the fistula on the vaginal wall. The presence of atypical flora will also be detected in a smear or during a thorough examination. During the examination, a bimanual rectovaginal examination may be performed. This way you can identify defects in the wall between the rectum and vagina.
Various methods are also used to study the intestines. These are sigmoidoscopy (examination of the rectum and sigmoid colon), colonoscopy (examination of the entire large intestine), irrigoscopy (use of barium suspension to contrast the intestine under the influence of X-ray radiation in the future).
Fistulography is often used. In this case, a contrast agent is injected into the suspected pathological canal, which makes it possible to determine all its possible courses for the subsequent most radical treatment.
Sometimes ultrasound examination of the abdominal and pelvic organs helps to identify fistula tracts and the organs involved in their formation.
Hysteroscopy is used if there is a suspicion of communication with the uterine cavity.
Cystoscopy (examination of the bladder), chromocystoscopy (additional use of contrast) and some other methods are used if the organs of the urinary system are involved.

Treatment of fistula after childbirth

The choice of treatment method largely depends on the size and structure of the fistula, how long the woman has had it, how it was formed and some other factors.

Regarding most obstetric similar moves, they have a more or less favorable prognosis for treatment. It's all about the mechanism of their formation. In 95% of cases, such fistulas have an entrance and exit opening at approximately the same level; leaks and multiple passages rarely form. This is their main difference from those that are formed according to the “fall on a stake” type, where multiple tissue defects are formed in the vertical plane.

It is possible to cure urogenital and enterogenital fistulas using a conservative method in rare cases, in approximately 3 - 5%. Surgery is considered a radical method.

The approach in each case is individual; several options and types can be used simultaneously. Access can be through the perineum, vagina, and less commonly, the rectum and bladder. Also, sometimes it is necessary to perform abdominal operations.

One-step interventions

They can only be used if there is no inflammation in the area of the fistula, which can be very difficult to achieve. In this case, the pathological canal is excised; if necessary, plastic surgery of the vagina, rectal wall, levatoroplasty (correction of the muscles that lift and close the anus) and some other manipulations are performed.

Intervention in several stages

They include the following:

creation of a colostomy;
conservative therapy to reduce the severity of inflammation;
surgery to remove the fistula tract;
colostomy removal.

On average, such treatment takes at least 3 - 6 months, most of the time the woman is forced to be on sick leave.

Colostomy is the artificial removal of the intestine in a specific area (most often the large intestine). As a result, the evacuation of all contents occurs into a reservoir specially fixed on the anterior abdominal wall. Feces do not reach the rectum and sigmoid colon. In this way, you can relieve all inflammatory processes in this area and prepare the area for surgical correction.

As soon as conditions allow, the fistula tract is excised and all necessary elements are repaired. Another month or more is allotted for healing. After this, the colostomy is reduced - the outlet on the anterior abdominal wall is removed and the normal passage of intestinal contents is restored.

Complications that mom may face

If a woman does not treat fistulas in a timely manner, they can contribute to the development of many diseases, not only gynecological, but also urological and proctological. Most often you encounter the following consequences:

infertility;
chronic inflammatory processes in the vagina, cervical canal, uterine cavity, etc.;
problems with pregnancy (threats, undeveloped pregnancies, premature birth, etc.), this is facilitated by constant infection of the genital area;
recurrent inflammatory processes of the urinary tract;
disruption of digestion and normal evacuation of food masses (constipation, etc.);
violation or complete impossibility of intimate relationships;
mental trauma, social phobia, etc.

Prevention of fistulas after childbirth

Fistulas bring a lot of inconvenience to a woman’s life, reduce the quality of her intimate relationships, and lead to poor health. Pathological passages are prone to relapses, especially if the treatment is irrationally selected or the causes that caused their appearance are not eliminated. Preventive measures to prevent their occurrence include the following:

A woman should prepare psychologically for pregnancy. This way she will be able to adequately respond to all comments during the birth process and thereby reduce the risk of injury.
You should follow all doctors’ recommendations for the care and treatment of perineal wounds, regulate stool and try to avoid constipation after epistomy, etc.
It is important to choose the right method of delivery. Sometimes a gentle caesarean section can save you from many problems in the future.

Postpartum fistulas are a serious pathology, untimely treatment of which can cause significant damage to a woman’s health. Proper psychological preparation for pregnancy and the birth of a baby, competent provision of all necessary obstetric care will help to avoid such complications.

The number of rectovaginal fistulas does not exceed 5% of all rectal fistulas. However, taking into account the polyetiology of the disease, the number of patients with rectovaginal fistulas is much higher. The true incidence of the disease is unknown, since these patients still remain “multidisciplinary” and receive care in gynecological, proctological, general surgical hospitals or are not treated at all.

According to currently available data, it is known that 88% of rectovaginal fistulas occur after obstetric trauma, while perineal trauma with subsequent fistula formation is observed in 0.1% of vaginal births. In addition, rectovaginal fistulas are a perianal complication in patients with inflammatory bowel diseases in 0.2-2.1% of cases. The incidence of rectovaginal fistula formation after various low rectal resections exceeds 10%.

In recent years, the number of postoperative rectovaginal fistulas has increased significantly due to the use of various staplers in the surgical treatment of hemorrhoids and the use of synthetic implants in the surgical correction of pelvic prolapse. The incidence of rectovaginal fistula formation after such surgical treatment is observed in 0.15% of cases. While the question of the frequency of the disease can be considered open and debatable, the difficulties of its surgical treatment are generally recognized. Eloquent proof of what has been said is that to eliminate a fistula that is apparently easily accessible and despite the apparent technical simplicity of the intervention itself, more than 100 methods of various operations have been proposed. Despite this, treatment results remain unsatisfactory, with relapse of the disease observed in 20-70% of cases.

Definition
Rectovaginal fistula is a pathological anastomosis between the rectum and vagina.

Prevention
Prevention of the formation of rectovaginal fistulas is as follows.
- Improving the quality of obstetric care, reducing postpartum complications.

If obstetric complications arise, correct and timely treatment is indicated (suturing ruptures) and adequate postpartum and postoperative management.
- Improving the quality of surgical care for patients with diseases of the anal canal and distal rectum:
- correct choice of surgical treatment;
- correct technique for performing these interventions.
- Improving the quality of perioperative patient management.
- Timely identification and proper management of patients with inflammatory bowel diseases.
- Correct selection of the dose of radiation therapy.

Screening
Specialized screening for the presence of rectovaginal fistula is not indicated.

Classification
By etiological factor:
Post-traumatic:
- postpartum;
- postoperative:
- low rectal resections (with hardware anastomoses and without interintestinal anastomosis);
- operations for hemorrhoids (staple resections, etc.);
- operations for pelvic prolapse (stapled transanal resection of the rectum - STARR, etc.);
- drainage of pelvic abscesses;
- injuries from foreign objects and sexual deviations.

Perianal manifestations (Crohn's disease, ulcerative colitis):
- inflammatory (paraproctitis, bartholinitis);
- tumor invasion.
- Post-radiation.
- Ischemic (local ischemia caused by the use of rectal suppositories with vasoconstrictor drugs, non-steroidal anti-inflammatory drugs, etc.).

According to the level of location of the fistula opening in the intestine:
- Intrasphincteric rectovaginal fistulas.
- Transsphincteric rectovaginal fistulas.
- Extrasphincteric rectovaginal fistulas.
- High level rectovaginal fistulas.

Formulation of diagnosis
When formulating a diagnosis, it is necessary to reflect the etiology of the disease, the level of location of the fistula opening in the intestine (indicated only for a high location of the fistula opening; for a low fistula, the ratio of the fistula tract to the anal sphincter is indicated), as well as the presence or absence of cavities, leaks along the fistula and their localization.

If a fistula is a manifestation of complications of inflammatory bowel diseases, then the diagnosis of the underlying disease is first fully formulated. Below are examples of diagnosis formulations.
- Postpartum high-level rectovaginal fistula.
- Transsphincteric rectovaginal fistula with subcutaneous edema.
- Crohn's disease in the form of colitis with damage to the ascending, sigmoid and rectum, chronic continuous course, severe form. Perianal manifestations in the form of a high-level rectovaginal fistula. Hormonal dependence.

Diagnostics
CLINICAL DIAGNOSTIC CRITERIA
The main clinical symptoms of a rectovaginal fistula include the release of intestinal components through the vagina; with low fistulas, there may be an external fistula opening on the skin of the perineum or in the vestibule of the vagina, discomfort, and pain in the anus. In the presence of an exacerbation of the purulent-inflammatory process in the pararectal tissue (given the anatomical structure of the rectovaginal septum, this is extremely rare), general inflammatory symptoms may appear, such as increased body temperature and fever. For any rectovaginal fistula, the examination of the patient must be supplemented with proctography, endorectal ultrasonography to determine the level of localization of the fistula opening in the rectum and assess the location of purulent cavities.

ESTABLISHING A DIAGNOSIS
The diagnosis is made based on a combination of history, clinical picture and typical changes detected by ultrasound and/or x-ray examination. To do this, the doctor needs to do the following.

MANDATORY RESEARCH METHODS IN THE PRESENCE OF RECTOVAGINAL FISTULA
Clinical methods
History taking. The etiological factors of the disease are identified: childbirth and the characteristics of its course; a history of surgical interventions on the pelvic organs; carrying out radiation therapy; intestinal symptoms are assessed.

The patient is examined on a gynecological chair in the position for lithotomy. At the same time, the location and closure of the anus, the presence of cicatricial deformation of the perineum and anus, the condition of the skin of the perianal, sacrococcygeal region and buttocks are assessed. Assess the condition of the external female genitalia. During palpation, the presence of scarring and inflammation in the perineal area, the presence of purulent streaks, and the condition of the subcutaneous portion of the external sphincter are determined.

Vaginal examination. The presence and level of location of the fistula opening in the vagina, the presence and severity of the cicatricial process in the vagina, and the presence of purulent leaks in the pelvic cavity are determined. Assessment of the anal reflex is used to study the contractility of the sphincter muscles. Normal reflex - with streak irritation of the perianal skin, a full contraction of the external sphincter occurs; increased - when, simultaneously with the sphincter, the muscles of the perineum contract; weakened - the reaction of the external sphincter is hardly noticeable.

Digital examination of the rectum. The presence and level of location of the fistula opening in the intestine, as well as the presence and extent of the cicatricial process in the area of the fistula opening and in the recto-vaginal septum are determined. Purulent leaks are detected in the pelvic cavity. The condition of the anal sphincter, the safety and condition of the pelvic floor muscles are assessed. The anatomical relationships of the muscle and bone structures of the pelvic ring are also determined. During the study, the tone and volitional efforts of the anal sphincter, the nature of its contractions, and the presence of gaping of the anus after the finger is removed are assessed.

Bimanual examination. The condition of the rectovaginal septum, the mobility of the anterior wall of the rectum and the posterior wall of the vagina relative to each other are assessed. The presence and severity of purulent leaks and cicatricial process in the rectovaginal septum and pelvic cavity are determined. The nature of the fistula tract is determined: tubular or spongy.

Probing the fistula tract. The nature of the fistulous tract, its length, and the relationship of the fistulous tract to the anal sphincter are determined. Dye test (performed only if there is an external fistula opening). The connection between the external fistula opening and the lumen of the rectum is identified, and additional fistula tracts and cavities are painted.

Instrumental methods
Anoscopy. The area of the anorectal line and the lower ampullary section of the rectum are examined, the condition of the walls of the anal canal is assessed, and the fistula opening is visualized.

Sigmoidoscopy. The mucous membrane of the rectum and distal sigmoid colon is examined. The nature of the vascular pattern and the presence of inflammatory changes in the distal colon are assessed. The area of the fistula opening is visualized.

Colposcopy. Assess the condition of the vaginal walls and cervix. The area of the fistula opening is visualized.

Colonoscopy. The condition of the colon mucosa, neoplasms, etc. is assessed.

X-ray methods
Proctography; irrigoscopy. The level of contrast release from the rectum into the vagina, the length of the fistulous tract with its tubular nature, the presence and prevalence of purulent leaks are determined. They also determine the relief of the rectal mucosa, the size of the rectoanal angle, the condition of the pelvic floor, the presence of narrowed and dilated areas, fecal stones, abnormal location of parts of the colon, etc.

Microbiological studies
Study of intestinal and vaginal microflora. In patients with rectovaginal fistula, the degree of vaginal cleanliness is examined.

Functional studies state of the obturator apparatus of the rectum Profilometry is a method for assessing the pressure in the lumen of a hollow organ when extending a measuring catheter. Anorectal profilometry provides recording of pressure in different planes along the entire length of the anal canal. Using a computer program, a graph of the distribution of pressure values is plotted and the maximum and average pressure values, as well as the asymmetry coefficient, are calculated. The processing program provides for the analysis of pressure data at any level of the cross-section of the anal canal. Anorectal manometry is a simple, non-invasive way to measure the tone of the internal and external anal sphincter and the length of the high pressure zone in the anal canal, as proven in several large studies.

Electromyography of the external sphincter and pelvic floor muscles is a method that allows you to assess the viability and functional activity of muscle fibers and determine the state of the peripheral nerve pathways innervating the muscles of the obturator apparatus of the rectum. The result of the study plays an important role in predicting the effect of plastic surgery.

Endorectal ultrasound examination
Ultrasound allows you to determine the nature of the fistulous tract, its length, relation to the anal sphincter, the presence and nature of purulent leaks. Local changes in the muscular structures of the obturator apparatus of the rectum, the presence and extent of its defects, and the condition of the pelvic floor muscles are also revealed. The undoubted effectiveness of transanal ultrasound in identifying defects of the internal and external sphincter has been proven. It should be noted that for rectal fistulas, the information content of ultrasound diagnostics is not inferior to magnetic resonance therapy.

Magnetic resonance imaging of the pelvis. Along with endorectal ultrasound, magnetic resonance imaging of the pelvis is the method of choice for assessing the location of the fistulous tract in relation to the anal sphincter, clarifying the localization of the fistulous opening in the vagina and intestine, diagnosing purulent leaks, and identifying additional fistulous tracts.

DIFFERENTIAL DIAGNOSTICS
Considering the characteristic clinical picture, differential diagnosis should be carried out only with fistulas between other parts of the gastrointestinal tract and the female genital organs (colovaginal fistulas, enterovaginal fistulas). It is most important to identify the etiological causes of the formation of a rectovaginal fistula.

Treatment
CONSERVATIVE TREATMENT

Single studies have described cases of rectovaginal fistula closure against the background of:
- restrictions on the passage of feces in the area of the fistula opening (high enemas, diet);
- sanitation of the rectum and vagina, effects on the lining of the fistulous tract using physical (curettage), chemical (alkaline solutions), biological (enzymatic preparations) methods;
- the use of autohemotherapy in the fistula area, etc. The studies were conducted on extremely small groups of patients, long-term results were not described.

For fistulas resulting from inflammatory bowel diseases, patients are prescribed specific anti-inflammatory treatment.

SURGERY
Indications. The presence of a rectovaginal fistula serves as an indication for surgical treatment. The choice of method of surgical treatment of a rectovaginal fistula depends on the level of location of the fistula tract in the intestine, the complexity of the fistula (the nature of the fistula tract, the presence of purulent leaks), the relationship between the fistula tract and the anal sphincter, the state of the obturator apparatus of the rectum (the presence sphincter defects along the anterior circumference). Conventionally, we can distinguish methods used in the treatment of low rectovaginal fistulas and methods for eliminating high rectovaginal fistulas.

Surgical treatment of low rectovaginal fistulas
1. Excision of the fistula into the intestinal lumen.
Indications. Performed on patients with intrasphincteric and transsphincteric fistulas (subcutaneous portion of the anal sphincter).

Methodology. Excision of the fistula into the intestinal lumen is performed. Treatment of patients can be achieved in 70-96.6% of cases.

2. Excision of the fistula. Sphincteroplasty.
Indications. Performed on patients with high transsphincteric and extrasphincteric fistulas when the fistula opening in the intestine is located below or at the level of the dentate line, in the presence of a sphincter defect along the anterior semicircle.

Methodology. Excision of the fistula into the intestinal lumen is performed. The ends of the sphincter are isolated and mobilized and, without tension, sutured end to end. Good treatment results are only possible with adequate mobilization of both ends of the sphincter. Treatment of patients can be achieved in 41-100% of cases.

3. Segmental proctoplasty (reduction of the mucomuscular flap).
Indications. Performed on patients with extrasphincteric fistulas with the fistula opening in the intestine located at the level of the dentate line or slightly higher (within the boundaries of the surgical anal canal). Methodology. Excision of the fistula is performed to the fistula opening in the intestine. The mucomuscular flap is mobilized and lowered with its fixation in the anal canal. Treatment of patients can be achieved in 50-70% of cases.

Surgical treatment of high rectovaginal fistulas
1. Martius operation (transposition of the bulbocavernosus muscle into the rectovaginal septum between sutured defects of the rectum and vagina. Operation options: movement of a fragment of adipose tissue on a vascular pedicle from the area of the labia majora or inguinal fold).

Methodology. The rectovaginal septum is split, fistula openings in the intestine and vagina are excised. Defects in the walls of the vagina and rectum are sutured. The bulbocavernosus muscle on the vascular pedicle (a fragment of adipose tissue on the vascular pedicle from the area of the labia majora or inguinal fold) is isolated and transposed into the rectovaginal septum. Cure of patients can be achieved in 50-94% of cases.

2. Transposition of the tender thigh muscle into the rectovaginal septum between sutured defects of the rectum and vagina.
Indications. High rectovaginal fistulas, recurrent rectovaginal fistulas, rectovaginal fistulas in Crohn's disease.

Methodology. The rectovaginal septum is split, fistula openings in the intestine and vagina are excised. Defects in the walls of the vagina and rectum are sutured. The tender thigh muscle on the vascular pedicle is isolated and transposed into the rectovaginal septum. Treatment of patients can be achieved in 50-92% of cases.

3. Suturing the defect or resection of the intestinal segment bearing the fistula opening using abdominal (laparoscopic) or combined access.
Indications. High (middle and upper ampullary rectum) rectovaginal fistulas, often recurrent high rectovaginal fistulas, rectovaginal fistulas in Crohn's disease with a high level of damage and widespread purulent process.

Methodology. Using an abdominal (laparoscopic) or combined approach, the rectum is mobilized (the volume of mobilization of the proximal colon is determined after intraoperative revision) and the posterior wall of the vagina distal to the fistula. Excision of the fistula and pathologically changed tissues in the area of the fistula openings is performed. Separate suturing of defects in the vaginal and rectal walls is performed. In case of pronounced manifestations of a purulent-inflammatory process, large size of the intestinal wall defect, pronounced cicatricial changes with deformation of the intestinal wall, resection of the rectal segment bearing the fistula opening is performed. A rectectal (colorectal) or rectoanal (coloanal) anastomosis is formed. Cure of patients is described in 75-100% of cases.

4. Elimination of the fistula using a split vaginal-rectal flap.
Indications. High rectovaginal fistulas of any etiology.

Methodology. The fistula is excised within healthy tissue. Then the rectovaginal septum is split and the posterior wall of the vagina and the anterior wall of the rectum are mobilized proximally from the wound. Then a bed is formed to fix the relegated split flap in the vagina and rectum. The split rectovaginal septum is lowered into a sleeve and fixed to the anal sphincter, in the rectum and in the vagina.

Preliminary results. Cure of patients was noted in 92% of cases.

The role of intestinal stoma in the treatment of rectovaginal fistulas The issue of stoma formation should be decided strictly individually in each specific case. For high and complex rectovaginal fistulas, regardless of etiology, the formation of a preventive intestinal stoma can significantly reduce the risk of developing postoperative complications and improve treatment results.

What not to do:
- It is unacceptable to perform surgical interventions without a thorough objective examination of the patient.
- It is unacceptable to perform operations on patients with IBD without prescribing specific therapy.
- It is unacceptable to perform plastic surgery against the background of a pronounced purulent-inflammatory process.
- It is unacceptable to perform operations on high and complex fistulas without stopping the passage of intestinal contents in the operation area.
- It is unacceptable for plastic surgeries to be performed outside of specialized centers by surgeons with insufficient experience.

Forecast
Surgery for rectovaginal fistulas requires knowledge of anatomy, physiology and clinical experience. Therefore, planned treatment of patients with rectovaginal fistulas should be carried out only in specialized hospitals.

The main complications after surgery are recurrence of the fistula and insufficiency of the anal sphincter. The causes of relapse can be errors in choosing the surgical method, technical errors, as well as defects in the postoperative management of the patient. Surgical treatment of patients with rectovaginal fistulas in specialized clinics allows for a cure after the first operation in 70-100% of cases. The exception is patients suffering from Crohn's disease, as well as post-radiation fistulas. Recurrence of the disease in this category of patients after the first surgical intervention is observed in 50% of cases.