RectoVaginal Fistulas

1. RectoVaginal Fistulas Omar Felix, MD

3. Etiology • Obstetric injury • Most frequent cause • Appear 7-10 days after delivery • Occur after 3rd or 4th degree laceration • Very common in developing countries • Due to necrosis of rectovaginal septum from prolonged labor.

4. Obstetric injury

5. Etiology • Infection • Inflammatory bowel disease • Crohn’s > Ulcerative Colitis • Operative Trauma • Vaginal wall incorporated in anastamosis • abscess secondary to anastamotic leak • Radiation • Sexual Assault

6. Evaluation • Identification of the fistula site • Assessment of surrounding tissue

7. Identification of Fistula Site • Most times readily visualized on exam • Sometimes may be elusive • Methylene Blue Test • Saline Instillation

8. Identification of Fistula Site • Radiological tests • Vaginography • CT scans • MRI • Ultrasound

9. Gastrogaffin Enema

11. Axial MRI

12. Sagittal MRI

13. Assessment of Local Tissue • Elicit symptoms of incontinence • MRI or Ultrasound assess anal sphincter • Evaluation of GI tract with colonoscopy and contrast studies. • Biopsies

14. Classification • Daniels • Low: rectal opening at dentate line • Middle • High: vaginal opening at cervix • Simple vs Complex • Simple are small (<2.5cm), low, due to trauma/inf • Complex are large, high, due to IBD, radiation, malig.

15. Management • Conservative • Small fistulas • Minimal symptoms • Optimizing bowel function • Controlling diarrhea • Surgical techniques

16. Surgical techniques • Local Repairs • Fibrin Sealant • Advancement Flaps • Rectal Sleeve Advancement • Excision of Fistula with layered Closure • Perineo-Proctotomy • Inversion of Fistula

17. Advancement Flap

18. Excision with Layered Closure

19. Inversion technique

20. Surgical techniques • Complex Repairs • Tissue Interposition • Muscle: most common is sphincteroplasty • Bowel: • low anterior resection • Sleeve coloanal technique

21. Tissue Interposition