Recto-Vaginal Fistula

What is it?
A recto-vaginal fistula is an abnormal opening between the rectum and vagina which allows the passage of small amounts of waste, normally contained in the rectum, to pass into the vagina leading to possible infections.

What is the cause?
The major cause is chronic active inflammation in the bowel, particularly Crohn's disease.

What are the symptoms?
The main symptom is passage of flatus (wind) through the vagina. There may also be faecal discharge.

How can it be treated?
Treatment tends to depend on the severity of symptoms and effect on quality of life.

• Minimal symptoms (i.e. passing gas through the vagina) would need no intervention unless it became a problem to live with.
• Other fistulae, complicated by pus and rectal disease causing perianal discomfort, may require more vigorous treatment such as:

• Insertion of a seton (a stitch) between the rectum and vagina, allowing drainage to occur as the tract is kept patent.
• Insertion of a small drainage tube into the tract.

2. Antibiotics
(e.g. Metronidazole)

3. Bulk laxatives
(e.g. Normacol, Fybogel, Celevac.)
It is helpful if the stool is firm so as to reduce the likelihood of faecal fluid contaminating the vagina.

4. Antidiarrhoeal agents (e.g. Loperamide)
Greater effects can be achieved when a bulk laxative and an antidiarrhoeal agent are taken simultaneously.

5. Vaginal douching
It is important to ensure that faecal fluid does not remain in the vagina. Flushing out or douching with warm water, will help keep it clean. Soaps and perfumes should be avoided and all residues washed away scrupulously.

It is occasionally possible for some surgeons to attempt to repair the fistula, although it is generally considered better to leave them alone as they can be made worse. However, surgical techniques have improved and if problems persist giving a poor quality of life, surgery should be considered. Good consultation with the surgeon beforehand is essential in order to be made clearly aware that complications may arise.

The repair can usually be performed in several ways:
a) Transanal (through the anus)
b) Transperineal (the skin between the vagina and rectum)
c) Transvaginal (through the vagina)

The success of repair techniques is dependant on the following factors:
i. The presence of proximal Crohn's disease (disease next to the fistula)
This tends to give poor results and active disease should be treated prior to surgery.
ii. Associated infection at the time of operation.
Antibiotics must be given prior to surgery.
iii. Whether a temporary stoma is used.
Diversion of the faecal stream by the formation of a temporary ileostomy/colostomy improves success rates of healing by avoiding contamination of the repair site with bowel motions.
iv. The degree of rectal involvement.
The more the rectum is affected, the lower the chances of successful healing. (Crohn's disease frequently spares the rectum)
v. Current drug treatment.
Immunosuppressants and steroids will delay healing.

Will it come back?
Fistulae can return, either as a consequence of failed surgery or due to a relapse of the disease.

In some studies patients have been treated successfully at a second operation, others have resorted to removal of the colon and ileostomy formation which has allowed the fistula to heal. It is a question of controlling the symptoms and improving the quality of life.

What about menstruation?
The amount of discomfort experienced will determine whether you use tampons or sanitary towels during the menstrual period. If tampons are used, it is important to remember to change these frequently and regularly.

What about sex?
Sexual intercourse will not make the fistula worse, but may be very uncomfortable. If you have a little discharge from time to time, both you and your partner may feel that sex is inappropriate, but a condom can always be worn.

If your usual method of contraception is the diaphragm (or dutch cap), it may still be possible to continue as most recto-vaginal fistulae are low down. You should discuss this further with your doctor.