Rectovaginal fistula: symptoms and treatment
A rectovaginal fistula is a pathological course that forms in the rectum, below the vagina, and connects the two organs. The contents of the intestines through this channel will enter the vagina, since the pressure in the intestines is higher.
A rectovaginal fistula can form during the intrauterine development of a girl, but most often this pathology is acquired in nature.
Rectovaginal fistulas can be low (located no higher than 3 cm from the anus), medium (located at the level of 3-6 cm from the anus) and high (formed above 6 cm above the anus).
Content:
- Reasons for the formation of a rectovaginal fistula
- Rectovaginal fistula symptoms
- Diagnostics of the rectovaginal fistula
- Rectovaginal fistula treatment
- Complications
- Preventive actions
- Forecast
Reasons for the formation of a rectovaginal fistula
The reasons why a rectovaginal fistula can form:
- Injuries sustained by a woman during labor.
- Difficult childbirth, which ended with surgery.
- Prolonged labor, which was accompanied by a long anhydrous interval. The reason for the formation of a fistula in this case lies in the fact that soft tissues begin to die off due to a prolonged lack of nutrition. After all, the child presses their head to the pelvic bone. The larger the affected area, the faster the fistula will form. In the postpartum period, it will appear on the 3rd-8th day.
- Other reasons associated with bearing a child and labor, which can lead to the formation of a fistula: a narrow pelvis, a large fetus, improper position of the fetus in the uterus, muscle divergence.
- Perineal rupture.
- Tumors in the rectal area.
- Inflammatory bowel disease.
- Injuries to the intestinal wall during surgery.
- Damage to the rectovaginal septum.
- Inflammatory diseases of the genitourinary system.
- Opening of abscesses in the vagina, which are formed against the background of infectious diseases, for example, due to tuberculosis of the genital organs or syphilis.
- Paraproctitis, in which the rectal tissue becomes inflamed and opens into the lumen of the vagina, damaging the rectovaginal septum.
- Fistulas can be a complication of Crohn's disease or rectal diverticulosis. This is especially true for women who have had their uterus removed.
As for congenital rectovaginal fistulas, they are diagnosed extremely rarely - no more than in 0.001% of cases. Between the ages of 40 and 60, rectovaginal fistulas are found in one in 300 women.
The vaginal wall is very closely adjacent to the rectal wall along its entire length. Therefore, with any appearance of a rectovaginal message, the intestinal mucosa instantly appears in the vaginal cavity. For a week, it grows circularly to the existing defect, which gives rise to the formation of a fistula. This process takes 3-4 months. As a rule, this picture is typical for postoperative and postpartum fistulas. Moreover, in most women, in this case, it is the lip-shaped fistula that forms.
Against the background of paraproctitis and colitis, fistulas are most often tubular, branched, have pockets into which pus flows.
Rectovaginal fistula symptoms
The following symptoms will indicate a rectovaginal fistula:
- The most common symptom is vaginal discharge of gas.
- Pus and feces may also come out of the vagina. This is due to the fact that in the rectum there is a locking apparatus in the form of a sphincter, which is controlled by a person. The vagina does not have such a device, therefore, it cannot retain the pathological contents in itself. The release of intestinal masses can occur at any time.
- A woman experiences pain in the perineum, an intimate life becomes impossible.
- Patients often suffer from dysuric disorders.
- Even with the highest quality hygiene, a woman cannot get rid of the unpleasant smell of feces that haunts her.
It is quite logical that a woman experiences incredible discomfort from this pathology, withdraws into herself, does not have the opportunity to enter into intimacy. Therefore, neuropsychiatric disorders are characteristic companions of rectovaginal fistulas. The situation is aggravated by long-term and not bringing the desired effect of treatment of vaginitis, which constantly "feed" E. coli, which enters the vagina through the existing channel.
It is worth noting that many women are embarrassed to address their problem to a doctor and try to cope with the existing disease on their own. As a result, the fistula increases in size, symptoms intensify, and further treatment becomes more difficult.
Diagnostics of the rectovaginal fistula
To identify the existing pathology, a woman must complain to a gynecologist. The doctor, during the examination on the mirrors, will be able to visualize the vagina along its entire length, so it will not be difficult for him to detect the fistula. Most often, the height of the fistula in the vagina corresponds to the height of its mouth in the rectum.
If the fistula has a labial structure, then its location is clarified using a digital examination of the rectum. With bimanual palpation, the degree of tissue scarring and the prevalence of the inflammatory process are determined. The closer the fistula is to the cervix, the more difficult it is to visualize. So, the first diagnostic step towards identifying a fistula is a visual examination of the vagina in the mirrors.
If a woman has a tubular fistula, then she is prescribed a test with a dye. To do this, methylene blue is mixed in equal proportions with hydrogen peroxide and fistulography is performed. The drugs are injected through the external opening of the fistula, which is located in the vagina. After that, using special mirrors and a rectoscope, the rectal lumen is examined.
Sometimes a doctor can send a patient to undergo:
- Manometry (measurement of pressure in the intestinal lumen);
- Colonoscopy (examination of the intestines);
- Irrigoscopy (examination of the intestines with the introduction of a contrast agent);
- Contrast radiography.
Additional research allows you to collect as much information as possible about a woman's health.
Without exception, all patients are prescribed sigmoidoscopy.
The state of the anal sphincter and how severe its insufficiency is, can be judged after sphincterometry and electromyography.
Differential diagnosis
If the doctor has a suspicion that a rectovaginal fistula is a consequence of a disease, and was not formed as a result of an injury or an operation performed, then a differential diagnosis is necessary.
There is always a risk that the fistula has grown into the vagina due to the presence of a malignant tumor. Therefore, a standard digital examination must necessarily be supplemented by cytological and histological analysis.
Diverticulosis and Crohn's disease exclude diagnostic techniques such as irrigoscopy and colonoscopy.
The doctor should be alerted to any protrusion on the vaginal wall or growth of granulation tissue. If the diagnosis remains in question, then a tissue biopsy is performed with further histological examination.
Rectovaginal fistula treatment
To rid the patient of the fistula, surgery is necessary. In other ways, this pathological channel cannot be eliminated.
There are three types of operations:
- Vaginal;
- Perineal;
- Rectal.
If a woman has an injury to the rectovaginal septum, then it can be sutured without the risk of complications, but this must be done within 1.5 days. For this, the wound surface is processed, after which the damaged tissue is sutured. Then the defect of the rectum is sutured, applying monofilament threads. In the vagina, the sutures are performed using catgut material, which will later dissolve on its own.
As for the removal of already formed rectovaginal fistulas, there are more than 30 surgical techniques aimed at eliminating them.
If a woman has purulent inflammation, then the operation can be carried out no earlier than 3 months after its extinction. To remove feces, a colostomy will be required.
If the fistula is located low, then access to it depends on which factor caused its development. With paraproctitis, access is carried out exclusively through the rectum, which allows you to remove not only the pathological canal itself, but also the infected crypt.
In all other situations, it is worth giving preference to the operation of bringing down the mucous-muscular flap of the rectum. The skin is cut in the form of an arc, after which the intestinal wall is fixed 2 cm above the fistula, and the canal itself is crossed. In this case, the vaginal part of the fistula will already be excised. If necessary, sphincteroplasty is performed. Fistulas that are high, near the cervix are most difficult to remove.
If the operation was successful, the stitches are removed in 12-14 days. Competent patient management in the early postoperative period is of great importance. The chair will need to be delayed for at least 4 days, cleansing the intestines exclusively with the help of siphon enemas for a week. The wound should be carefully controlled from both the vagina and the rectum.
In the future, for several weeks, a woman will need to adhere to a diet with no vegetable fiber in the menu. Food must be liquid.
Self-treatment of a rectovaginal fistula is unacceptable. This will only lead to increased symptoms and complication of further professional therapy.
Complications
The operation is not always successful. In 10-15% of cases, fistula recurrence is observed. Although, if measures are taken in a timely manner, it is possible to achieve conservative healing of the canal after surgery. For this, patients are prescribed siphon enemas and laser therapy. In 50% of cases, it is necessary to resort to a second operation with the removal of the fistula by the ligature method.
If in 3-4 months it is not possible to achieve a persistent relapse, then a repeated radical intervention is necessary.
Preventive actions
In order to prevent the formation of a fistula, it is necessary to qualitatively treat all diseases of the gynecological sphere. Any inflammatory processes in the intestines should be treated under the supervision of a professional.
Forecast
As a rule, when a woman applies to a specialized institution, the prognosis for recovery is the most favorable. More than 96% of patients completely get rid of the existing problem and live a high-quality, fulfilling life. As for delivery, it is possible in the future, but only with the help of a cesarean section.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.
