Clinical Manifestations

The clinical presentation of a rectovaginal fistula depends on the size and location of the fistula. In

patients with small or low fistulas, the most common symptom is the passage of flatus from the vagina.

Patients with large fistulas may complain of vaginal discharge with fecal odor, passage of flatus or stool

from the vagina, recurrent urinary tract infections, or painful vaginitis.

Diagnosis is typically made on physical examination. Digital rectal examination or bimanual

examination of rectum and vaginal may demonstrate the defect. Anoscopy may be helpful in visualizing

the opening in low fistulas, while proctoscopy or flexible sigmoidoscopy may be required in mid or high

fistulas. If a rectovaginal fistula is suspected clinically but no defect can be visualized, a methylene blue

rectal enema may be administered following vaginal tampon insertion. Staining on the tampon is

suggestive of a fistula. A contrast rectal enema under fluoroscopy may be needed in more complex cases

to identify the fistula.

CLASSIFICATION

Table 70-4 Classification System Based on the Location, Size, and Cause of

Rectovaginal Fistula

Management

Spontaneous healing of rectovaginal fistulas may occur in some small fistulas that are secondary to

obstetrical trauma. In these patients, it is important to wait 3 to 6 months before considering surgical

repair, as this will allow resolution of any inflammation. Nonoperative healing is much less likely to

occur in patients with fistulas secondary to inflammatory bowel disease or radiation. In patients with

small fistulas and minimal symptoms, medical treatment with bulk agents such as fiber may be

sufficient in controlling symptoms.

Treatment of low rectovaginal or anovaginal fistulas may be accomplished by endorectal

advancement flap, vaginal advancement flap, or perineal procedures. Advancement flap is typically the

initial procedure in patients without symptoms of incontinence. Most colorectal surgeons prefer to

perform an advancement flap transanally rather than vaginally as the repair is to the high-pressure side.

After the fistula site in the rectum is excised and closed, a rectal flap consisting of mucosa, submucosa,

and a portion of the internal sphincter muscle is advanced to cover the opening in the rectal wall (Fig.

70-21). The opening in the vagina may be left open to drain. Success rates of endorectal advancement

flaps for simple low rectovaginal fistulas are as high as 83%.23

If a low rectovaginal fistula is associated with incontinence secondary to a defect in the anal

sphincter, repair with an overlapping sphincter repair has been shown to have good results. Using this

technique, an incision is made over the perineal body, and the plane between the rectum and vagina is

developed. The cut ends of the anal sphincter are identified and mobilized. The fistula tract is excised

and closed, and the ends of the sphincter muscle are reapproximated in an overlapping fashion. Patients

with no evidence of sphincter defect who have failed endorectal advancement flap may be candidates

for closure with an interposition graft. This involves closure of the fistula and placement of wellvascularized tissue between the rectum and vagina. The bulbocavernosus muscle (Martius flap) and

gracilis muscle are the most commonly used muscle flaps. These latter procedures are usually performed

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after a stoma has been created. The stoma is closed after healing has been documented by both rectal

and vaginal contrast studies and examination under anesthesia.

Rectovaginal fistulas located higher in rectum often require a transabdominal repair. Simple fistulas

with healthy surrounding tissue may sometimes be repaired by mobilization of the rectovaginal septum,

division of the fistula, and layered closure of the rectal defect. Most cases, particularly larger fistulas

and/or fistulas associated with Crohn’s disease or radiation, will require resection of the rectum to

below the site of the fistula as a low anterior resection with coloanal anastomosis. It may be useful in

these cases to also place healthy tissue such as omentum or muscle between the rectum and vagina to

prevent recurrent fistula. While patients with simple rectovaginal fistulas do not typically require fecal

diversion, those with complex fistulas will often require creation of a colostomy in conjunction with

surgical repair. Elderly patients or patients with severe Crohn disease may be better served by a

permanent colostomy.

Pilonidal Disease

Pilonidal disease refers to a subcutaneous infection occurring in the midline of the sacrococcygeal area,

the gluteal cleft. Pilonidal disease typically presents in young patients, occurs more frequently in men

than women, and is more prevalent in hirsute individuals. The exact etiology of pilonidal disease is

unknown, however it is believed to be related to hair. Pilonidal abscess or sinuses develop either from

an infection within hair follicles in the area, or from a foreign-body reaction to hairs that become

embedded in the skin.

Diagnosis

The presenting symptoms in many patients with pilonidal abscess are pain, swelling, and erythema near

the top of the gluteal cleft. A pilonidal sinus occurs following spontaneous or surgical drainage of a

pilonidal abscess, and present as a nonhealing wound or chronic drainage from the area. Early in the

development, patients may complain of pain while sitting, and may have only mild cellulitis. A painful

fluctuant mass can often easily be seen in patients with acute abscess. Chronic pilonidal sinuses can be

visualized in the intergluteal fold. The majority of these tracts run cephalad, however occasionally a

tract may run toward the anus; in these patients, it is important to differentiate pilonidal disease from

hidradenitis suppurativa and anal fistula. Careful examination can demonstrate an opening or openings

in the midline referred to as “pits,” and likely represent either ruptured hair follicles or the site at which

a hair shaft penetrates the skin.

Treatment

Incision and drainage is the treatment of choice for an acute pilonidal abscess. This can typically be

done in the office with the use of local anesthesia, although rarely may require drainage in the

operating room. A longitudinal or elliptical incision is made over the abscess, and any hair within the

cavity is removed. Patients are instructed to clean the wound regularly and to cover the wound. Packing

is not necessary. Antibiotics are not indicated, unless there is significant associated cellulitis.

Chronic pilonidal sinuses have been treated in numerous ways, however no one specific treatment has

proved completely satisfactory. Nonoperative treatments that have been suggested include shaving or

laser hair removal of the area surrounding the sinus until healing has occurred, although the efficacy of

this strategy is unknown. The most common surgical treatments include wide local excision, excision

with flap closure, or specialized procedures such as the Bascom procedure.

Wide local excision incorporates removal of the pilonidal sinus, any associated pits, as well as some

normal surrounding tissue. The wound may be left open to heal by secondary intention, or may be

primarily closed. Patients whose wounds are left open often require intensive wound care with wet-todry dressings and gentle debridement of devitalized tissue and exudates, and complete healing may take

several months. In an effort to reduce wound healing times, the edges of the wound may be

“marsupialized” by suturing the wound edges to the base. As the pilonidal sinus may be chronically

infected, postoperative infection is a concern in patients with primary closure. In a randomized trial,

patients who underwent primary closure had significantly higher rates of postoperative infection and

recurrence when compared with those patients whose wounds were left open.24

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