Symptoms

Depending on the size and location of the fistula, you may have very minor symptoms or significant problems with continence and hygiene. Signs and symptoms of a rectovaginal fistula may include:

• Passage of gas, stool or pus from your vagina
• A foul-smelling vaginal discharge
• Recurrent vaginal or urinary tract infections
• Irritation or pain in the vulva, vagina and the area between your vagina and anus (perineum)
• Pain during sexual activity

When to see a doctor
If you experience any signs or symptoms of rectovaginal fistula, make an appointment to see your doctor. A fistula may be the first indication of a more serious problem, such as an area of infection where pus has collected (abscess), or cancer. It's important that your doctor identify the cause of the fistula and determine whether and when it should be repaired. Depending on the cause of your fistula, your doctor may refer you to a colorectal or gynecologic surgeon.

Causes

A rectovaginal fistula may form as a result of:

• Injuries in childbirth. Obstetric injuries are the most common cause of rectovaginal fistulas. Such injuries include tears in the perineum that extend to the bowel or an infection or tear of an episiotomy — a surgical incision to enlarge the perineum during vaginal delivery. These may happen following a long, difficult labor. Fistulas arising from childbirth may also involve injury to your anal sphincter, the rings of muscle at the end of the rectum that help you hold in stool.
• Crohn's disease. The second most common cause of rectovaginal fistulas, Crohn's disease is a type of inflammatory bowel disease in which the lining of your digestive tract becomes inflamed. Most women with Crohn's disease never develop a rectovaginal fistula, but having Crohn's disease does increase your risk of the condition.
• Surgery involving your vagina, perineum, rectum or anus. Prior surgery in your lower pelvic region, such as removal of your uterus (hysterectomy), in rare cases can lead to development of a fistula.
• Cancer or radiation treatment in your pelvic area. A cancerous tumor in your rectum, cervix, vagina, uterus or anal canal can lead to development of a rectovaginal fistula. Radiation therapy for cancers in these areas can also put you at risk of developing a fistula. A fistula caused by radiation usually forms within two years following the treatment. Before the fistula forms, you may experience pain in your anus or rectum, bloody diarrhea, or bright red blood in your stool. If you spot these warning signs, your doctor will first rule out a return of cancer as the cause.
• Other causes. Less commonly, a rectovaginal fistula may be caused by infections in your anus or rectum; infections of small, bulging pouches in your digestive tract (diverticulitis); or vaginal trauma.

Complications

Physical complications of rectovaginal fistula may include incontinence, problems with hygiene, and irritation or inflammation of your vagina, perineum or the skin around your anus. In some cases, a fistula may become infected and form an abscess, a problem that can become life-threatening if not treated. Among women with Crohn's disease who develop a fistula, the chance of another fistula forming later is high.

Preparing for your appointment

You're likely to start by seeing your family doctor or primary care provider. However, in some cases when you call to set up an appointment you may be referred immediately to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist).

Here's some information to help you prepare for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance to prepare for common diagnostic tests.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Make a list of your key medical information, including any other conditions for which you're being treated, and the names of any medications, vitamins or supplements you're taking.
• Consider questions to ask your doctor and write them down.Bring along notepaper and a pen to jot down information as your doctor addresses your questions.

For rectovaginal fistula, some basic questions to ask your doctor include:

• What's causing these symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Will I need surgery?
• Do you have any brochures or other printed material that I can take with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you begin experiencing your symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Are you able to have regular bowel movements?
• Do you experience uncontrolled loss of stool, also called fecal incontinence?
• Have you given birth vaginally? Were there any complications?
• Have you ever had pelvic surgery?
• Have you ever been treated for a gynecologic cancer?
• Have you had pelvic radiation therapy?
• Do you have any other medical conditions, such as Crohn's disease?

Tests and diagnosis

Physical examination
To figure out the cause of a rectovaginal fistula, your doctor will perform a physical examination to try to locate the fistula and check for a possible tumor mass, infection or abscess. The exam includes a visual inspection of your vagina, anus and the area between them. Your doctor will perform a digital exam, inserting a gloved and lubricated finger into your vagina while feeling the perineum with another gloved finger, and then perform a rectal exam by inserting his or her gloved finger into your anus.

Unless the fistula is very low in the vagina and readily visible, your doctor may use a speculum to visualize the inside of the vagina. This may allow him or her to see the opening of the fistula inside your vagina. An instrument similar to a speculum, called a proctoscope, may be inserted into your anus and rectum to check the health of your rectum.

Tests for identifying fistulas
Often a fistula isn't found during the physical exam. A variety of other tests may be used to locate and evaluate a rectovaginal fistula. These tests also help your medical team in planning for surgery.

• Water and blue dye tests. Filling the vagina with water and the rectum with air can help locate the fistula. Air passing from the rectum through the fistula forms bubbles on the vaginal side of the passage. Another test involves placing a tampon into your vagina, then injecting blue dye into your rectum. Blue staining on the tampon shows the presence of a fistula.
• Contrast tests. A vaginogram or a barium enema can help identify a fistula located in the upper rectum. These tests use a contrast material to show either the vagina or the bowel on an X-ray image.
• Computerized tomography (CT). A CT scan is a special X-ray technique that provides more detail than a standard X-ray does. A CT scan of your abdomen and pelvis can help locate a fistula and determine its cause.
• Magnetic resonance imaging (MRI). This test uses a magnetic field and radio waves to create images of soft tissues in your body. MRI can show the location of a fistula as well as involvement of pelvic organs or the presence of a tumor.
• Anorectal ultrasound. This procedure uses sound waves to produce a video image of your anus and rectum. Your doctor inserts a narrow, wand-like instrument into your anus and rectum. Anorectal ultrasound can evaluate the structure of your anal sphincter and may show defects caused by obstetric injury.
• Anorectal manometry. In this test, a narrow, flexible tube is inserted into your anus and rectum and a small balloon at the tip of the tube is expanded. The test measures the sensitivity and function of your rectum and can provide useful information when a fistula is due to Crohn's disease or radiation. This test does not locate fistulas but can help with planning repair.
• Other tests. If your doctor suspects you may have inflammatory bowel disease, he or she may order a colonoscopy. This test allows your doctor to view your colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can take small samples of tissue (biopsy) for laboratory analysis, which can help confirm the diagnosis of Crohn's disease. If you've received radiation therapy to your pelvic region, your doctor may do more small bowel tests, including X-rays, to make sure you don't also have a small bowel fistula.

Treatment and drugs

Treatment for a rectovaginal fistula depends on its cause, size, location and effect on surrounding tissues. Sometimes fistulas heal on their own, but most people need surgery to close or repair the abnormal connection. Before an operation can be done, the skin and other tissue around the fistula must be healthy, with no signs of infection or inflammation. Your doctor may advise a waiting period of up to three months before surgery to ensure the surrounding tissue is healthy and see if the fistula closes on its own.

Medications
If the area around your fistula is infected, you'll take a course of antibiotics before surgery. Antibiotics may also be recommended for women with Crohn's disease who develop a fistula. Another medication that may help heal a fistula in women with Crohn's disease is infliximab (Remicade). This drug blocks the action of an immune system protein called tumor necrosis factor-alpha (TNF-alpha), which causes inflammation. Side effects may include chest pain, chills, fever, flushing, hives, itching and troubled breathing.

Surgery
An operation to close a fistula may be done by a gynecologist or a colorectal surgeon. The goal is to remove the fistula tract and close the opening by sewing together healthy tissue around it. The repair may require using a tissue graft taken from an adjacent part of the body, or folding a flap of healthy tissue over the fistula opening. More complicated operations may be needed if the anal sphincter muscles are also damaged or if there's scarring or tissue damage from radiation or Crohn's disease.

To clean out your bowel before the operation, you may take laxatives or follow a liquid diet prior to surgery. This may be followed by an enema shortly before surgery. You'll also be given an antibiotic medication before surgery.

In some more complex or recurrent cases, the surgeon may do a colostomy before repairing a fistula. A colostomy is an operation that diverts stool through an opening in your abdomen instead of through your rectum. This may be needed if you've had tissue damage or scarring from previous surgery or radiation treatment, an ongoing infection or significant fecal contamination, a cancerous tumor, or an abscess. If a colostomy is needed, your surgeon may wait eight to 12 weeks before repairing the fistula.

After an operation to close a fistula, you'll be on a liquid diet for about three days, followed by a low-fiber diet for several weeks. A low-fiber diet reduces the frequency and volume of stools. Your care team may recommend that you take sitz baths two to three times a day and dry off with a blow dryer to keep the area clean and dry.

Lifestyle and home remedies

Good hygiene can help ease discomfort and reduce the chance of vaginal or urinary tract infections:

• Wash with water. Gently wash your outer genital area with warm water each time you experience vaginal discharge or passage of stool. Soap can dry and irritate your skin but may be necessary in moderation. Avoid rubbing with dry toilet paper. Premoistened, alcohol-free towelettes or wipes or moistened cotton balls may be a good alternative for cleaning the area.
• Dry thoroughly. Allow the area to air-dry after washing, or gently pat the area dry with toilet paper or a clean washcloth.
• Avoid irritants. These include harsh or scented soap and scented tampons and pads.
• Use a cold compress. Apply a cold compress, such as a washcloth, to the labial area.
• Apply a cream or powder. Moisture-barrier creams help keep irritated skin from having direct contact with fecal matter. Ask your doctor to recommend a product. Be sure the area is clean and dry before you apply any cream. Nonmedicated talcum powder or cornstarch also may help relieve discomfort.
• Wear cotton underwear and loose clothing. Tight clothing can restrict airflow, making skin problems worse. Change soiled underwear quickly. Products such as absorbent pads and disposable underwear can help if you're passing liquid or stool. If you use pads or adult diapers, be sure they have an absorbent wicking layer on top.

Symptoms of a rectovaginal fistula can be very distressing, but treatment generally offers good results.