The number of rectovaginal fistulas does not exceed 5% of all rectal fistulas. However, taking into account the polyetiology of the disease, the number of patients with rectovaginal fistulas is much higher. The true incidence of the disease is unknown, since these patients still remain “multidisciplinary” and receive care in gynecological, proctological, general surgical hospitals or are not treated at all.

According to currently available data, it is known that 88% of rectovaginal fistulas occur after obstetric trauma, while perineal trauma with subsequent fistula formation is observed in 0.1% of vaginal births. In addition, rectovaginal fistulas are a perianal complication in patients with inflammatory bowel diseases in 0.2-2.1% of cases. The incidence of rectovaginal fistula formation after various low rectal resections exceeds 10%.

In recent years, the number of postoperative rectovaginal fistulas has increased significantly due to the use of various staplers in the surgical treatment of hemorrhoids and the use of synthetic implants in the surgical correction of pelvic prolapse. The incidence of rectovaginal fistula formation after such surgical treatment is observed in 0.15% of cases. While the question of the frequency of the disease can be considered open and debatable, the difficulties of its surgical treatment are generally recognized. Eloquent proof of what has been said is that to eliminate a fistula that is clearly within easy reach and despite the apparent technical simplicity of the intervention itself, more than 100 methods of various operations have been proposed. Despite this, treatment results remain unsatisfactory, with relapse of the disease observed in 20-70% of cases.

Definition
Rectovaginal fistula is a pathological anastomosis between the rectum and vagina.

Prevention
Prevention of the formation of rectovaginal fistulas is as follows.
- Improving the quality of obstetric care, reducing postpartum complications.

If obstetric complications arise, correct and timely treatment is indicated (suturing ruptures) and adequate postpartum and postoperative management.
- Improving the quality of surgical care for patients with diseases of the anal canal and distal rectum:
- correct choice of surgical treatment;
- correct technique for performing these interventions.
- Improving the quality of perioperative patient management.
- Timely identification and proper management of patients with inflammatory bowel diseases.
- Correct selection of the dose of radiation therapy.

Screening
Specialized screening for the presence of rectovaginal fistula is not indicated.

Classification
By etiological factor:
Post-traumatic:
- postpartum;
- postoperative:
- low rectal resections (with hardware anastomoses and without interintestinal anastomosis);
- operations for hemorrhoids (staple resections, etc.);
- operations for pelvic prolapse (stapled transanal resection of the rectum - STARR, etc.);
- drainage of pelvic abscesses;
- injuries from foreign objects and sexual deviations.

Perianal manifestations (Crohn's disease, ulcerative colitis):
- inflammatory (paraproctitis, bartholinitis);
- tumor invasion.
- Post-radiation.
- Ischemic (local ischemia caused by the use of rectal suppositories with vasoconstrictor drugs, non-steroidal anti-inflammatory drugs, etc.).

According to the level of location of the fistula opening in the intestine:
- Intrasphincteric rectovaginal fistulas.
- Transsphincteric rectovaginal fistulas.
- Extrasphincteric rectovaginal fistulas.
- High level rectovaginal fistulas.

Formulation of diagnosis
When formulating a diagnosis, one should reflect the etiology of the disease, the level of location of the fistula opening in the intestine (indicated only for a high location of the fistula opening; for a low fistula, the ratio of the fistula tract to the anal sphincter is indicated), as well as the presence or absence of cavities, leaks along the fistula and their localization.

If a fistula is a manifestation of complications of inflammatory bowel diseases, then the diagnosis of the underlying disease is first fully formulated. Below are examples of diagnosis formulations.
- Postpartum high-level rectovaginal fistula.
- Transsphincteric rectovaginal fistula with subcutaneous edema.
- Crohn's disease in the form of colitis with damage to the ascending, sigmoid and rectum, chronic continuous course, severe form. Perianal manifestations in the form of a high-level rectovaginal fistula. Hormonal dependence.

Diagnostics
CLINICAL DIAGNOSTIC CRITERIA
The main clinical symptoms of a rectovaginal fistula include the release of intestinal components through the vagina; with low fistulas, there may be an external fistula opening on the skin of the perineum or in the vestibule of the vagina, discomfort, and pain in the anus. In the presence of an exacerbation of the purulent-inflammatory process in the perirectal tissue (given the anatomical structure of the rectovaginal septum, this is extremely rare), general inflammatory symptoms may appear, such as increased body temperature and fever. For any rectovaginal fistulas, the examination of the patient must be supplemented with proctography, endorectal ultrasonography to determine the level of localization of the fistula opening in the rectum and assess the location of purulent cavities.

ESTABLISHING A DIAGNOSIS
The diagnosis is made based on a combination of history, clinical picture and typical changes detected by ultrasound and/or x-ray examination. To do this, the doctor needs to do the following.

MANDATORY RESEARCH METHODS IN THE PRESENCE OF RECTOVAGINAL FISTULA
Clinical methods
History taking. The etiological factors of the disease are identified: childbirth and the characteristics of its course; a history of surgical interventions on the pelvic organs; carrying out radiation therapy; intestinal symptoms are assessed.

The patient is examined on a gynecological chair in the position for lithotomy. At the same time, the location and closure of the anus, the presence of cicatricial deformation of the perineum and anus, the condition of the skin of the perianal, sacrococcygeal region and buttocks are assessed. Assess the condition of the external female genitalia. During palpation, the presence of scarring and inflammation in the perineal area, the presence of purulent streaks, and the condition of the subcutaneous portion of the external sphincter are determined.

Vaginal examination. The presence and level of location of the fistula opening in the vagina, the presence and severity of the cicatricial process in the vagina, and the presence of purulent leaks in the pelvic cavity are determined. Assessment of the anal reflex is used to study the contractility of the sphincter muscles. Normal reflex - with streak irritation of the perianal skin, a full contraction of the external sphincter occurs; increased - when, simultaneously with the sphincter, the muscles of the perineum contract; weakened - the reaction of the external sphincter is hardly noticeable.

Digital examination of the rectum. The presence and level of location of the fistula opening in the intestine, as well as the presence and extent of the cicatricial process in the area of ​​the fistula opening and in the recto-vaginal septum are determined. Purulent leaks are detected in the pelvic cavity. The condition of the anal sphincter, the safety and condition of the pelvic floor muscles are assessed. The anatomical relationships of the muscle and bone structures of the pelvic ring are also determined. During the study, the tone and volitional efforts of the anal sphincter, the nature of its contractions, and the presence of gaping in the anus after the finger is removed are assessed.

Bimanual examination. The condition of the rectovaginal septum, the mobility of the anterior wall of the rectum and the posterior wall of the vagina relative to each other are assessed. The presence and severity of purulent leaks and cicatricial process in the rectovaginal septum and pelvic cavity are determined. The nature of the fistula tract is determined: tubular or spongy.

Probing the fistula tract. The nature of the fistulous tract, its length, and the relationship of the fistulous tract to the anal sphincter are determined. Dye test (performed only if there is an external fistula opening). The connection between the external fistula opening and the lumen of the rectum is identified, and additional fistula tracts and cavities are painted.

Instrumental methods
Anoscopy. The area of ​​the anorectal line and the lower ampullary section of the rectum are examined, the condition of the walls of the anal canal is assessed, and the fistula opening is visualized.

Sigmoidoscopy. The mucous membrane of the rectum and distal sigmoid colon is examined. The nature of the vascular pattern and the presence of inflammatory changes in the distal colon are assessed. The area of ​​the fistula opening is visualized.

Colposcopy. Assess the condition of the vaginal walls and cervix. The area of ​​the fistula opening is visualized.

Colonoscopy. The condition of the colon mucosa, neoplasms, etc. is assessed.

X-ray methods
Proctography; irrigoscopy. The level of contrast release from the rectum into the vagina, the length of the fistulous tract with its tubular nature, the presence and prevalence of purulent leaks are determined. They also determine the relief of the rectal mucosa, the size of the rectoanal angle, the condition of the pelvic floor, the presence of narrowed and dilated areas, fecal stones, abnormal location of parts of the colon, etc.

Microbiological studies
Study of intestinal and vaginal microflora. In patients with rectovaginal fistula, the degree of vaginal cleanliness is examined.

Functional studies state of the obturator apparatus of the rectum Profilometry is a method for assessing the pressure in the lumen of a hollow organ when extending a measuring catheter. Anorectal profilometry provides recording of pressure in different planes along the entire length of the anal canal. Using a computer program, a graph of the distribution of pressure values ​​is plotted and the maximum and average pressure values, as well as the asymmetry coefficient, are calculated. The processing program provides for the analysis of pressure data at any level of the cross-section of the anal canal. Anorectal manometry is a simple, non-invasive way to measure the tone of the internal and external anal sphincter and the length of the high pressure zone in the anal canal, as proven in several large studies.

Electromyography of the external sphincter and pelvic floor muscles is a method that allows you to assess the viability and functional activity of muscle fibers and determine the state of the peripheral nerve pathways innervating the muscles of the obturator apparatus of the rectum. The result of the study plays an important role in predicting the effect of plastic surgery.

Endorectal ultrasound examination
Ultrasound allows you to determine the nature of the fistulous tract, its length, relation to the anal sphincter, the presence and nature of purulent leaks. Local changes in the muscular structures of the obturator apparatus of the rectum, the presence and extent of its defects, and the condition of the pelvic floor muscles are also revealed. The undoubted effectiveness of transanal ultrasound in identifying defects of the internal and external sphincter has been proven. It should be noted that for rectal fistulas, the information content of ultrasound diagnostics is not inferior to magnetic resonance therapy.

Magnetic resonance imaging of the pelvis. Along with endorectal ultrasound, magnetic resonance imaging of the pelvis is the method of choice for assessing the location of the fistulous tract in relation to the anal sphincter, clarifying the localization of the fistulous opening in the vagina and intestine, diagnosing purulent leaks, and identifying additional fistulous tracts.

DIFFERENTIAL DIAGNOSTICS
Considering the characteristic clinical picture, differential diagnosis should be carried out only with fistulas between other parts of the gastrointestinal tract and the female genital organs (colovaginal fistulas, enterovaginal fistulas). It is most important to identify the etiological causes of the formation of a rectovaginal fistula.

Treatment
CONSERVATIVE TREATMENT

Single studies have described cases of rectovaginal fistula closure against the background of:
- restrictions on the passage of feces in the area of ​​the fistula opening (high enemas, diet);
- sanitation of the rectum and vagina, effects on the lining of the fistulous tract using physical (curettage), chemical (alkaline solutions), biological (enzymatic preparations) methods;
- the use of autohemotherapy in the fistula area, etc. The studies were conducted on extremely small groups of patients, long-term results were not described.

For fistulas resulting from inflammatory bowel diseases, patients are prescribed specific anti-inflammatory treatment.

SURGICAL TREATMENT
Indications. The presence of a rectovaginal fistula serves as an indication for surgical treatment. The choice of method of surgical treatment of a rectovaginal fistula depends on the level of location of the fistula tract in the intestine, the complexity of the fistula (the nature of the fistula tract, the presence of purulent leaks), the relationship between the fistula tract and the anal sphincter, the state of the obturator apparatus of the rectum (the presence sphincter defects along the anterior circumference). Conventionally, we can distinguish methods used in the treatment of low rectovaginal fistulas and methods for eliminating high rectovaginal fistulas.

Surgical treatment of low rectovaginal fistulas
1. Excision of the fistula into the intestinal lumen.
Indications. Performed on patients with intrasphincteric and transsphincteric fistulas (subcutaneous portion of the anal sphincter).

Methodology. Excision of the fistula into the intestinal lumen is performed. Treatment of patients can be achieved in 70-96.6% of cases.

2. Excision of the fistula. Sphincteroplasty.
Indications. Performed on patients with high transsphincteric and extrasphincteric fistulas when the fistula opening in the intestine is located below or at the level of the dentate line, in the presence of a sphincter defect along the anterior semicircle.

Methodology. Excision of the fistula into the intestinal lumen is performed. The ends of the sphincter are isolated and mobilized and, without tension, sutured end to end. Good treatment results are only possible with adequate mobilization of both ends of the sphincter. Treatment of patients can be achieved in 41-100% of cases.

3. Segmental proctoplasty (reduction of the mucomuscular flap).
Indications. Performed on patients with extrasphincteric fistulas with the fistula opening in the intestine located at the level of the dentate line or slightly higher (within the boundaries of the surgical anal canal). Methodology. Excision of the fistula is performed to the fistula opening in the intestine. The mucomuscular flap is mobilized and lowered with its fixation in the anal canal. Treatment of patients can be achieved in 50-70% of cases.

Surgical treatment of high rectovaginal fistulas
1. Martius operation (transposition of the bulbocavernosus muscle into the rectovaginal septum between sutured defects of the rectum and vagina. Operation options: movement of a fragment of adipose tissue on a vascular pedicle from the area of ​​the labia majora or inguinal fold).

Methodology. The rectovaginal septum is split, fistula openings in the intestine and vagina are excised. Defects in the walls of the vagina and rectum are sutured. The bulbocavernosus muscle on the vascular pedicle (a fragment of adipose tissue on the vascular pedicle from the area of ​​the labia majora or inguinal fold) is isolated and transposed into the rectovaginal septum. Cure of patients can be achieved in 50-94% of cases.

2. Transposition of the tender thigh muscle into the rectovaginal septum between sutured defects of the rectum and vagina.
Indications. High rectovaginal fistulas, recurrent rectovaginal fistulas, rectovaginal fistulas in Crohn's disease.

Methodology. The rectovaginal septum is split, fistula openings in the intestine and vagina are excised. Defects in the walls of the vagina and rectum are sutured. The tender thigh muscle on the vascular pedicle is isolated and transposed into the rectovaginal septum. Treatment of patients can be achieved in 50-92% of cases.

3. Suturing the defect or resection of the intestinal segment bearing the fistula opening using abdominal (laparoscopic) or combined access.
Indications. High (middle and upper ampullary rectum) rectovaginal fistulas, often recurrent high rectovaginal fistulas, rectovaginal fistulas in Crohn's disease with a high level of damage and widespread purulent process.

Methodology. Using an abdominal (laparoscopic) or combined approach, the rectum is mobilized (the volume of mobilization of the proximal colon is determined after intraoperative revision) and the posterior wall of the vagina distal to the fistula. Excision of the fistula and pathologically changed tissues in the area of ​​the fistula openings is performed. Separate suturing of defects in the vaginal and rectal walls is performed. In case of pronounced manifestations of a purulent-inflammatory process, large size of the intestinal wall defect, pronounced cicatricial changes with deformation of the intestinal wall, resection of the rectal segment bearing the fistula opening is performed. A rectectal (colorectal) or rectoanal (coloanal) anastomosis is formed. Cure of patients is described in 75-100% of cases.

4. Elimination of the fistula using a split vaginal-rectal flap.
Indications. High rectovaginal fistulas of any etiology.

Methodology. The fistula is excised within healthy tissue. Then the rectovaginal septum is split and the posterior wall of the vagina and the anterior wall of the rectum are mobilized proximally from the wound. Then a bed is formed to fix the relegated split flap in the vagina and rectum. The split rectovaginal septum is lowered into a sleeve and fixed to the anal sphincter, in the rectum and in the vagina.

Preliminary results. Cure of patients was noted in 92% of cases.

The role of intestinal stoma in the treatment of rectovaginal fistulas The issue of stoma formation should be decided strictly individually in each specific case. For high and complex rectovaginal fistulas, regardless of etiology, the formation of a preventive intestinal stoma can significantly reduce the risk of developing postoperative complications and improve treatment results.

What not to do:
- It is unacceptable to perform surgical interventions without a thorough objective examination of the patient.
- It is unacceptable to perform operations on patients with IBD without prescribing specific therapy.
- It is unacceptable to perform plastic surgery against the background of a pronounced purulent-inflammatory process.
- It is unacceptable to perform operations on high and complex fistulas without stopping the passage of intestinal contents in the operation area.
- It is unacceptable for plastic surgeries to be performed outside of specialized centers by surgeons with insufficient experience.

Forecast
Surgery for rectovaginal fistulas requires knowledge of anatomy, physiology and clinical experience. Therefore, planned treatment of patients with rectovaginal fistulas should be carried out only in specialized hospitals.

The main complications after surgery are recurrence of the fistula and insufficiency of the anal sphincter. The causes of relapse can be errors in choosing the surgical method, technical errors, as well as defects in the postoperative management of the patient. Surgical treatment of patients with rectovaginal fistulas in specialized clinics allows for a cure after the first operation in 70-100% of cases. The exception is patients suffering from Crohn's disease, as well as post-radiation fistulas. Recurrence of the disease in this category of patients after the first surgical intervention is observed in 50% of cases.

Patients with rectovaginal fistulas always complain of the release of gases and (or) feces from the vagina. If the fistula is small, discharge is observed only occasionally when the stool is soft or liquid. Patients with large fistulas are depressed by the constant discharge of feces from the vagina, foul odor and irritation of the perineal tissue.

Most rectovaginal fistulas, located in the distal parts of the rectum, are formed as a result of damage to the perineum during childbirth and errors during episiotomy. In many cases, fistulas are the result of unsuccessful attempts to restore the perineum after a third or fourth degree episiotomy, when high and deep sutures diverge, and the tissues of the lower parts of the perineum and rectal sphincter grow together well.

Other surgical procedures that can lead to fistula formation include posterior colporrhaphy, incision of the vaginal wall to drain abscesses or hematomas in the pelvic area, and removal of hemorrhoids.

In case of cancer of the rectum, cervix and vagina, the rectovaginal septum is sometimes involved in the process, and conditions arise that promote the formation of rectovaginal fistulas. In addition, the cause of their appearance may be the consequences of radiation therapy for malignant neoplasms of the genital organs or gastrointestinal tract.

All patients with rectovaginal fistulas have a history of one or more of the above causes, with the exception of very rare cases of congenital anatomical defects of the rectovaginal septum.

Diagnosis of rectovaginal fistulas

A defect in the vaginal mucosa is easy to detect after wiping its walls with a tampon, especially if it is filled with feces or stained with them. If the fistula is located in the upper parts of the vagina, speculums can be used to identify it. When establishing the location of small fistulas, certain difficulties may arise. Even with very small fistulas, a slight retraction or change in the nature of the vaginal mucosa can usually be detected. It is possible to accurately determine the location of the fistula tract by carefully examining the suspicious area of ​​the mucous membrane with a thin wire probe. The presence of communication between the rectum and vagina can be confirmed by finding the tip of the probe in the rectum during rectal examination. Sometimes, with a very small fistula, it is difficult to detect it even with the help of such a probe. In these cases, the introduction of methylene blue into the vagina makes it possible to identify its connection with the rectum using rectoscopy.

Treatment of rectovaginal fistulas

Surgical treatment of rectovaginal fistulas can be either simple or very complex. Before attempting to perform plastic surgery on the vaginal wall, you must wait 4-6 months from the moment it was damaged. Preparation of an intestinal graft before fistula closure is a matter of choice for each surgeon, although some authors consider it necessary. Small fistulas can be closed with one or two purse-string sutures, as well as using the Latzko method. The purpose of the operation is to compare and restore all layers of healthy tissue located between the vagina and rectum, as far as technically possible. The key to its success is the accurate determination of the location of the fistula tract. In cases where the fistula is large or located directly above the rectal sphincter, in our clinic a IV degree episiotomy is performed, and then (after excision of the fistula tract) the incision is sutured in layers. For large fistulas, as well as those arising as a result of radiation therapy or after repeated plastic surgeries, it may be necessary to drain feces from the surgical site by applying a temporary fistula. In addition, when closing large or radiation-induced fistulas, it may be necessary to use the Martius technique - the formation of a bulbocavernous cushion. Almost all rectovaginal fistulas can be closed using a transvaginal approach, although sometimes (if the fistula is located high) the abdominal approach is more convenient.

A fistula in the vagina is a pathological formation in the form of fistulas that connect the organs of the genitourinary system with the intestines. The disease is diagnosed during a gynecological examination. The contents of the intestines and urinary canal enter the vagina. This brings psychological and physiological discomfort to the woman. First of all, the pathology affects the functioning of the urinary system.

What are vaginal fistulas

A fistula is an abnormal canal that forms in different parts of the vagina during fetal development or as a result of injury. The walls of the vagina are in close proximity to the intestines and bladder. When wall defects occur, urine and feces enter the vaginal cavity. In most cases, the deviation is acquired.

Classification of internal fistulas by shape and location

The type and clinical manifestation of the disease depend on the cause of its occurrence. According to their shape, fistulas are divided into colic-vaginal, vesicovaginal, small-bowel-vaginal, rectovaginal and urethrovaginal. Treatment is selected taking into account the type of pathology. Based on location, fistulas are divided into the following types:

• low(at the bottom of the vagina);
• average(located in the middle third of the organ);
• high(located high in the vaginal vault).

The occurrence of vesicovaginal fistulas provokes surgical intervention during labor or for diagnostic purposes. During a caesarean section, the bladder may be damaged. As a result, the probability of the formation of anomalous moves increases. Rectovaginal anastomosis most often have a congenital nature. Urogenital fistulas are the result of prolapse of the anterior vaginal wall, cystic formations and urinary incontinence.

Reasons for the formation of vaginal fistulas

Most often, fistulas appear as a result of damage to the vaginal walls during surgical procedures or overly active sexual intercourse.

But sometimes they are a congenital defect in the structure of organs. In this case, the problem forms in the womb as a result of toxic poisoning or lack of nutrients. Symptoms directly depend on the factors that provoke the disease. Possible causes of pathology include:

• birth injuries;
• inflammatory process;
• complications after surgery;
• mechanical damage;
• congenital anomalies.

Postpartum injuries

One of the most common causes of fistula formation is birth trauma. The risk of developing pathology increases with complicated labor. When a child has a difficult passage through the birth canal, the vaginal tissues are torn. Most often, ruptures are localized on the back wall of the vagina. The damaged areas are stitched using special medical instruments. But over time, defects may form in this place. Therefore, during the postpartum period, it is especially important for women to regularly visit the gynecologist’s office.

In gynecology, the concept of “rectovaginal fistula,” which is also called a fistula, refers to pathological changes that do not exist normally. Rarely, a fistula is congenital, but in most cases, a fistula is classified as an acquired disease with a variety of causes and the only treatment method is surgery.

Rectovaginal fistula: what is it?

From the point of view of medical terminology, a fistula is a canal in the septum connecting the cavities of organs to each other or to the external environment. In gynecology, a narrow canal opened from the inside by the epithelium is a damage to the rectovaginal septum. The result of the development of the pathological condition is the formation of a passage from the vagina into the rectal space.

The consequence of the unnatural lumen between the chambers is the passage of feces with mucus and gases through the vagina.

The disease is accompanied by pain in the perineal area, pain during sexual intercourse, and dysuric disorders.

What is known about congenital pathology

The description of the disease is included in the 10th version of the ICD, which is a list of the International Classification of Diseases. The description of congenital rectovaginal fistula is included in the chain of classes of congenital anomalies of the female genital organs - position 5, number Q52.2. The protocol contains complete information for medical professionals about the disease of the female genital area.

Factors provoking the appearance of the disease

The detection of rectovaginal fistulas in adults is considered a rather rare occurrence; in ICD-10 its code is N82.3. Congenital defects in female children are successfully eliminated surgically in childhood.

The causes of acquired pathology are as follows:

• birth injuries - mechanical rupture of the septum due to the passage of a large fetus, some obstetric manipulations;
• a protracted labor process with the death of soft tissues due to the baby’s head being pressed against the pelvic bone, which leads to a lack of nutrition and moisture;
• inflammation of infected wounds as a result of postpartum tears, even with proper stitching, which slows down the healing of defects after childbirth;
• injury to the rectum due to damage to the septum during tumor resection operations or during anal sexual intercourse;
• inflammatory diseases of the intestines and genitourinary organs, breakthrough of purulent masses in the vagina, complications after Crohn's disease, as well as diverticulosis.

The postpartum type of rectovaginal fistula often has a simple structure - the location of the defects in the rectum and vagina is similar. Fistulas of a traumatic nature, formed due to colitis or due to an acute form of paraproctitis, have a more complex form. In this case, the opening of the inflamed tissue of the rectum occurs in the vagina, causing damage to the barrier by a fistula of a branched structure with chambers of purulent exudate.

The photo shows a rectovaginal fistula

Conditions for the formation of the fistula mouth

In light of the structure of the organs (vagina and rectum), their adjacent walls are in close contact with each other along an extended trajectory. Intravaginal pressure is significantly less than intraintestinal pressure. This leads to prolapse of the mucous membrane of the walls of the rectum into the vaginal cavity through the rectovaginal communication, which arises for any reason.

The result of intestinal ectropion is the release of intestinal contents into the vaginal space.

A temporarily formed fistula after 7-8 days turns into a permanent problem, resulting in fusion of the mucous membranes of the rectum with the walls of the vagina at the site of the defect.

Classification

The types of rectovaginal canals in the interstitial septum are usually classified according to the location of the fistula tube in the space of the rectum relative to the linea pectinea (anus):

• high type - the mouth of the fistula is 60 mm or more above the anus;
• medium type - the fistula channel is localized 60 mm above the anus, but not lower than 30 mm;
• low type - the entrance to the tube is found below 30 mm under the anus.

Most of the defects have a lip-like structure. The openings of classical types of fistulas coincide in both cavities, having a short and straight channel. Branched fistulas that form in the rectal area have a different topographic-anatomical picture. Fistulas of a tubular structure are surrounded by purulent bags or streaks that infect the surrounding tissue.

Symptoms of the pathological condition

The severity of signs signaling the formation of a rectovaginal fistula depends on the size and location of the interstitial canal. The main and most unpleasant symptom of female pathology is the evacuation of stool with pus from the rectum through the vagina. The most common sign of the disease is uncontrolled vaginal discharge of gases (intestinal).

Other symptoms of rectovaginal fistula are:

• inflammation bothers a woman with pain in the perineal area, especially during intimacy, forcing her to refuse sexual contacts;
• the appearance of an accompanying fistula () causes the vagina to fill with urine, causing great inconvenience to the patient;
• no less debilitating are dysuric disorders along with the unpleasant odor of feces, even with good hygiene.

For young women, such symptoms bring physical and moral suffering, worsening intimate life and family relationships, and the development of psychoneurological disorders. The presence of a constant source of infection in the vaginal cavity increases the frequency of exacerbations of inflammatory processes in the female genital tract (colpitis), as well as diseases of the urinary system.

Features of diagnostic methods

If the gynecologist suspects the formation of a rectovaginal fistula, during the interview with the patient, the doctor finds out the development of the clinical picture, specifying the number and type of diseases, the number of births, and the presence of operations.

To diagnose fistula pathology, a complex of informative examinations will be required:

• Examination on a gynecological chair using a speculum system allows visualization of the posterior wall of the vagina to locate the canal. During the manual examination, the fistula itself and the scars in its surroundings are identified.
• The method of two-handed examination of the vaginal and rectal space complements the gynecological examination. This is the possibility of detecting an anastomosis in the plane of the anterior rectal wall, connecting the intestine to the vagina.
• Using sigmoidoscopy, a detailed examination of the mucous membrane inside the rectum is continued in search of a rectovaginal fistula. The use of an endoscope allows you to determine the diameter and direction of the tube and take a biopsy sample.
• Fistulography is considered the most informative, especially in the formation of tubular fistulas. By saturating the fistula with a contrast agent, it is possible to detect the exact number of tubes, as well as leaks and cavities, in the images.

In the case of branching fistula tracts with severe tissue scarring, the results of additional diagnostic techniques may be required. During a rectal ultrasound examination, the likelihood of external or internal damage to the colon is determined. Modern diagnostics using colonoscopy makes it possible to assess the condition of the large intestine along its entire length; the pressure in its lumen is measured during manometry.

If the doctor suspects that the cause of the rectovaginal fistula could be concomitant pathologies (Crohn's disease, tumor, diverticulosis, etc.), it is necessary to conduct a differential diagnosis together with a proctologist and oncologist.

How to treat pathology?

The only way to get rid of a rectovaginal fistula is through surgery. If no more than 18 hours have passed since the damage to the rectal-vaginal septum, the integrity of the septum is restored by suturing the wound while simultaneously excision of its edges. Treatment of fully formed fistulas is quite difficult.

With many developed techniques, the following operations most often eliminate tissue defects:

Rectal vaginal fistula. Genitourinary and vaginal-rectal fistulas Rectovaginal fistula- direct communication between the rectum or anal canal and the vagina. As a result of higher pressure in the rectum, stool and gases may pass through the vagina. The amount of discharge depends on the diameter and length of the fistulous tract, its location, stool consistency, and intraintestinal pressure. Most rectovaginal fistulas- acquired, for example, as a result of childbirth or surgical interventions in the anorectal region (rectocele plastic surgery, hemorrhoidectomy, NPR), radiation injuries, perirectal or perineal abscesses (cryptoglandular origin or Crohn's disease). Treatment(type of operation and time) depends on the severity of symptoms, etiological factors, tissue condition (for example, after recent surgery, radiation therapy, etc.) and the level of the fistula (is it accessible from the perineum or not?): it is necessary to distinguish a rectovaginal fistula from Colovaginal/enterovaginal fistula (high). A) Epidemiology. The overall incidence is unknown due to the variety of etiological factors. Damage during childbirth leads to the formation of a rectovaginal fistula in 0.1-1% of cases, radiation - in 1-6%, Crohn's disease - in 5-10%. b) Symptoms of rectovaginal fistula: Passing gas or stool through the vagina. Associated symptoms: pain, bleeding, stool changes, diarrhea, fever/sepsis, urinary tract infection, perianal and vulvar irritation. Small fistulas may be asymptomatic. V) Differential diagnosis: - Colovesical fistula. - Rectovaginal fistula: Abscess (acute paraproctitis, abscess of Bartholin's glands, etc.). Post-traumatic: obstetric trauma, foreign body, etc. Postoperative: hemorrhoidectomy, rectocele repair, CPR, colproctectomy, etc. Tumors. . Post-radiation (in particular, after undergoing brachytherapy). Venereal lymphogranulomatosis. Congenital rectovaginal fistulas (for example, in combination with anal atresia). G) Pathomorphology. Depends on the disease that led to the formation of the fistula. d) Examination for rectovaginal fistula Minimum Standard Required: History: accurate description and sequence of symptoms? Previous diseases, operations, time of occurrence => an educated guess about the intra-abdominal or pelvic origin of the fistula? Previous attempts to eliminate the fistula? Clinical examination: examination of the rectum and vagina, anoscopy/sigmoidoscopy, abdominal examination => differentiation between low/moderate rectovaginal fistula and high rectovaginal/colovaginal fistula. Additional research (optional): Air test: colposcopy (introduction of air into the rectum through a sigmoidoscope in the Trendelenburg position with the vagina filled with saline => entry of air bubbles from the vagina?). Test with a tampon inserted into the vagina: injection of about 200 ml of saline solution with 0.5 ampoule of methylene blue into the rectum. Checking the swab after 30 minutes => the test is considered positive if there is dye on the top of the swab and the base is clean. False positive, negative and false negative results are possible. Imaging methods: proctography, vaginography, CT/MRI. Endoscopy (colonoscopy, fibrosigmoidoscopy): 1) examination; 2) screening in accordance with standards. e) Classification: High: colovaginal, enterovaginal, high rectovaginal fistula. Medium: rectovaginal fistula. Low: rectovaginal, anovaginal fistula. and) Treatment without surgery for rectovaginal fistula: Stool hardeners. If the patient has already had urine/stool diversion => wait-and-see (3-6 months) and re-examination. a - closure of the rectovaginal fistula is accelerated by the interposition of the bulb of the vestibule of the vagina and the surrounding fatty tissue. b - the cross-section shows the location of the neovascular fat layer h) Surgery for rectovaginal fistula Indications. Any symptomatic rectovaginal fistula. Surgical approach: - Waiting strategy: proximal stoma to gain time (for example, severe symptoms, recent surgery) => appropriate reconstruction and elimination of the fistula as planned after 3-6 months. - Definitive palliative measures without fistula elimination and reconstruction: colostomy, BPE. - Primary/secondary elimination of fistula (depending on etiology and time): perineal or abdominal access: Reduction of a flap from the rectal wall. Dissection of the fistula with layer-by-layer suturing and reconstruction of the rectovaginal septum. Installation of a collagen filling. Carrying out the ligature. Perineal approach with interposition: for example, collagen plate, muscles - tender muscle, rectus abdominis muscle, bulbocavernosus muscle (Martius flap). Transabdominal access: NPR/BAR with coloanal anastomosis, omental interposition. There are no indications for simple dissection of the fistula or plastic surgery with a vaginal flap. And) Results of treatment of rectovaginal fistula. Depends on etiological factors, tissue condition, number of previous attempts to eliminate the fistula, nutritional status, reconstruction option. To) Observation and further treatment. Re-examination of the patient 2-4 weeks after the start of treatment or surgery. If problems associated with the fistula are resolved => closure of the stoma as planned. Further observation depends on the disease that caused the formation of the fistula.

What is the danger

As with any surgery, there may be complications after surgery to remove a rectovaginal fistula. Depending on the type of manipulation, the incidence of recurrent fistula ranges from 10-30%. It takes 3-4 months to wait for a lasting result; otherwise, repeated radical intervention is necessary. If a positive result is achieved, the woman can plan a pregnancy by preparing for a caesarean section.

Preventive measures to protect against rectovaginal fistulas are simple - it is important to promptly and completely cure gynecological diseases identified during regular examinations. You should also pay special attention to the treatment of inflamed intestines under the supervision of a proctologist. The absence of fistulas in the thickness of the rectovaginal septum excludes the appearance of purulent foci.
Treatment of rectovaginal fistula by installing a plug: