A rectovaginal fistula is an abnormal opening between the rectum and the vagina that allows wind, stool or malodorous discharge to pass into the vagina. Its commonest cause is a complicated obstetric tear or infection of a repaired birth injury, followed by Crohn disease, previous pelvic and rectal surgery, pelvic radiotherapy, and an abscess that was not treated in time. The characteristic complaint is passage of wind or stool through the vagina, often with recurrent vaginal or urinary infections. Diagnosis is essentially clinical, by vaginal and rectal examination, and is completed by defining the position and size of the opening and the integrity of the anal sphincter; endoanal ultrasound or pelvic MRI may be requested, along with endoscopy of the colon or rectum as appropriate and a search for inflammatory bowel disease when suspected. How the fistula is characterised — low or high, simple or complex, with or without incontinence, obstetric, radiation-related or inflammatory — determines the type of repair and its timing, because these cases are not interchangeable. Treatment usually proceeds in stages. First, any infection or abscess is controlled and drained, and tissue quality is improved through nutrition, stopping smoking and controlling diabetes. A period of waiting follows for small, recent obstetric fistulas, since a proportion close on their own. Repair is then carried out: an advancement flap from the rectal or vaginal wall to cover the opening, a repair combined with reconstruction of a torn sphincter, or interposition of tissue between rectum and vagina to interrupt the tract. In selected cases a temporary stoma diverts stool to protect the repair and is closed later. The limits matter. Repair closes the opening but does not necessarily restore control of stool when the sphincter is damaged; that is a separate problem, assessed and treated in its own right with rehabilitation or sphincter reconstruction. Recurrence is not rare, more than one attempt may be needed, and the first attempt is the one with the best tissue conditions, which is why it should not be rushed or performed on inflamed tissue. No cream, antibiotic or wash closes a fistula; medication only manages infection or an associated disease. Candidacy, timing and the type of repair are determined by clinical examination and imaging, and the case is best managed by a joint team from colorectal surgery and gynaecology.
Procedure steps
- 1
Clinical assessment and characterising the fistula
Vaginal and rectal examination defines the position, size and height of the opening and the quality of surrounding tissue, with questions about deliveries, operations, radiotherapy and bowel symptoms. Control of stool and wind is assessed carefully, because coexisting incontinence changes what kind of repair is required.
- 2
Imaging and supporting tests
Endoanal ultrasound or pelvic MRI is requested to assess the sphincter, the fistula course and any collection, with endoscopy and blood tests as indicated and a search for Crohn disease when the picture suggests it. These results shape both the timing and the type of repair.
- 3
Controlling infection and optimising tissue
Any abscess is drained and infection treated first, while tissue quality is improved through nutrition, diabetes control, stopping smoking and treating any associated disease. For small, recent obstetric fistulas a period of observation may precede repair, since some close spontaneously.
- 4
Surgical repair
Under suitable anaesthesia the rectum is separated from the vagina at the opening and the edges are freshened, then the tract is closed in layers using a flap from the rectal or vaginal wall, with reconstruction of a torn sphincter where needed, or by interposing tissue between the two organs to prevent the connection re-forming.
- 5
Temporary diversion when needed, and follow-up
In complex, recurrent or post-radiation cases a temporary stoma may divert stool to protect the repair and is closed once healing is established. You are followed up to confirm closure of the opening and to assess continence, with pelvic floor exercises or a further step planned if required.
Before the procedure
Give your doctor a precise history: the details of your deliveries, including any difficult labour, forceps or vacuum delivery, extensive tear or a repair that later became infected, and exactly when symptoms began. Mention any previous rectal, vaginal or pelvic surgery and any pelvic radiotherapy and its date. Report bowel symptoms such as chronic diarrhoea, blood in the stool, abdominal pain or weight loss, since these may indicate inflammatory bowel disease that must be diagnosed before repair because it changes the whole plan. State frankly any leakage of wind or stool or weakness of control, as this determines whether the sphincter needs repairing alongside the fistula. List your medicines, particularly blood thinners, steroids and immune-modulating drugs, plus allergies and diabetes status. Stop smoking as early as possible, since it is one of the strongest causes of failure in this specific repair. Ask directly whether the plan is one stage or more and whether a temporary stoma is possible.
After the procedure
Follow your doctor instructions about diet, fluids and bowel regulation exactly: the aim is soft, regular stool with neither straining nor diarrhoea, and you may be prescribed a softener or a specific diet for some weeks. Keep the area clean and dry, wash with water and pat dry gently after every bowel motion, and do not use vaginal douches, pessaries or tampons without your doctor approval. Abstain from intercourse until your doctor explicitly permits it, and avoid heavy lifting, exertion and vigorous exercise for the period specified. If a temporary stoma was created, follow the care training and never decide on its closure yourself, since the timing is a medical judgement. Record any passage of wind or stool through the vagina and report it immediately even if slight, as it is the single most important indicator of the outcome of the repair. **Seek care immediately for fever or chills, increasing pelvic pain, pus or foul discharge, heavy bleeding, inability to pass urine, or new leakage of stool after a period when it had stopped.**
Expected duration
Repair usually takes one to about two and a half hours depending on the type of flap and whether sphincter reconstruction is needed, with a stay of roughly one to three days.
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