At a glance
A rectovaginal fistula is an abnormal connection (tunnel) between the rectum and the vagina. It allows contents from the bowel — gas, liquid, and sometimes stool — to pass into the vagina. It is an uncommon but deeply distressing condition that significantly affects quality of life.
This guide covers the causes, diagnosis, and treatment options. It is written with sensitivity to the fact that this is a difficult condition to discuss, but understanding it is the first step toward effective treatment.
Causes
Obstetric injury
The most common cause. A difficult or prolonged vaginal delivery can damage the tissue between the rectum and vagina (the rectovaginal septum):
- Prolonged second stage of labour
- Forceps or vacuum-assisted delivery
- Third- or fourth-degree perineal tear
- Episiotomy complications
In many cases, the injury is repaired at the time of delivery. A fistula may develop if the repair does not heal completely or if the injury was not fully recognised.
Crohn’s disease
Crohn’s disease can cause fistulas anywhere in the gastrointestinal tract, and rectovaginal fistulas are one of the recognised complications. The chronic inflammation of Crohn’s disease weakens the tissue and creates tracts between organs.
Previous surgery or radiation
- Pelvic surgery (hysterectomy, prolapse repair, colorectal procedures) can occasionally result in a fistula
- Radiation therapy for pelvic cancers can damage tissue and lead to delayed fistula formation
Infection
A perianal or pelvic abscess can erode into the vagina, creating a fistula tract.
Symptoms
The hallmark symptoms are:
- Passage of gas from the vagina — often the first and most noticeable symptom
- Passage of liquid or stool from the vagina — depending on the size of the fistula
- Foul-smelling vaginal discharge — from faecal contamination
- Recurrent vaginal or urinary infections — from the abnormal connection
- Pain — in the perineal area, particularly during bowel movements or intercourse
The severity of symptoms depends on the size and location of the fistula. Small fistulas may only allow gas to pass; larger ones may allow stool.
Diagnosis
Diagnosis may involve:
- Physical examination — the fistula opening may be visible on vaginal or rectal examination
- Imaging — MRI provides detailed visualisation of the tract
- Endoanal ultrasound — to assess the sphincter muscles and tract
- Examination under anaesthesia — for a thorough assessment
Accurate assessment of the fistula’s size, location, and relationship to the sphincter muscles is essential for planning the correct surgical approach.
Treatment
Conservative management
In some cases, conservative measures may be tried first:
- Treating any underlying infection
- Optimising nutrition and healing conditions
- Managing Crohn’s disease if applicable
- Small fistulas may close if the underlying cause is addressed
Surgical repair
Most rectovaginal fistulas require surgical repair. Options include:
Transanal or transvaginal repair — approaching the fistula from the anal or vaginal side, excising the tract, and closing the opening with layered tissue closure.
Advancement flap — raising a flap of healthy tissue (from the rectal mucosa, vaginal wall, or surrounding tissue) to cover the fistula opening.
Gracilis or other muscle flap — for complex or recurrent fistulas, a muscle from the inner thigh can be used to bring healthy, well-vascularised tissue to the repair site.
Temporary diverting stoma — in some cases, diverting the faecal stream away from the repair with a temporary stoma allows the repair to heal without contamination. The stoma is reversed once healing is confirmed.
Biological plugs or sealants — newer techniques that attempt to close the tract with biological materials.
The role of specialist care
Rectovaginal fistula repair is specialised surgery. Outcomes are best when performed by surgeons with specific experience in this area. If you have been diagnosed with a rectovaginal fistula, being seen by a colorectal surgeon or a gynaecological surgeon with fistula experience is important.
The emotional impact
Rectovaginal fistulas have a profound impact on quality of life:
- The symptoms are embarrassing and difficult to manage in social settings
- Intimate relationships are often affected
- Self-confidence and body image may suffer significantly
- The condition can feel deeply isolating
These emotional effects are understandable and valid. They are a recognised part of the condition, not an overreaction. Seeking support — from healthcare professionals, from peer communities, or from mental health services — is an important part of managing the overall impact.
Moving forward
A rectovaginal fistula is a treatable condition. The path to resolution may involve specialist assessment, surgical repair, and a period of recovery, but the outcomes — particularly with experienced surgical care — are good. If you are experiencing symptoms that suggest a rectovaginal fistula, seeking specialist assessment is the most important step.