Skip to main content

Rectovaginal Fistula

A rectovaginal fistula (RVF) is an epithelialized communication between the rectum (or anal canal) and the vagina, allowing passage of flatus and feces per vagina. Although RVF is owned operatively by colorectal surgery, the urogynecologist and reconstructive pelvic surgeon are routinely involved — RVF clusters with sphincter injury after obstetric trauma, frequently coexists with VVF or rectourethral fistula in multi-compartment cases, and is the prototypical setting for Martius and gracilis interposition in the female perineum.[1][2] Modern management follows the ASCRS 2022 Clinical Practice Guidelines, which dictate an etiology-driven, stepwise approach.[1]

For complex multi-compartment cases, see the Fistulas section landing. For the male equivalent, see Rectourethral Fistula.

Epidemiology and Etiology​

RVF is uncommon in high-resource settings but a significant problem in low-resource countries due to obstructed labor.[1][3] Etiology distribution differs by setting — globally, obstetric trauma accounts for up to 88%; in high-resource referral series, the mix is more diverse, with iatrogenic and Crohn's-related fistulas making up substantial fractions.[1][2][6]

Setting / causeNotes
Obstetric traumaDominant cause globally; fourth-degree perineal tear with unrecognized sphincter injury; reported RVF rate 0.4–3.0% after fourth-degree tear[4]
Crohn's diseaseUp to 43% in referral-center series; tied to active rectal inflammation[6][7]
Iatrogenic — colorectal anastomosisRVF complicates ~1.6% of low anterior resection (~2.2% of colorectal anastomoses overall); higher with very low tumors and unsatisfactory anastomosis[1][5]
Iatrogenic — gynecologic surgeryHysterectomy (cuff into rectum), prolapse repair (especially mesh), anorectal surgery
CryptoglandularPerianal abscess eroding into vagina
Pelvic radiationCervical, endometrial, or rectal cancer treatment; median onset ~20 months after radiotherapy[8]
MalignancyDirect invasion from rectal, cervical, or vaginal cancer

Classification​

The single most operative-decision-relevant categorization:[1][9]

SimpleComplex
LocationLow (anal canal ↔ lower vagina)Mid- or high-vaginal septum
Diameter< 2.5 cm≥ 2.5 cm
EtiologyObstetric or traumaticCrohn's, radiation, malignancy, anastomotic
Tissue bedHealthyInflamed, irradiated, scarred
Prior repairNoneOne or more failed

Anatomic level is also commonly described — low (at or near the dentate line), mid (mid-septum, the most common), and high (vault, post-hysterectomy or anastomotic) — and dictates the operative approach.

Clinical Presentation​

  • Passage of flatus per vagina — often the earliest symptom
  • Passage of feces per vagina — pathognomonic
  • Foul-smelling vaginal discharge
  • Recurrent vaginitis and UTI
  • Fecal incontinence — frequent in obstetric RVF because of concurrent sphincter damage; nearly universal as a presenting complaint in modern series[2]
  • Dyspareunia and significant psychosocial morbidity

Diagnostic Evaluation​

The ASCRS guideline emphasizes that the workup must define both the fistula and the sphincter complex, since sphincter status drives the choice of repair.[1]

Bedside​

  • Inspection of the perineum — scarring, deformity, external opening
  • Speculum exam — vaginal opening of the tract
  • Digital rectal exam — palpation of the tract; resting and squeeze sphincter tone; integrity assessment
  • Anoscopy / proctoscopy — rectal opening
  • Examination under anesthesia is often required to fully define the anatomy[1]

Imaging​

ModalityRoleNotes
MRI pelvis (with vaginal gel)The diagnostic workhorse for RVFBest characterization of tract, secondary extensions, abscess, sphincter destruction, neoplasm; contrast-enhanced MRI carries the highest accuracy[3][9][10]
3D endoanal ultrasound (EAUS)First-line for sphincter mapping; comparable to MRI for simple tractsMRI superior for complex/secondary extensions (97% vs 74% sensitivity)[1][10]
Anorectal manometryQuantifies resting and squeeze sphincter pressuresAdjunct to EAUS; informs whether sphincteroplasty is required
Vaginography / contrast enemaDefines the tract when MRI is equivocal
Proctoscopy / sigmoidoscopyMandatory when Crohn's is suspectedSurgery is deferred until endoscopic mucosal healing is achieved[7]

Management — ASCRS Stepwise Algorithm​

1. Conservative management (Recommendation 12, Weak / 2C)​

For obstetric and minimally symptomatic benign RVF: sitz baths, perineal hygiene, infection control, and stool-bulking fiber for 3–6 months. Reported spontaneous closure in 52–66% of obstetric RVF.[1]

2. Seton drainage (Recommendation 13, Strong / 1C)​

A draining seton controls acute inflammation or sepsis around the tract, provides durable symptomatic relief in patients who are not surgical candidates, and improves the success of subsequent definitive repair. Particularly important in Crohn's, where setons should be placed before initiation of immunosuppression.[1][7]

3. Endorectal advancement flap (ERAF) — procedure of choice (Recommendation 14, Strong / 1C)​

The default operation for most RVF.[1]

Technique:

  1. Trans-anal exposure (prone-jackknife)
  2. Full- or partial-thickness flap of rectal mucosa, submucosa, ± internal sphincter raised proximal to the fistula opening
  3. Excise or curette the tract
  4. Close the rectal opening
  5. Advance the flap distally to cover the closed defect
  6. Leave the vaginal side open to drain

Outcomes:

SettingHealing
ERAF alone41–78% (etiology-dependent)[1]
ERAF + sphincteroplasty (when sphincter defect present)80%[1]
Repeat ERAF after initial failure55–93%[1]

Failure predictors: sphincter defect on EAUS or manometry, Crohn's disease, prior pelvic radiation, recurrent fistula. Diverting stoma is not consistently shown to improve ERAF outcomes and is decided on a per-patient basis.[1]

4. Episioproctotomy (Recommendation 15, Strong / 1C)​

A transperineal "convert and repair" technique for low RVF with anterior sphincter defect (classically obstetric or cryptoglandular). The anterior anal sphincter complex and rectovaginal septum are intentionally divided to lay open the fistula, then reconstructed in layers with overlapping sphincteroplasty.[1]

  • Healing 78–100%
  • Postoperative fecal incontinence reported as "rare" in 92% of patients
  • Diversion used in ~50–72% but not significantly associated with outcome

5. Tissue interposition flaps (Recommendation 16, Strong / 1C)​

For recurrent or complex RVF, vascularized tissue interposition is the operative inflection point. The Pastier head-to-head series found Martius and gracilis to have equivalent success at 23 months (~69% each) with shorter LOS and similar morbidity for Martius — supporting Martius as the first-line interposition and gracilis as salvage after Martius failure.[11] A 2024 systematic review and proportional meta-analysis of Martius flaps reported 91.4% healing for primary RVF and 94.6% for radiation-induced RVF.[12]

FlapHealingNotes
Martius flap (bulbocavernosus / labial fat pad)65–94% (primary); 77.5% (recurrent); 91.4% pooled (primary); 94.6% (radiation)[1][11][12]Shorter LOS than gracilis; stoma not mandatory (27% in Pastier series done without diversion); first-line tissue interposition
Gracilis muscle flap50–92% (individual series); 69% at 23 months[1][11]Higher morbidity (28–47%): wound infection, thigh numbness, hematoma; reserve for salvage after Martius failure

The only modifiable negative predictor of interposition success in the Pastier cohort was smoking (p = 0.02).[11]

6. Anastomotic-related RVF (Recommendation 17, Strong / 1C)​

RVF after low anterior resection or other colorectal anastomosis usually requires a transabdominal approach.[1]

  • Fecal diversion is the typical first step; healing with diversion alone ~37%
  • Persistent fistulas need redo colorectal anastomosis, ERAF, or transperineal interposition

7. Radiation-induced RVF (Recommendation 18, Weak / 2C)​

The most challenging subset — endarteritis obliterans produces a hostile, progressive bed.[1][8]

  • Median time to radiation-induced RVF: 20 months (range 5–240) after radiotherapy[8]
  • Fecal diversion alone was the only feasible option in 96% of patients in one series; only 12% healed spontaneously; healing was associated with fistula > 7 cm from anal verge (OR 18) and loop ileostomy (OR 17)[8]
  • Martius flap for radiation RVF: healing in 11/12 and 13/14 in two series — high success[1][12]
  • Proctectomy with coloanal anastomosis (sleeve excision or pull-through): healing 75–100%[1][13]
  • Delayed coloanal anastomosis (Turnbull–Cutait): 81% success in the multicenter GRECCAR cohort, but with substantial morbidity (45% overall, 23% major) and durable functional sequelae (42% with severe LARS or permanent stoma)[14]
  • Restorative resection outperforms colostomy alone for symptom relief and quality of life — 30% of restorative-resection patients ultimately reverse stomas vs 0% in colostomy-only[15]

8. Crohn's-disease-associated RVF​

Combined medical–surgical management is mandatory.[7][16]

  • Anti-TNF therapy (infliximab) is first-line; combination with an immunomodulator is preferred for fistulizing disease
  • Antibiotics (ciprofloxacin + metronidazole) as adjuncts
  • Setons before immunosuppression for any complex tract
  • Surgical repair only when endoscopic healing of the rectosigmoid has been achieved
  • Diverting stoma for refractory disease; long-term success of diversion alone in perianal Crohn's is poor
  • Proctectomy / total proctocolectomy with permanent stoma in the most severe cases

Outcomes are markedly worse than for traumatic RVF — inflammatory etiologies (Crohn's, cryptoglandular, anastomotic) had healing of only 7.1% after index surgery and 46.4% at final follow-up, vs 45.9% / 91.7% for traumatic (obstetric / iatrogenic) fistulas.[17]

Outcomes and Prognostic Factors​

FactorEffect
Traumatic etiology (obstetric / iatrogenic)Best — 91.7% final healing[17]
Inflammatory etiology (Crohn's, cryptoglandular, anastomotic)Worst — 46.4% final healing (p = 0.001)[17]
Major procedure (gracilis, coloanal anastomosis) for failed local repairOR 6.4 for success[6]
Diverting stoma in complex casesOR 3.5 for success[6]
Early surgery (within 9 months of diagnosis)OR 2.3 for success[6]
Repair at a specialized centerOR 3.2 for success[6]
SmokingOnly modifiable negative predictor of interposition success[11]
Sphincter defect, prior radiation, recurrent fistulaPredict ERAF failure[1]

In the Corte 79-patient / 286-procedure series, the operative algorithm of early temporary stoma + escalating to a major procedure after failure of local repair delivered the highest cumulative success rates.[6]

Operative Principles​

  • Etiology drives strategy — obstetric, Crohn's, radiation, and anastomotic RVF have distinct pathways
  • Sphincter assessment is mandatory — sphincter defects mandate sphincteroplasty or episioproctotomy
  • Control infection and inflammation first — drain, divert, and treat before definitive repair
  • Repair from the high-pressure side — the rectal advancement flap covers the rectal opening, directing intraluminal pressure away from the suture line
  • Vascularized tissue interposition for any recurrent, complex, or radiated fistula — Martius first, gracilis as salvage
  • Fecal diversion is decided per patient — unequivocally helpful with major reconstruction and radiation, less essential for ERAF alone
  • Smoking cessation is the only modifiable negative predictor in tissue-interposition repair[11]
  • Fibrin glue and fistula plugs have prohibitively poor success rates in RVF and are not recommended[1]

References​

1. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

2. Thayalan K, Krause H, Goh J. "A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia." Aust N Z J Obstet Gynaecol. 2022;62(2):263–267. doi:10.1111/ajo.13444

3. Expert Panel on Gastrointestinal Imaging, Levy AD, Liu PS, et al. "ACR Appropriateness Criteria® anorectal disease." J Am Coll Radiol. 2021;18(11S):S268–S282. doi:10.1016/j.jacr.2021.08.009

4. Fernando RJ, Sultan AH, Kettle C, Thakar R. "Methods of repair for obstetric anal sphincter injury." Cochrane Database Syst Rev. 2013;(12):CD002866. doi:10.1002/14651858.CD002866.pub3

5. Zheng H, Guo T, Wu Y, et al. "Rectovaginal fistula after low anterior resection in Chinese patients with colorectal cancer." Oncotarget. 2017;8(42):73123–73132. doi:10.18632/oncotarget.17046

6. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

7. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465

8. Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A. "Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies — new patients, old problem?" Langenbecks Arch Surg. 2017;402(7):1079–1088. doi:10.1007/s00423-016-1539-4

9. VanBuren WM, Lightner AL, Kim ST, et al. "Imaging and surgical management of anorectal vaginal fistulas." Radiographics. 2018;38(5):1385–1401. doi:10.1148/rg.2018170167

10. Qi C, Li J. "Diagnostic performance of three-dimensional endoanal ultrasound compared with MRI in anal fistula: a systematic review and meta-analysis." Acad Radiol. 2026. doi:10.1016/j.acra.2026.01.058

11. Pastier C, Loriau J, Denost Q, et al. "Rectovaginal fistula: what is the role of Martius flap and gracilis muscle interposition in the therapeutic strategy?" Dis Colon Rectum. 2024;67(8):1056–1064. doi:10.1097/DCR.0000000000003148

12. Swindon D, Izwan S, Ng J, et al. "Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis." ANZ J Surg. 2024;94(9):1471–1479. doi:10.1111/ans.18922

13. Karakayali FY, Tezcaner T, Ozcelik U, Moray G. "The outcomes of ultralow anterior resection or an abdominoperineal pull-through resection and coloanal anastomosis for radiation-induced recto-vaginal fistula patients." J Gastrointest Surg. 2016;20(5):994–1001. doi:10.1007/s11605-015-3040-8

14. Collard MK, Tuech JJ, Fernandez B, et al. "Delayed coloanal anastomosis for rectovaginal fistulas: insights from a multicenter cohort (GRECCAR)." Surgery. 2025;188:109767. doi:10.1016/j.surg.2025.109767

15. Zhong Q, Yuan Z, Ma T, et al. "Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only." World J Surg Oncol. 2017;15(1):37. doi:10.1186/s12957-017-1100-0

16. Feuerstein JD, Ho EY, Shmidt E, et al. "AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease." Gastroenterology. 2021;160(7):2496–2508. doi:10.1053/j.gastro.2021.04.022

17. Söderqvist EV, Cashin PH, Graf W. "Surgical treatment of rectovaginal fistula — predictors of outcome and effects on quality of life." Int J Colorectal Dis. 2022;37(7):1699–1707. doi:10.1007/s00384-022-04206-7