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Episioproctotomy for Rectovaginal Fistula

Episioproctotomy is a transperineal technique for rectovaginal fistula (RVF) repair that intentionally divides the anterior anal sphincter complex and rectovaginal septum, then reconstructs all layers under direct vision. Per the ASCRS Clinical Practice Guidelines (2022), episioproctotomy may be used to repair obstetric or cryptoglandular RVF in patients with anal-sphincter defects (Recommendation 15, Grade 1C), with fistula-healing rates of 78–100% and superior continence and sexual function compared to endorectal advancement flap.[1][3] The operation is conceptually equivalent to converting the fistula into a fourth-degree perineal laceration and then performing a meticulous layered repair.[1][2]

For first-line repair when the sphincter is intact see ERAF ± Sphincteroplasty. For preoperative optimization and the broader nonoperative pathway see Nonoperative RVF Management. Background at Rectovaginal Fistula.

Indications​

  • Obstetric RVF with anterior sphincter defect — the most common indication[1][3]
  • Cryptoglandular RVF with sphincter compromise[1][3]
  • Cloaca / cloaca-like deformity — complete perineal-body disruption with a common rectovaginal opening[2]
  • Recurrent RVF after failed local repair (e.g., failed ERAF)
  • Preexisting fecal incontinence from sphincter disruption — fistula and sphincter can be reconstructed simultaneously

Best candidates: low or mid-level RVF in patients whose anterior sphincter is already disrupted or significantly damaged — intentional division becomes a corrective rather than destructive maneuver.[2]

Contraindications / Poor Candidates​

  • Intact anal sphincter — risks de novo incontinence; ERAF or transvaginal repair is preferred
  • Crohn's disease — impaired wound healing and risk of worsening perianal disease[4]
  • Radiation-induced RVF — poor tissue quality precludes reliable layered perineal repair
  • High RVF — out of perineal reach
  • Active infection / abscess — drain and treat (often with seton) before definitive repair[1]

Episioproctotomy vs Sphincteroplasty (with or without ERAF)​

The ASCRS distinguishes the two by the amount of perineal skin, external sphincter, and rectovaginal septum that must be divided to reach and repair the fistula.[1]

FeatureEpisioproctotomySphincteroplasty (± ERAF)
ApproachTransperineal — divides perineal body, sphincter, and rectovaginal septumPerineal — mobilizes and overlaps existing sphincter ends without full septal division
Extent of divisionFull anterior sphincter complex + rectovaginal septum down to the fistulaLimited to the existing sphincter defect
Fistula exposureComplete — fistula opened into a controlled wound, then layered repairIndirect — fistula excised or closed separately from sphincter repair
Healing rate78–100%[1][2][3]> 80%[1]
Continence outcomes92% "rare" incontinence; significantly better fecal function vs ERAF (P < 0.001)[1][3]~70% perfect continence[1]
Best forSignificant sphincter disruption, cloaca, failed prior repairsModerate sphincter defect with concurrent RVF

Surgical Technique​

Positioning and preparation​

  • Prone jackknife (preferred) or lithotomy
  • Mechanical bowel prep day before surgery
  • Perioperative IV antibiotics
  • Foley catheter
  • EUA to confirm fistula anatomy, sphincter-defect extent, and tissue quality

Step 1 — Identify the fistula tract​

Probe the tract from vaginal to rectal opening; correlate the anterior-sphincter defect with preoperative endoanal US or MRI.

Step 2 — Perineal incision​

Curvilinear or midline incision from posterior fourchette toward the anus, deepened through the perineal body.

Step 3 — Division of the anterior sphincter complex​

  • Divide the external anal sphincter anteriorly through the existing defect or scar.
  • Divide the internal anal sphincter as needed.
  • Continue through the rectovaginal septum until the fistula is fully exposed.
  • In cloaca, the anterior sphincter is already absent — dissection proceeds directly into the septum.

Step 4 — Fistula excision​

Completely excise the tract — granulation, scar, and epithelialized lining. Freshen rectal and vaginal openings to healthy, well-vascularized tissue. Thorough debridement is essential.

Step 5 — Layered closure: rectal wall​

Close mucosa + muscularis with interrupted absorbable suture (3-0 Vicryl) in a transverse direction to avoid anal-canal narrowing.

Step 6 — Rectovaginal septum / levatorplasty​

Approximate the septum (including available levator ani fibers) over the rectal closure with interrupted absorbable sutures. Levatorplasty — plication of the levator ani anterior to the rectum — adds bulk and reinforces the repair.

Step 7 — Sphincter reconstruction (overlapping sphincteroplasty)​

  • Identify and mobilize the divided external sphincter ends.
  • Overlapping repair with horizontal mattress sutures of delayed-absorbable material (2-0 PDS or Vicryl).
  • This is the critical step that distinguishes episioproctotomy from simple fistula excision and provides the continence benefit.

Step 8 — Perineal-body reconstruction​

Approximate the bulbocavernosus muscles and perineal tissues in the midline to restore anatomic separation between the vagina and anus.

Step 9 — Vaginal-wall closure​

Close the posterior vaginal wall with interrupted absorbable suture.

Step 10 — Skin closure​

Loosely approximate or leave partially open to allow drainage and reduce hematoma / infection risk.

Key technical principles​

  • Multiple non-overlapping suture lines — rectal wall, septum/levator, sphincter, vaginal wall each closed separately with offset suture lines so a single breakdown cannot expose all layers.
  • Tension-free closure — adequate mobilization of every plane.
  • Complete fistula excision — remove all epithelialized and granulation tissue.
  • Gentle handling to preserve vascularity.

Outcomes — Evidence Summary​

SeriesnEtiologyHealingContinence outcomesFollow-upKey findings
Hull 200742Obstetric (mostly) + cloaca74% RVF; 100% cloacaMedian Wexner 5 (healed) vs 8 (recurrence)Mean 37 mo8/11 recurrences had ≥ 1 prior failed repair; no variable significantly predicted recurrence[2]
Hull 201150 episioproctotomy vs 37 ERAFObstetric + cryptoglandular78% vs 62.2% (P = 0.1)Significantly better fecal (P < 0.001) and sexual (P = 0.04) function with episioproctotomyMean 49.2 moComparable healing but superior functional outcomes[3]
El-Gazzaz 201050 (within 100 total)Obstetric 60%, cryptoglandular 40%78% episioproctotomy; 68% overallPreop incontinence 42%; dyspareunia in 25.5% of sexually active patientsMean 45.8 moHigher BMI (P = 0.001) and prior repairs (P = 0.02) predicted failure[5]
Rahman8Obstetric100%No fecal incontinence reported6 mo – 8 yrSmall series; excellent results[1]
Hull 2011 (ASCRS data)50Obstetric + cryptoglandular78%92% "rare" postop incontinence; preop incontinence reduced from 50% to 8%Median 49 moStoma closure at median 3.4 mo; diversion not significantly associated with outcomes[1]

Continence outcomes​

The simultaneous restoration of sphincter function is the operation's defining advantage:[1][3]

  • Preoperative fecal incontinence in 50% (25/50) in Hull's series → only 8% (4/50) postoperatively.[1]
  • Fecal function significantly better than ERAF (P < 0.001) in the head-to-head comparison.[3]
  • 92% report "rare" postoperative incontinence (near-perfect continence) at median 49-mo follow-up.[1]
  • Median Wexner: 5 (IQR 2–6) when healed vs 8 (IQR 7–12) with recurrence.[2]
  • Rahman: 0/8 with fecal incontinence at 6 mo – 8 yr.[1]

Sexual function​

Episioproctotomy yielded significantly better sexual function than ERAF (P = 0.04) — likely because the perineal-body and posterior-vaginal-wall reconstruction restores normal anatomy.[3] Dyspareunia was reported in 25.5% (12/47) of sexually active patients across all RVF repair types in El-Gazzaz; quality of life and sexual function were similar regardless of healing status.[5]

Role of fecal diversion​

Diversion is not mandatory and has not been shown to affect outcomes:[1][2]

  • Hull 2007: 55% (23/42) had a stoma — diversion not significantly associated with outcomes.[2]
  • Hull 2011: 72% (36/50) had a stoma; closure at median 3.4 months.[1]
  • El-Gazzaz: temporary diversion in 72% for recurrent fistula or extensive scarring; healing not affected on multivariate analysis.[5]

Decision is individual — diversion is more commonly used for recurrent fistula, extensive scarring, or judged-suboptimal tissue quality.

Risk Factors​

Associated with failure:[2][5]

  • Higher BMI — independent predictor (P = 0.001)
  • Number of prior repairs (P = 0.02)
  • Prior failed repair — 8 of 11 recurrences in Hull 2007 occurred in this group

Not significantly associated: age, smoking, comorbidities, preoperative seton, stoma use, etiology (obstetric vs cryptoglandular).[2][5]

Episioproctotomy for cloaca​

A cloaca / cloaca-like deformity represents the most severe obstetric perineal injury — complete perineal-body disruption with a common rectovaginal opening. In Hull 2007:[2]

  • 9 patients with cloaca
  • 0 recurrences (100% healing)
  • Episioproctotomy is particularly well-suited because the sphincter is already absent anteriorly

Postoperative Care​

  • Stool softeners + fiber — soft formed stools, minimize straining
  • Sitz baths — perineal wound care
  • Antibiotics — perioperative prophylaxis; extended course if wound infection
  • No vaginal intercourse for ≥ 6–8 weeks
  • Pelvic-floor PT — may optimize continence after sphincter reconstruction
  • Stoma closure, if diverted, at 3–4 months after fistula healing confirmed (median 3.4 mo)[1]
  • Follow-up: clinical exam at 6–8 wk, then 3, 6, 12 mo. Endoanal US to assess sphincter integrity if needed.

Place in the Surgical Algorithm​

  1. First-line for most RVF: ERAF ± sphincteroplasty (ASCRS Recommendation 14)
  2. First-line for RVF with significant sphincter defects: Episioproctotomy or sphincteroplasty (ASCRS Recommendation 15) — episioproctotomy preferred when the defect is extensive or there is cloaca-like deformity
  3. Recurrent / complex RVF: tissue interposition (Martius or gracilis) (Recommendation 16)
  4. Refractory / radiation-related RVF: proctectomy ± coloanal anastomosis (Recommendation 18)

Episioproctotomy is a first-line option whenever the anterior sphincter is compromised — not a salvage procedure.[2]

Advantages and Disadvantages​

Advantages:

  • Simultaneous fistula and sphincter repair in a single operation
  • Superior fecal continence vs ERAF
  • Superior sexual function vs ERAF
  • Excellent healing (78–100%)
  • Direct visualization and complete fistula excision
  • Layered closure with multiple non-overlapping suture lines
  • Diversion not mandatory

Disadvantages:

  • More extensive than ERAF — intentional sphincter division
  • Inappropriate when the sphincter is intact
  • Not suitable for Crohn's or radiation RVF
  • Limited to low and mid-level fistulae accessible perineally
  • Perineal wound complications (infection, dehiscence) possible
  • Requires surgeon experienced with perineal anatomy and sphincter reconstruction

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. Hull TL, Bartus C, Bast J, Floruta C, Lopez R. "Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula." Dis Colon Rectum. 2007;50(1):97–101. doi:10.1007/s10350-006-0790-0

3. Hull TL, El-Gazzaz G, Gurland B, Church J, Zutshi M. "Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin." Dis Colon Rectum. 2011;54(1):54–59. doi:10.1097/01.dcr.0000388926.29548.36

4. Otero-Piñeiro AM, Jia X, Pedersen KE, et al. "Surgical intervention is effective for the treatment of Crohn's-related rectovaginal fistulas: experience from a tertiary inflammatory bowel disease practice." J Crohns Colitis. 2023;17(3):396–403. doi:10.1093/ecco-jcc/jjac151

5. El-Gazzaz G, Hull TL, Mignanelli E, et al. "Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function." J Gastrointest Surg. 2010;14(11):1758–1763. doi:10.1007/s11605-010-1259-y