Proctology

Rectovaginal Fistula

Rectovaginal Fistula

Recto vaginal fistula is fistula between the gleams of the rectum and vagina.

In most cases the disease is acquired in nature, much less is innate. In such cases fistulas distinguished by their peculiar topographic forms and methods of treatment, carried out by pediatricians. Here we will talk about the disease in adults.

Causes

Causes of recto vaginal fistula is quite diverse. The most common of them abnormal childbirth (prolonged labor, prolonged dry period, ruptures of the perineum) and inflammatory complications of the operational benefits during childbirth. Relatively less recto-vaginal fistulae can occur due to injury of the wall of the rectum when performing various operations on the pelvic organs, spontaneous dissection of acute abscess in the lumen of the vagina, traumatic injury, recto vaginal septum. Often recto vaginal fistulas are a complication of Crohn’s disease, diverticulosis of the colon (especially in women undergoing removal of the uterus).

Formation of a fistula with prolonged labor or prolonged waterless period are prolonged ischemia and necrosis of soft tissue due to prolonged pressing of their head of the fetus to the bony ring of the pelvis. Depending on the size of the defeat, the rejection of necrotic tissues and formation of a fistula occur by 3-8 days post-partum period.

Often there are other reasons. Various inconsistencies of the birth canal and the size of the fetus, improper position, obstetric surgery can lead to rupture of the perineum with damage to the walls of the vagina, the rectum, the divergence of the front portions of the muscles that raise the anus (levator), and a rupture of the sphincter of the rectum. In these situations performed emergency surgery, with about one in ten patients develop inflammatory complications in the field operations, most often it is the failure of sutures on the bowel wall. The symptoms of the defect of the stitches appear on the 3-5-th day of postoperative period and is manifested by the release of gases and fecal contents from the vagina. In such a situation, one might wish to urgently re-suturing the defect. Such actions are a gross mistake, as the healing of purulent wounds was impossible under any circumstances, and the repeated failure of the joints only increases its size.

The vaginal wall closely adjacent the wall of the rectum throughout its length, while internal intestinal pressure significantly exceeds endovaginal. Therefore, when any appearance of recto-vaginal fistulae messages through it immediately occurs the loss of the intestinal mucosa into the lumen of the vagina. The mucous membrane of the intestine in 7-8 days circular adheres to the walls of the defect of the vagina — is the beginning of the formation of a fistula, finally ending in 3-4 months. after decrease of all infectious processes in the surrounding tissues.

Such a course of pathological process develops usually in postpartum and postoperative fistulas. As a result, they are gubbey, with defects in both bodies are the same height. The absence of fistulous has extremely important practical value in the recto vaginal septum never found purulent cavity or streaks.

Other topographic features are identified in trauma (according to the “falling number”), fistulas on the basis of colitis or acute abscess. One-third of such patients is defined by a tubular fistula, the course it is often branched, with osmawani of purulent cavities or streaks in the surrounding tissue.

Symptoms

The most typical complaint is the release of gases and feces from the vagina. Frequent complaints of allocation of pus from the vagina, dysuria, perineal pain, inability to exercise sexual contact. The evolution of gas and fecal contents through the vagina in the presence of a recto vaginal fistula due to the presence of muscle obturator apparatus in the distal intestine and the lack of it in the vaginal tube. Because of this accumulated intestinal secretions at any time, under any circumstances and in any quantities freely evacuated out not naturally, but through the vagina.

Needless to say how tragic these phenomena for women. The natural tendency to hide illness from others is the need to be isolated from any society, to change or even to leave work. Forced untidiness creates insurmountable obstacles in private life, may lead to family breakdown or inability of its creation. This background burden and the prospect of the imposition of preventive colostomy for one of the stages of treatment. Therefore, among the concomitant diseases on the forefront of various neuropsychiatric disorders. Additional difficulties in the existing situation contributes to the persistent, at times unsuccessful, treatment of vaginitis, supported by the permanent colonization of intestinal microflora.

Finally, almost every fourth patient is detected and related incompetence of the anal sphincter. The defect of the sphincter of various lengths, for various reasons, may persist after surgical treatment of rupture of the perineum III degree or occur after surgery to eliminate the fistula.

Classification and types

Recto vaginal fistulas are divided into:

  • low level (no higher than 3 cm from the edge of the anus);
  • medium level (3 to 6 cm from the edge of the anus);
  • high level (6 cm and above from the edge of the anus).

Diagnostics

It is most convenient to determine the height of the fistula at the fistula opening in the vaginal wall, the length of the vaginal tube is about 9 cm, the back wall is available for inspection in the mirrors almost to the arch, you can see the anastomosis itself and the discharge from fistula. And since the vast majority of cases the hole in the wall of the colon and vagina are the same, the height of the fistula can be judged by the localization of fistulous openings into the vagina.

When souljah their structure and localization are specified using the finger study of the rectum and inspection of the vagina in the mirror while using bellied probe. When bimanual study determined the degree of scarring and inflammatory preprocessed. Some difficulties can arise under high coloseeum the location of the defect.

More volume can be studies in a tubular fistula. They include a sample of the dye (mixture of methylene blue with hydrogen peroxide 1:1), fistulography using water-soluble contrast media. It is more expedient to introduce drugs through the outer opening, the inner verificarea with a rectal mirror, rektoromano – or sigmoscopy. In difficult cases the most complete information was given procto-, Vagin – or irrigography. Diagnosis of concomitant degree of insufficiency of the anal sphincter and the volume of cicatricial lesions includes statutory definition rectoanal reflex and rectal finger examination. The most objective information provide a pathophysiological studies (sfinkterami, electromyography, manometry), as the clinical assessment of incontinence the individual components of the intestinal content is masked by their vaginal discharge.

All patients performed a sigmoidoscopy and, if necessary, the differential diagnosis — of colono – and barium enema.

Differential diagnosis. The need for differential diagnosis occurs in those cases when there is a suspicion that recto vaginal fistula is a complication of a disease. Fistula may form as a result of germination in wall of vagina malignant tumors. Digital and endoscopic examination must be supplemented by cytological or histological. Errigo, and colonoscopy can help to eliminate diseases such as Crohn’s disease, diverticulosis, gives complications with the formation of a recto vaginal fistula. In Crohn’s disease fistula can be multiple. Any unusual eye view of the defect (polovinnyi education in the wall or a marked proliferation of granulation tissue) should be alerted. In these cases, performed a biopsy of the affected tissue with subsequent histological examination. Fistulae resulting from the complicated course of a disease, cannot be the object of independent operations, they are eliminated, if this fails, in the course of radical intervention about the underlying disease.

Treatment

The only method of radical treatment of recto vaginal fistula is surgical.

Acute traumatic injuries of recto vaginal septum can be eliminated with minimal risk of septic complications during the first 18 h from the time of their formation. The operation is in an advanced primary treatment of the wound by freshening its edges, excising all crushed and nonviable tissue with subsequent layer-by-layer suturing of the defect of the rectum and levatores with the use of monofilament sutures on atraumatic needle. The defect in the vagina is sutured with catgut.

More difficult is the surgical elimination of formed fistula. Universal radical surgery, there can be, not by chance, because of the variety of anatomic and topographic situations, to date, was proposed more than 30 operational techniques, some of which have received recognition of domestic and foreign surgery.

The main principle is the individual choice of method in each concrete patient. It is based on a comprehensive evaluation of such factors as the etiology of the fistula, the distance of its position from the edge of the anus, the relationship of the defect or fistulous muscular apparatus pulp, cicatrical periprotsessa, functional status zamechatelnogo apparatus of the rectum. Note that the presence of purulent periprotsessa requires the imposition of preventive colostomy, which radical intervention becomes real in 2-3 months. In practice, we use 3 line access: vaginal, perineal and rectal.

At low fistula (fistulous opening is located below 3 cm from the edge of the anus) access depends on the etiology of the disease. If his cause was acute paraproctitis, rectal is used only access, since it is necessary to eliminate not only the fistula, but the root cause — the infected crypt. In all other cases, the most reliable is the operation being relegated Muco-muscle flap of the rectum. For this purpose, an arcuate incision of skin and subcutaneous tissue from 3 to 9 o’clock on the dial at a distance of 0.5 cm from the skin and mucous edge of the anus. Sharp through the intestinal wall is mobilized, 1.5—2.0 cm above the fistula with his crossing (vaginal portion of the fistula before it is already cut), the transplant is reduced outside of the wound with fixation of nodal silk sutures to the edges so that the inner opening of the fistula is below these seams. Requires constant monitoring of the flap for timely action if it is necrosis or retraction. When uncomplicated amputation of the graft and removal of stitches are produced on the 12-14-th day after surgery. Low recto vaginal fistula, as well as cryptogenic recto, may be intra-, TRANS – or extrasphincter move. Of surgery is not have their peculiarities, except that there is a excision of fistulous openings into the vagina by suturing the wound with catgut.

If the pulp defect of any of the following operations must simultaneously be accompanied by its correction by sphincteroplasty (when the length of it about a quarter of a muscular ring) or sphincteroplasty (if more extensive damage).

Approximately 50 % of cases occur fistula secondary level (fistulous opening at a height of from 3 to 6 cm from the perianal skin). Their removal is performed as perineal and vaginal access. The first is the exposure of the anterior rectum and posterior wall of the vagina by sharp dissection after semilunar incision of the perineum to the intersection and excision of inner and outer holes, the second — the same goal is achieved after excision of the triangular flap of the vagina along with the defect. After economical excision of scars monofilament strands sutured internal hole in the intestinal wall. The next stage is produce front levatoroplasty to create a natural “strip” — the demarcation between the two bodies, and then suturing of the defect of the vagina with catgut. If the operation was performed perineal access, the skin is sutured nodal silk sutures. It should be emphasized that vaginal access is preferable, since there are no skin wounds and the risk of inflammatory complications is much less.

As a rule, extreme technical difficulties accompany the interventions at the high-level fistulas (fistulous opening above 6 cm from the perianal skin). Very localized defect leaves only one operational access — razvlekatelny, complicating everything is the manipulation of the narrowness of the surgical field.

Rarely fails to execute the intervention according to the methods used for the elimination of fistula average. In these cases, a modification of the operation of A. E. Mandelstam, who used a “sealing” of the defect lip of the cervix. The essence of the proposal is that after excision of the fistula defect of the intestinal wall is sutured single-row atraumatic suture, followed by mobilization of the posterior lip of the cervix and stitching the nodal joints of the edges of wounds of the vagina and cervix.

With extensive cicatricial process is the only alternative — the elimination of the fistula and closure of defects in both bodies through a laparotomy. This proposed a number of methods which are used in conditions of specialized hospitals.

Extremely important in the successful outcome of treatment plays a correct management in the early postoperative period, including the delay of a stool for 4-5 days, subsequent cleaning of the bowel only with enemas siphon for 5-7 days, careful monitoring of the condition of the wound from the rectum and vagina.

The frequency of postoperative complications, the most formidable of which are the failure of intestinal sutures and the inevitable recurrence of the fistula, in the range of 10-15 %. Approximately V4 of patients can achieve healing with conservative measures (high siphon enema, laser), 50 % of operated have to perform a dissection of recurrent fistula or liquidation of its actual method. In the formation of persistent relapse, becoming clear after 3-4 months. patients are subject to repeated radical surgery.

The prognosis is favorable. The specialized departments are able to heal more than 96 % of the patients; they live a full life, some have re-birth (by caesarean section).

Reviewed by the QSota Medical Advisory Board