What is the occurrence percentage of rectovaginal fistula (Rectovaginal Fistula) post-delivery?

From the Guidelines

Rectovaginal fistulas occur in approximately 0.1% to 0.5% of all deliveries, making them a relatively rare complication of childbirth. The incidence is higher in developing countries, where it may reach up to 1-2% of deliveries due to limited access to obstetric care and higher rates of prolonged obstructed labor 1. These abnormal connections between the rectum and vagina typically result from obstetric trauma, particularly prolonged labor causing tissue necrosis, or from direct injury during delivery.

Key Points

• Risk factors include instrumental deliveries (forceps or vacuum), large birth weight babies, episiotomies that extend into the rectum (fourth-degree perineal tears), and inadequate repair of obstetric lacerations.
• Symptoms include passage of stool or gas through the vagina, recurrent vaginal infections, and fecal incontinence.
• Early recognition and appropriate surgical management are essential, as these fistulas rarely heal spontaneously.
• Prevention strategies include adequate prenatal care, appropriate labor management, careful delivery techniques, and prompt recognition and repair of perineal tears during delivery. The most common cause of a rectovaginal fistula is obstetric or vaginal trauma (88% of cases) 1, followed by Crohn's disease, which accounts for approximately 9% of cases. Other causes include radiation, pelvic infections, malignancies of the anorectum, perineum, and gynecologic organs, and iatrogenic injury and postoperative complications.

Management

• Medical therapy alone or in combination with surgery would appear to offer benefit to some patients in the management of enterovaginal and enterovesical fistulae 1.
• Patients should be discussed in multidisciplinary meetings and treatment individualised, considering patients’ symptoms and situation.

From the Research

Rectovaginal Fistula Occurrence Percentage Post-Delivery

The occurrence percentage of rectovaginal fistula post-delivery can be understood through various studies that have investigated the risk factors and outcomes associated with this condition.

• According to a study published in 2024 2, out of 19,370 deliveries, 61 had fourth-degree perineal lacerations (0.31%), and of these 61 women, 5 (8.2%) developed rectovaginal fistulas 2-3 weeks after their deliveries.
• This study highlights that the occurrence of rectovaginal fistulas is relatively rare but can be a complication of fourth-degree perineal lacerations, which are associated with certain risk factors such as nulliparity, midline episiotomy, vacuum extraction, and forceps delivery.
• Another study from 2017 3 discusses the management of rectovaginal fistulas and patient outcomes, emphasizing the need for a deep understanding of the disease and treatment options for successful resolution.
• A 2017 study 4 on the outcomes of rectovaginal fistula repair found that recurrence rates after repair are high and did not differ by fistula etiology, but the abdominal repair approach had significantly fewer recurrences.
• A 2016 study 5 on the presentation and management of rectovaginal fistulas after delivery noted that due to modern obstetric care, fistulas are rare in industrialized countries, and the choice of repair should be tailored to the underlying pathology and patient's wishes.
• Lastly, a 2021 study 6 on rectovaginal fistula repair outcomes a year later highlighted that while the overall satisfaction rate after surgery is high, true success defined as permanent fistula closure is not necessarily problem-free, with long-term morbidity and management of unique sequelae being underreported.

Risk Factors and Management

Key points regarding the risk factors and management of rectovaginal fistulas include:

• The importance of identifying risk factors such as nulliparity, midline episiotomy, and instrument-assisted delivery in the development of fourth-degree perineal lacerations and subsequent rectovaginal fistulas 2.
• The need for individualized treatment approaches based on the etiology of the fistula and the patient's specific condition 4, 5.
• The variety of surgical techniques available for rectovaginal fistula repair, including local, transvaginal, endorectal, abdominal, and definitive approaches, each with its own success rates and considerations 3, 4.
• The significance of long-term follow-up to address potential complications and sequelae following fistula repair, such as sexual dyspareunia, anal sphincter problems, and intermittent urination issues 6.