How do rectovaginal fistulas form and can they occur in normal, healthy women?

From the Guidelines

Rectovaginal fistulas are abnormal connections between the rectum and vagina that typically do not occur in normal, healthy women without predisposing factors. These fistulas most commonly form as a result of trauma, particularly obstetric injuries during childbirth (such as severe tears or episiotomy complications), surgical complications (especially from colorectal, gynecologic, or pelvic surgeries), inflammatory bowel diseases (particularly Crohn's disease), pelvic radiation therapy, or infections (like diverticulitis or perirectal abscesses) 1. The fistula creates a pathway allowing stool and gas to pass from the rectum into the vagina, causing symptoms such as passage of gas or stool through the vagina, recurrent vaginal infections, and foul-smelling vaginal discharge. Some key points to consider in the formation and treatment of rectovaginal fistulas include:

• The development of a rectovaginal fistula requires some form of tissue injury and breakdown between these two structures, which doesn't happen without an underlying cause.
• Treatment typically involves surgical repair after addressing any underlying condition, with the specific approach depending on the size, location, and cause of the fistula.
• Medical treatment, such as with infliximab, may be effective in closing rectovaginal fistulas, especially in patients with Crohn's disease, with studies showing that infliximab is more effective than placebo in prolonged closure of these fistulas 1.
• Small fistulas may occasionally heal with conservative management, but most require surgical intervention for complete resolution.
• The most effective treatment approach should prioritize the patient's quality of life, taking into account the potential benefits and risks of medical and surgical interventions. In terms of the occurrence of rectovaginal fistulas in normal, healthy women, it is essential to note that these fistulas are relatively rare in the absence of predisposing factors, and their development usually indicates an underlying condition that requires medical attention. Key considerations for clinicians include:
• Identifying and addressing the underlying cause of the fistula
• Evaluating the size, location, and severity of the fistula to determine the best treatment approach
• Discussing the potential benefits and risks of medical and surgical interventions with the patient
• Prioritizing the patient's quality of life and overall well-being in the treatment decision-making process 1.

From the Research

Formation of Rectovaginal Fistulas

• Rectovaginal fistulas can form due to various reasons, including Crohn's disease 2, 3, 4 and obstetrical injury 5.
• In Crohn's disease, the formation of rectovaginal fistulas is a rare but dreaded complication that is exceedingly difficult to manage 2.
• Obstetrical injury is also a common cause of rectovaginal fistulas, which can occur during childbirth 5.

Occurrence in Normal, Healthy Women

• While rectovaginal fistulas are often associated with Crohn's disease and obstetrical injury, they can also occur in normal, healthy women 5, 6.
• However, the studies provided do not specifically address the incidence of rectovaginal fistulas in normal, healthy women without any underlying medical conditions.
• It is worth noting that rectovaginal fistulas are a relatively rare condition, and their occurrence in normal, healthy women is likely to be low 6.

Key Factors in Formation and Occurrence

• The formation and occurrence of rectovaginal fistulas can be influenced by various factors, including the presence of underlying medical conditions such as Crohn's disease 2, 3, 4.
• The severity of the condition, as well as the effectiveness of treatment, can also impact the formation and occurrence of rectovaginal fistulas 3, 5.
• A multidisciplinary approach to management, including medical and surgical treatment, is often necessary to successfully treat rectovaginal fistulas 2, 4.