What is the management of a rectovaginal fistula?

From the Guidelines

The management of a rectovaginal fistula should prioritize medical treatment with anti-TNF agents, such as infliximab, as the initial approach, with surgical closure considered in selected patients who do not respond to medical therapy 1. The goal of management is to control symptoms, promote healing, and improve quality of life. Initial management includes controlling infection with appropriate antibiotics, ensuring adequate nutrition, and treating any underlying inflammatory bowel disease if present.

• Medical therapy with anti-TNF agents, such as infliximab, has been shown to be effective in closing rectovaginal fistulas, with a study demonstrating that 44.8% of fistulas responded to induction regimen with infliximab and were closed 1.
• Surgical treatment, such as transvaginal, transperineal, transanal, or abdominal approaches, may be considered for patients who do not respond to medical therapy or have complex or recurrent fistulas.
• The timing of surgery is crucial, and it should be delayed until local inflammation subsides, typically 3-6 months after the initial injury.
• A multidisciplinary approach involving gynecologists, colorectal surgeons, and sometimes urologists is necessary to address this challenging condition that significantly impacts quality of life.
• Postoperatively, patients should maintain bowel rest, follow a low-residue diet when feeding resumes, continue antibiotics as prescribed, and avoid sexual intercourse for 6-8 weeks.
• The success rate for primary repair ranges from 70-90%, with recurrence being a significant concern, and temporary fecal diversion with a colostomy or ileostomy may be necessary for complex or recurrent fistulas 1.

From the FDA Drug Label

RENFLEXIS is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease.

The management of a rectovaginal fistula includes treatment with infiximab (IV), specifically RENFLEXIS, which is indicated for reducing the number of draining rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease. The recommended dose is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks 2.

From the Research

Management of Rectovaginal Fistula

The management of rectovaginal fistula is a complex process that requires a deep understanding of the disease, treatment options, and familiarity with different surgical techniques 3.

• Surgical Techniques: Various surgical techniques are available for the treatment of rectovaginal fistula, including rectal advancement flap, which seems to have the most successful results in selected patients 4.
• Medical Treatment: Medical treatments have low rates of long-term symptomatic control and high rates of recurrence, making them less favorable 4.
• Combined Medical and Surgical Therapy: The management of rectovaginal fistula should involve both gastroenterologists and coloproctologists, with the best surgical results being achieved in patients receiving optimum medical therapy 4.
• Patient Assessment: Accurate assessment of the entire gastrointestinal tract is essential for successful management, and establishing reasonable goals and expectations of therapy is crucial for both the patient and surgeon 5, 6.
• Surgical Repair Methods: The choice of surgical repair methods depends on various fistula and patient characteristics, and a wide variety of success rates have been reported for all management options 5.

Considerations in Management

• Timing of Operative Intervention: Proper timing of operative intervention is important for the success of primary repair of rectovaginal fistulas 7.
• Perioperative Management: Perioperative management and surgical technique are critical factors in the success of surgical treatment 7.
• Patient Selection: Selection of patients is crucial for the success of surgical treatment, and careful selection can lead to greater success than is generally maintained in the literature 7.