What is the best course of treatment for a patient with a rectovesical fistula?

Management of Rectovesical Fistula

Surgical intervention with fecal and urinary diversion is the primary treatment for rectovesical fistula, with subsequent definitive repair after control of local inflammation. 1

Initial Assessment and Management

• Imaging studies: Pelvic MRI is essential to define fistula anatomy and identify any associated abscesses or collections 2
• Infection control: Treat any abscesses with intravenous antibiotics and radiological drainage before proceeding with definitive management 2
• Diversion: Initial management requires diversion of both fecal and urinary streams to prevent ongoing contamination and allow inflammation to subside 1

Treatment Algorithm

Step 1: Control Infection and Diversion

• Drain any abscesses radiologically where possible 2
• Create a diverting colostomy to prevent fecal contamination 1
• Place suprapubic catheter or urinary diversion as needed 1

Step 2: Definitive Repair Options

Based on fistula complexity and patient factors:

1. Surgical Approach (Primary recommendation):

   • Trans-perineal, trans-anal, or posterior/transrectal surgical repair with:
     • Dissection of the rectovesical plane
     • Interrupted rectal closure
     • Omental interposition between rectum and bladder
     • Bladder closure with drainage 1, 3

2. Endoscopic Approach (For selected cases):

   • May be considered in patients with hostile abdomen or high surgical risk
   • Involves combined cystoscopic and endoscopic procedures with suturing and clipping 4
   • May require multiple procedures to gradually downsize the fistula 4

3. Medical Therapy (For inflammatory causes):

   • If fistula is due to Crohn's disease, medical control of inflammation with:
     • Infliximab (anti-TNF therapy) may be considered 2
     • Azathioprine or 6-mercaptopurine as adjunctive therapy 2
   • Note: Medical therapy alone is rarely sufficient for rectovesical fistulae and should be combined with surgical management 2

Step 3: Reversal of Diversion

• After confirmation of complete healing (typically 3-6 months)
• Perform contrast studies to verify fistula closure before reversal 1
• Restore bowel continuity only after confirming no recurrence 3

Special Considerations

• Complex fistulas: Multiple tracts or associated stenosis reduce healing rates with medical therapy and increase need for surgery 2
• Crohn's disease: Joint medical and surgical management is required 2
• Post-surgical fistulas: Higher success rates with surgical repair compared to inflammatory fistulas 1

Potential Complications and Management

• Recurrence: Occurs in up to 50% of cases, may require repeat surgical intervention 5
• Incontinence: Assess anal sphincter function before surgery; avoid procedures that may compromise continence 5
• Persistent drainage: May require longer diversion period or alternative surgical approach 1

Follow-up

• Regular clinical assessment for symptoms of recurrence
• Contrast studies before reversal of diversion
• Long-term monitoring for delayed recurrence, particularly in inflammatory causes

Pitfalls to Avoid

• Attempting repair without adequate control of local infection
• Premature reversal of diversion before complete healing
• Failure to identify and address underlying disease (e.g., Crohn's disease, malignancy)
• Inadequate tissue interposition between repaired structures

Remember that success should be measured not just by fistula closure but also by patient satisfaction with post-operative function and quality of life 5.