What is the recommended treatment for a rectourethral fistula?

Management of Rectourethral Fistula

Surgical repair with a staged approach is the recommended treatment for rectourethral fistula, with the specific technique determined by fistula complexity, etiology, and presence of local inflammation.

Initial Assessment and Management

• Diagnostic evaluation:

  • Pelvic MRI is essential to define fistula anatomy and identify associated abscesses 1
  • Complete physical examination including digital rectal examination 2

• Initial management:

  • Control of infection and inflammation:
    • Intravenous antibiotics for sepsis or surrounding soft tissue infection 2
    • Drainage of any associated abscesses 1
    • Medical control of inflammation in cases related to inflammatory bowel disease 2

Treatment Algorithm

Step 1: Diversion and Initial Management

• Fecal diversion with transverse colostomy 3, 4
• Urinary diversion with suprapubic or indwelling silicone Foley catheter 3
• Allow 3-6 months for decrease in inflammation and possible spontaneous closure 3
• For Crohn's disease-related fistulas: medical therapy with infliximab, azathioprine, or 6-mercaptopurine 2, 1

Step 2: Definitive Surgical Repair (if spontaneous closure doesn't occur)

• For simple, small fistulas without rectal inflammation:

  • Rectal advancement flap 4
  • Transanal or transvaginal advancement flaps for rectovaginal fistulas 2

• For complex or recurrent fistulas:

  • Posterior approach (modified York-Mason procedure) providing excellent exposure 3
  • Interposition flap techniques:
    • Gracilis muscle flap interposition (most common) 4, 5, 6
    • Omental flap interposition 4
    • Ensure offset suture lines to promote better healing 3

Step 3: Restoration of Continuity

• Closure of colostomy after confirming successful fistula repair 3
• Removal of urinary catheter if no recurrence 3
• Timing should be individualized based on postoperative course 3

Special Considerations

• Inflammatory Bowel Disease-Related Fistulas:

  • Control active rectal inflammation with medical therapy before surgical repair 2
  • Options include thiopurines, infliximab, or adalimumab 2
  • For refractory cases, consider diverting ostomy with proctectomy as last resort 2

• Radiation-Induced Fistulas:

  • Higher complexity requiring more advanced techniques 5
  • Lower success rates (84% vs 100% for non-radiated) 5
  • Higher rate of permanent fecal diversion (31%) 5

Outcomes and Prognosis

• Success rates vary by etiology:

  • Non-radiated fistulas: Up to 100% closure with single procedure 5
  • Radiation-induced fistulas: 84% closure rate, with 31% requiring permanent fecal diversion 5

• Potential complications:

  • Urinary strictures and incontinence may occur but typically resolve with simple treatments 4
  • Recurrence rates are higher following endorectal advancement flap procedures 2

The 3-step approach (diversion, repair, restoration) has demonstrated the best outcomes in managing rectourethral fistulas, with the specific surgical technique tailored to the fistula's complexity and etiology 6.