What is the treatment approach for a patient with a vaginal fistula?

Treatment Approach for Vaginal Fistula

The treatment of vaginal fistula requires a multidisciplinary approach with initial assessment of fistula type and anatomy, followed by appropriate surgical intervention based on fistula classification, with rectovaginal fistulas typically requiring surgical repair after control of inflammation. 1

Classification and Diagnosis

• Vaginal fistulas are classified based on the connecting structure (rectovaginal, vesicovaginal, enterovaginal) and complexity (simple vs. complex) 2
• Initial diagnosis requires imaging to define fistula anatomy, with MRI being the preferred modality for comprehensive assessment 1
• Endoanal ultrasound can be used as an alternative or complementary imaging technique, with reported PPV of 90-100% for fistula identification 1, 2
• Vaginography has high sensitivity (79%) and PPV (100%) for identification of fistulous tracts and can be useful in certain clinical scenarios 1

Treatment Algorithm by Fistula Type

Rectovaginal Fistulas

• Initial management should include control of any underlying inflammation, particularly in cases associated with Crohn's disease 1
• Medical therapy should be used first to control active luminal disease, with anti-TNF agents (infliximab) showing effectiveness in up to 45% of rectovaginal fistulas 1
• Surgical repair should only be performed after endoscopic healing of rectosigmoid mucosa 1
• Surgical options include:
  • Transanal or transvaginal advancement flaps for symptomatic fistulas with healed rectal mucosa 1
  • Seton placement for complex fistulas or those with active inflammation 1

Vesicovaginal Fistulas

• Transvaginal repair is the preferred approach with success rates of 70-100% in non-radiated patients 3
• A waiting period of 4-6 weeks from fistula onset is recommended before attempting surgical repair 3
• Surgical techniques include modifications of the Latzko procedure or layered closure with or without a Martius flap 3, 4
• For radiation-induced fistulas, more individualized management is required with success rates of 40-100% 3

Enterovaginal Fistulas

• Enterovaginal fistulas often require resective surgery, especially when associated with abscess, bowel stricture, or causing excessive diarrhea and malabsorption 1
• For colovaginal fistulas, sigmoid resection with primary anastomosis has shown complete symptom resolution in 84% of cases 5

Management of Complex and Refractory Cases

• For complex perianal fistulas, a combination of seton placement and medical therapy (anti-TNF agents) is recommended 1, 2
• For refractory cases not responding to medical and surgical treatment, diverting ostomy may be considered 1
• Proctectomy should be considered only as a last resort for severe disease with irreversible perineal destruction 1, 2

Special Considerations

• Asymptomatic low anal-introital fistulas may not require surgical treatment 1
• The Martius procedure (labial fat pad interposition) shows superior outcomes for urethrovaginal and vesicovaginal fistulas, especially for recurrent or multiple fistulas 4
• Clinical closure does not equal MRI closure, with high risk of recurrence without complete fibrotic tract on MRI 2
• Fistula repair does not guarantee continence of urine or feces due to potential underlying damage to bowel and bladder 6

Monitoring and Follow-up

• Regular follow-up with clinical assessment (decreased drainage) is usually sufficient to evaluate treatment response 1
• MRI or anal endosonography in combination with clinical assessment is recommended to evaluate improvement of fistula track inflammation 1
• Monitoring for development of malignancy in chronic fistula tracts is recommended, particularly in long-standing cases 2