How is a rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) treated?

Management of Rectovaginal and Vesicovaginal Fistulae

Major anatomic defects including rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) require surgical repair as definitive treatment, but the approach differs fundamentally based on etiology—inflammatory bowel disease (IBD)-related fistulae require medical control of inflammation before surgery, while non-IBD fistulae proceed directly to surgical repair. 1

Initial Assessment and Etiology Determination

The first critical step is determining whether the fistula is related to Crohn's disease or other inflammatory conditions versus obstetric trauma, surgical injury, or malignancy:

• For suspected IBD-related fistulae: Perform proctosigmoidoscopy to assess rectosigmoid inflammation, as active inflammation dramatically affects surgical outcomes 1
• Obtain pelvic MRI to define fistula anatomy and identify associated abscesses or collections 1
• Rule out malignancy before any treatment, as malignant fistulae require oncologic resection, never local repair, and anti-TNF therapy is contraindicated 2

Management Algorithm for IBD-Related Fistulae

Step 1: Control Sepsis First

• Never initiate anti-TNF therapy before draining abscesses—this increases mortality 1, 2, 3
• Treat intra-abdominal or pelvic abscesses with IV antibiotics plus radiological drainage 1
• Surgical drainage may be required if radiological drainage fails 1

Step 2: Medical Management (Enterovaginal/Enterovesical Fistulae)

For enterovaginal and enterovesical fistulae in Crohn's disease:

• Initiate combination therapy with infliximab plus an immunosuppressor (azathioprine, 6-mercaptopurine, or methotrexate) as first-line treatment 1, 2
• Use infliximab induction dosing: 5 mg/kg at weeks 0,2, and 6, followed by maintenance every 8 weeks 2
• Add immunosuppressor from the start to prevent immunogenicity and maintain remission 2
• Medical therapy achieves complete response in 65.9% of enterovesical fistulae, making it the appropriate initial approach 2

Common pitfall: Do not assume clinical closure equals complete healing—high recurrence risk exists without complete fibrotic tract formation on imaging 2, 4

Step 3: Surgical Indications for IBD-Related Fistulae

Surgery is indicated when:

• Bowel obstruction, ureteral obstruction, or recurrent urinary tract infections develop 2
• Abscess formation occurs 2
• Medical therapy fails after adequate trial 1, 2
• Recurrence after medical therapy 2

Critical timing: Surgical repair should only occur after achieving endoscopic mucosal healing of the rectosigmoid colon 2

Step 4: Surgical Approach for Rectovaginal Fistulae in IBD

• Surgical treatment should only be attempted in the absence of active rectosigmoid inflammation 1
• Never perform fistulotomy for rectovaginal fistulae due to sphincter injury risk 1
• Surgical options include: primary closure, transanal advancement flap, sleeve advancement flap, or transvaginal advancement flap 1
• Success rates range from 50-100% when performed in the absence of active inflammation 1
• For IBD-related RVF, infliximab achieved 45% closure at week 14 in clinical trials 1

Management Algorithm for Non-IBD Fistulae

Obstetric and Traumatic Fistulae

These represent the most common etiology in developing countries (81% from obstructed labor) and require direct surgical approach: 5

• Proceed directly to surgical repair without medical therapy 6, 5
• Transvaginal approach is used in 91.9% of VVF cases 5
• Transabdominal approach reserved for complex cases (2.7%) 5
• First surgery achieves cure in 54-85% of cases 6, 5

Post-Surgical/Iatrogenic Fistulae

• Account for 18.92% of cases in surgical series 5
• Excision and closure of fistula tract with omental flap interposition is effective for both RVF and VVF occurring after pelvic surgery 7
• Transabdominal and transperineal approaches may be combined for simultaneous RVF and VVF repair 7

Special Considerations

Pregnancy Management

• Pregnant women with existing fistulae require cesarean delivery to prevent obstetric complications 8
• Close monitoring throughout pregnancy is mandatory 8
• Fistula repair should be deferred until after delivery 8

Vesicovaginal Fistula Specific Management

• VVF alone occurs in 78.8% of fistula patients, while 16.9% have both VVF and RVF 6
• Surgical cure rates at first attempt: 84.6% overall 6
• Stress incontinence occurs in 9.1% post-repair 6

Critical Pitfalls to Avoid

• Do not perform local repair procedures on malignant fistulae—these are contraindicated and will fail; oncologic resection is required 2
• Do not discontinue immunosuppressors after achieving closure with infliximab—maintenance combination therapy is essential to prevent recurrence 2
• Do not initiate anti-TNF therapy without first excluding and draining abscesses—this worsens sepsis 1, 2, 3
• Do not attempt surgical repair of IBD-related fistulae with active rectal inflammation—wait for mucosal healing 1, 2