Experiences of Rectovaginal Fistula in Anorectal Malformation.

BACKGROUND: Rectovaginal fistulas (RVFs) are very rare malformations in females with anorectal malformations (ARMs). Here, we share the clinical features of RVF and report the long-term outcomes. METHODS: RVF patients were classified using a retrospective analysis of ARM patients who underwent operations at Seoul National University Hospital between January 1999 and May 2017. The Krickenbeck continence scoring system was used to evaluate bowel function 5 and 10 years after surgery. RESULTS: Of the total 460 ARM patients, 203 were female, 7 of whom were diagnosed with RVF. The median age and weight at the time of anorectoplasty were 292 days (range, 140-617) and 8.2 kg (range, 5.5-12), respectively. Six patients had associated anomalies and three patients underwent redo-anorectoplasty. Voluntary bowel movements were observed in 6 out of 7 patients at 5 and 10 years of age. Soiling was observed in all patients at the age of five years and in 6 out of 7 patients at the age of ten years. Constipation was observed in 6 out of 7 patients at both five and ten years of age. CONCLUSIONS: An RVF is a very rare malformation, accounting for 1.5% of total ARMs and 3.4% of ARMs in females. Long-term counseling, education, and guidance are needed for effective management of patients' bowel movements. TYPE OF STUDY: Prognosis study LEVEL OF EVIDENCE: Level IV.

Identifying Outcomes in Clinical Trials of Fistulizing Crohn's Disease for the Development of a Core Outcome Set.

Fistulizing complications develop in approximately one third of patients with Crohn's disease (CD), resulting in morbidity and impaired quality of life.1 Sites of fistulae most commonly include perianal fistulae, but also enterocutaneous, enteroenteric, enterovesical, and rectovaginal. Its management requires combined medical and surgical strategies to prevent abscess formation and induce healing. Biologic agents have improved the medical treatment of CD-related fistulae, but many patients still require surgical intervention. Hence, there is considerable interest in the development of novel pharmaceutical agents to treat fistulizing CD.

The use of viable cryopreserved placental tissue in the management of a chronic rectovaginal fistula.

We present a case of a chronic recurrent rectovaginal fistula that initially arose from complications of haemorrhoid surgery and had failed multiple prior surgical repairs. The fistula was successfully managed using viable cryopreserved placental tissue.

Vaginal agenesis and rectovestibular fistula. Experience utilizing distal ileum for the vaginal replacement in these patients, preserving the natural fecal reservoir.

BACKGROUND: The association of rectovestibular fistula (RVF) and vaginal agenesis (VA) presents a diagnostic and management challenge. The vaginal replacement is usually performed with rectum or sigmoid, which are the natural fecal reservoirs; thus, the fecal control could be affected. We present our experience utilizing ileum to preserve the rectum and sigmoid. METHODS: We performed a retrospective study of eight patients with RVF and VA treated from May 2011 to June 2015 at two colorectal centers, at Pittsburgh and Mexico. We recorded the age at diagnosis of VA, treatment, presence of other associated malformations and outcome. RESULTS: Eight of forty-nine girls with RVF had an associated VA (16.3%). Three patients had a timely diagnosis and five a delayed diagnosis. Six patients were submitted to a vaginal replacement with ileum and achieved fecal control. Two are waiting for surgery. CONCLUSIONS: A high index of suspicion of vaginal agenesis helps in a timely diagnosis in girls with RVF. The use of ileum allows for preservation of the fecal reservoirs, thus optimizing the chance for fecal control in patients with anorectal malformations.

Musculoskeletal sequelae in patients with obstetric fistula - a case-control study.

BACKGROUND: Obstetric fistula is essentially a result of pelvic injury caused by prolonged obstructed labour. Foot drop and walking difficulties in some of these women signify that the injury may extend beyond the loss of tissue that led to the fistula. However, these aspects of the pelvic injury are scarcely addressed in the literature. Here we specifically aimed at assessing musculoskeletal function in women with obstetric fistula to appreciate the extent of the sequelae of their pelvic injury. METHODS: This case-control study compared 70 patients with obstetric fistula with 100 controls matched for age and years since delivery. The following was recorded: height, weight, past and present walking difficulties, pain, muscle strength and joint range of motion, circumference and reflexes. Differences between groups were analysed using independent sample t-test and chi-square test for independence. RESULTS: A history of leg pain was more common among cases compared to controls, 20% versus 7% (p = 0.02), and 29% of the cases had difficulties walking following the injuring delivery compared to none of the controls (p ≤ 0.001). Of these, four women reported spontaneous recovery. Cases had 7° less range of motion in ankle dorsal flexion (95%CI: -8.1, -4.8), 8° less ankle plantar flexion (95%CI: -10.6, -6.5), 12° less knee flexion (95%CI: -14.1, -8.9), and 4° less knee extension (95%CI: 2.9, 5.0) compared to controls. Twelve % of the cases had lower ankle dorsal flexion strength (p = 0.009). Foot drop was present in three (4.3%) compared with none among controls. Women with fistula had 4° greater movement in hip extension (95%CI: -5.9, -3.1), 2° greater hip lateral rotation (95%CI: 0.7, 3.3) and 9° greater hip abduction (95%CI: 6.4, 10.7). Twelve % of the cases had stronger medial rotation in the hip (p = 0.04), 20% had stronger hip lateral rotation (p ≤ 0.001), 29% had stronger hip extension (p ≤ 0.001), and 15% had stronger hip abduction (p = 0.04) than controls. CONCLUSIONS: Women with obstetric fistula commonly experienced walking difficulties after the delivery, had often leg pain and reduced function in the ankle and knee joints that may have been compensated by increased motion and strength in the hip.

Large rectovaginal fistula due to a cube pessary despite routine follow-up; but what is 'routine'?

Vaginal pessaries are generally considered a safe and effective form of management for pelvic organ prolapse. Serious complications such as rectovaginal fistula can develop with or without regular follow-up. This case report describes the rapid development over a 10-week period of a large rectovaginal fistula in a 75-year-old woman, despite routine follow-up and replacement of her cube pessary. Currently, there is a lack of evidence-based guidelines for pessary care and, in particular, the frequency of pessary replacement. Intervals for pessary replacements vary greatly and are often based on the manufacturer's recommendations. This case highlights the rapidity at which serious complications can develop and also represents the first reported case of a cube pessary-induced rectovaginal fistula.

Complicated rectovaginal fistula secondary to Bartholin's cyst infection.

Rectovaginal fistula formation secondary to Bartholin's cyst is a very rare complication, and to date only three cases were reported in the literature. We report a case of a 32-year-old woman who suffered recurrent episodes of Bartholin's cyst infection with subsequent abscess formation that resulted in rectovaginal fistula formation. We treated her initially with transperineal repair; however, the fistulous tract recurred a month later. A laparoscopic colostomy and transperineal repair using biological graft was then performed, with excellent results. The patient underwent reversal of colostomy after 2 months, and remained asymptomatic upon follow-up 12 months later.

Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula.

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Crohn disease and the gynecologic patient.

Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.

Desgarro rectovaginal con esfínter anal íntegro: una complicación obstétrica infrecuente / Rectovaginal tear with intact anal sphincter: an uncommon obstetric complication

El desgarro rectovaginal aislado es una complicación de baja incidencia en el ámbito de la obstetricia. Existen pocas publicaciones al respecto, factor que contribuye a la ausencia de consenso en cuanto a su manejo. En el presente artículo, describimos la ocurrencia de dos lesiones de este tipo en nuestro hospital (1.800 partos/año) en el curso de 10 años. Mediante revisión bibliográfica exponemos factores de riesgo y principios de tratamiento. Resulta fundamental la detección precoz de la lesión, así como su reparación quirúrgica minuciosa. En cuanto a la prevención, el fórceps parece ser el principal factor asociado, por lo que resulta conveniente optar por instrumentos menos lesivos, especialmente en pacientes añosas, primíparas o fetos macrosómicos (AU)

The incidence of isolated rectovaginal tear is low in obstetrics and the scarcity of publications on the subject contributes to the lack of consensus on its management. The present article describes the occurrence of two such injuries in our hospital (1800 births / year) over the course of 10 years. Through a literature review, we discuss the risk factors and principles of treatment. Early detection of the injury is essential, as well as meticulous surgical repair. Forceps seems to be the main causative factor and therefore choice of less harmful instruments is advisable, especially in the elderly, primiparous patients, and macrosomic fetuses (AU)

Surgical outcome of obstetric fistula: a retrospective analysis of 595 patients.

OBJECTIVE: The aim of the study was to investigate obstetric fistula in terms of patient demographics, fistula characteristics and predictors of surgical outcome. DESIGN: Retrospective cross-sectional study. SETTING: Fistula referral hospital in eastern Democratic Republic of Congo. Population. Five hundred and ninety-five women receiving fistula repair from November 2005 to November 2007. METHODS: Review of patient records for information on patient demographics, obstetric history, clinical data for index pregnancy, fistula characteristics and surgical information. Cross-tabulations and multivariate logistic regression models were used to predict surgical outcome. MAIN OUTCOME MEASURES: Fistula closure and incontinence despite fistula closure. Results. 82.9% had developed fistula following obstructed labor, 17.1% after medical interventions of which 71.1% involved cesarean section or peripartum hysterectomy. Median age at fistula development was 23 years; 40.8% were primiparous and 43.2% were parity three or more. Women took a median of two years to seek treatment. Closure rate was 87.1%, with 15.6% remaining incontinent. Failure to close the fistula was significantly associated with previous repairs, amount of fibrosis and fistula size. Compared with primary repairs, the odds ratio of failure was almost five times greater for three or more repairs (odds ratio 4.7, 95% confidence interval 2.2-10.0). Incontinence was significantly associated with previous repairs, amount of fibrosis and fistula location. Compared with fistulas with a high location, the odds ratio of incontinence for low, circumferential fistulas was 6.3 (95% confidence interval 2.5-16.4). CONCLUSIONS: Fistula in Democratic Republic of Congo was found in both primiparous and multiparous women, indicating a need for increased access to obstetric care for all pregnant women. Fistulas repaired for the first time, with no fibrosis and size <2 cm, had the best surgical outcome.

Analysis of function and predictors of failure in women undergoing repair of Crohn's related rectovaginal fistula.

PURPOSE: Crohn's-related rectovaginal fistulae have significant impact on quality of life including sexual function. The aim of this study was to obtain long-term follow-up of Crohn's related rectovaginal fistulae to assess variables that influence surgical success and determine its effects on quality of life and sexual function. METHODS: All women with Crohn's-related rectovaginal fistulas who underwent surgical repair from 1997 to 2007 were contacted for long-term follow-up. Variables assessed were age, body mass index, smoking, presence of active Crohn's disease, type of surgical procedure performed, use of perioperative seton or stoma, number of previous procedures, time interval between last repair and current repair, use of immunomodulators, and steroids. SF-12, Fecal Incontinence Quality-of-Life Scale, and Female Sexual Function Index were used to assess quality of life and sexual function. Multivariable logistic regression model was used to identify variables associated with surgical failure. RESULTS: Sixty-five women were identified at median follow-up of 44.6 months (interquartiles, 13.1-79.1) of which 30 patients (46.2%) were successfully healed. Methods of repair included advancement flap (n = 47), episioproctotomy (n = 8), colo-anal anastomosis (n = 7), and fibrin glue or plug (n = 3). Twenty-eight women (43.1%) were sexually active at follow-up, and of those, nine complained of dyspareunia, all within the unhealed group of patients. On multivariate analysis, only immunomodulators were associated with successful healing (p = 0.009). Smoking and steroids were associated with failure (p = 0.04). Sexual function and quality-of-life scores were comparable between healed and unhealed groups. CONCLUSIONS: Crohn's-related rectovaginal fistulae are difficult to treat. Healing increased with use of immunomodulators; however, smoking and steroids were predictors of failure. Dyspareunia was higher in unhealed women.

Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula.

PURPOSE: The aim of this study was to assess the efficacy of gracilis muscle transposition for recurrent rectovaginal fistula. METHODS: Gracilis muscle transposition for recurrent rectovaginal fistula was performed in eight patients. Causes of fistulas included Crohn's disease (n = 5), perineal surgery (n = 2), and obstetrical injury (n = 1). All patients underwent a mean of three (range, 1-6) previous repairs. Fecal diversion was performed in all cases. RESULTS: Six of eight patients (75%) healed after gracilis muscle transposition alone. The other two patients required a second gracilis. These two patients failed with another recurrence and one of them underwent laparotomy with successful omental interposition. Thus, after a median follow-up of 28 (range, 4-55) months, the per-gracilis muscle transposition healing rate was 60% (6/10) and the overall healing success rate after gracilis muscle transposition and other procedures was 88% (7/8). For patients with Crohn's disease, four of five (80%) presented no recurrent rectovaginal fistula. Seven of eight patients underwent ileostomy closure after gracilis, but two required subsequent stomas, one for a late recurrence. Overall, five of eight patients are stoma-free. Despite healing, postoperative quality of life and sexual activity remained significantly altered. CONCLUSION: Gracilis muscle transposition can be proposed in cases of recurrent rectovaginal fistula. The procedure has a good success rate, especially in Crohn's disease patients.

Interposition of vital bulbocavernosus graft in the treatment of both simple and recurrent rectovaginal fistulas.

OBJECTIVE: The objective of the study is to assess the efficacy of vital bulbocavernosus graft transposition in the treatment of rectovaginal fistula. MATERIALS AND METHODS: From March 2003 to October 2007, nine consecutive patients diagnosed with rectovaginal fistula were refereed to our institute. All patients were treated using an interposing vital bulbocavernosus graft between rectum and vagina. RESULTS: Median patient age was 33 years (range, 19-61) and seven of the nine patients had undergone between one and six fistula repair sessions prior to this grafting procedure. The etiology included congenital in three, surgery injury in four, obstetric in one, and radiation in one. No wound infections or abscesses occurred postoperatively, and the in-hospital mortality rate was zero. No recurrence was reported during the follow-up period and all patients had normal fecal continence. Only one patient had mild dyspareunia and no further surgical treatment needed. CONCLUSION: Both simple and complex rectovaginal fistula can be reliably repaired using a bulbocavernosus graft.

Anterior sagittal anorectoplasty for anovestibular fistula.

Anterior sagittal anorectoplasty (ASARP) was used for the definitive correction in 107 cases of anovestibular fistula (AVF) between 1996 and 2005. These cases were subjected to three different types of treatment regimes during the same period. Majority of the cases (78) were operated in one stage where postoperatively an early oral feed was started (A). Cases were discharged in 2-4 days. In the second group (B), there were ten cases who were also operated in one stage but with prolonged fasting of 9-10 days postoperatively. Nineteen cases (C) were operated under cover of colostomy during the same period. In the immediate postoperative period, among the group A, one case had a major wound disruption requiring a colostomy and a redo surgery. Three cases had subcutaneous leak. In seven cases there was premature dehiscence of mucocutaneous or skin sutures. In groups B and C, there were no significant complications in the immediate postoperative period. In the follow-up period, out of 107 cases, 63 (58.8%) had constipation at the end of 3 months. However, at the end of one year, only 24.3% (26 cases) cases had constipation. Regarding fecal continence, 86 cases (90.5%) were totally continent. Seven had history of occasional soiling and in two cases, soiling was more frequent. As far as repair or correction of AVF or vestibular anus is concerned, we feel that anterior sagittal approach is more suitable as it requires less pelvic dissection. Separation of posterior vaginal wall from rectum, which is considered, is the most important step of the operation, takes place under direct vision. We also feel that AVF can be repaired in one stage with an early postoperative oral feed, provided we are meticulous in pre and postoperative bowel management. It reduces hospital stay and the cost of treatment. This provides a good option to cases who are not able to afford prolonged hospitalization (fasting) or are not willing for a colostomy.

Use of urethral plugs for urinary incontinence following fistula repair.

A common complication following anatomical closure of obstetric genito-urinary fistula is urinary incontinence. Management is often suboptimal with lack of urodynamic equipment in most fistula centres in developing countries. Surgical interventions have been described with varying success. The aim of this paper is to describe the use of urethral plugs as an alternative management for women with postfistula incontinence, in a developing country. A pilot study was undertaken to assess the effectiveness of the urethral plugs in these women. The use of urethral plugs appear to be an effective short-term management of women with postfistula incontinence, with minimal complications. Longer follow-up and in larger numbers are required.

Histotopographic study of the rectovaginal septum.

The rectovaginal septum (RVS) is described as a strong connective tissue between the rectum and the vagina. The aim of the present study was to investigate the topography and histological structure of the RVS in 20 cadavers (age range: 54-72 years). After in situ formalin fixation, the pelvic viscera and the surrounding connective tissue were removed, together with the pelvic floor. In 8 cases, the topographical relationships of the septum with the vagina and rectum were studied during dissection. In 8 other cases, serial macrosections of the bladder base, vagina, lower rectum and pelvic floor complex were stained with hematoxylin-eosin, azan-Mallory and Weigert Van Gieson. RVS thickness was evaluated on transverse sections collected at the cranial and caudal levels of the middle third of the vagina (level II) and inferior third (level III). In the other 4 cases, specimens were cut with a slicer in 2-3 mm thick axial slices and plastinated using the von Hagens E12 technique. The RVS is located in an oblique coronal plane, close to the posterior vaginal wall, and is formed of a network of collagen, elastic fibres, smooth muscle cells with nerve fibres, emerging from the autonomic inferior hypogastric plexus, and variable numbers of small vessels. The RVS was thicker at cranial levels II and III, with respect to caudal level II, both in the midline (1.75 and 1.70 vs 0.2 mm, p<0.05) and lateral portions of the septum (2.67 and 2.64 vs 0.17 mm, p<0.05). At caudal level II, there was no statistically significant difference between the thicknesses of the lateral portions and the midline (0.17 vs 0.2 mm, P>0.05). The RVS resembles an hourglass, with a flattened central portion in the frontal plane. Given its position in the centre of the pelvis, the RVS plays a connecting role between the perineal body and the overlying portions of the endopelvic fascia, and may also play an active role in modulating the tone of the musculature of the pelvic walls during variations in endorectal pressure.

Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula.

OBJECTIVE: To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence. DESIGN: An observational clinical study. SETTING: A specialised fistula unit in a developing country. POPULATION: Women following successful anatomical closure of obstetric genitourinary fistula. METHODS: Fifty-five women were enrolled from the Fistula Hospital in Ethiopia, following obstetric fistula repair. Their case records were reviewed and details regarding (1) antecedent obstetric factors, (2) the site, size and type of fistula and (3) pre-operative bladder neck mobility and vaginal scarring were recorded. All women were questioned regarding symptoms of faecal and urinary incontinence. Women reporting urinary incontinence following fistula repair underwent urodynamic investigations. MAIN OUTCOME MEASURES: Clinical and urodynamic assessment. RESULTS: The mean age of the women was 23 years (range 16-45 years). The fistula in 38 women (69%) followed the first delivery and in 17 women (31%) following a subsequent delivery. The mean duration of labour was four days (range 1-9 days). Forty-four women (80%) had an isolated vesico-vaginal fistula and 11 (20%) had a combined vesico-vaginal and recto-vaginal fistula. The mean diameter of the fistula was 2.9 cm (0.5-6 cm). Successful repair occurred in all women. Thirty women (55%) reported persistent urinary incontinence and 21 (38%) altered faecal continence at follow up. In the former group, urodynamic investigations identified genuine stress incontinence in 17 women (31%), detrusor instability in two (4%) and mixed incontinence in 11 (20%). CONCLUSION: This study demonstrates the high rate of successful closure of the fistula in a specialised fistula unit, but highlights the problem of persistent urinary incontinence following closure.