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Rectovaginal Fistula

A rectovaginal fistula (RVF) is an epithelialized communication between the rectum (or anal canal) and the vagina, allowing passage of flatus and feces per vagina. Obstetric RVF can accompany anal sphincter injury; severe obstructed-labor injury may also produce a vesicovaginal or urethrovaginal fistula. Martius or gracilis interposition is used for selected complex repairs.[1][2][25] Modern management follows the ASCRS 2022 Clinical Practice Guidelines, which recommend an etiology-driven, stepwise approach without prescribing a single technique for all fistulas.[1]

For complex multi-compartment cases, see the Fistulas section landing. For the male equivalent, see Rectourethral Fistula. For operative selection across all repair routes, see the Female Fistula Repair database.

Epidemiology and Etiology​

RVF is uncommon in high-resource settings but a significant problem in low-resource countries due to obstructed labor.[1][3] Etiology distribution differs by setting. Older series reported obstetric trauma in up to 88% of RVFs[29]; in high-resource referral series, the mix is more diverse, with iatrogenic and Crohn's-related fistulas making up substantial fractions.[1][2][6]

Setting / causeNotes
Obstetric traumaDominant cause globally; fourth-degree perineal tear, or unrecognized or failed sphincter repair; in the Australian urogynecology series of 41 patients undergoing 46 repairs, obstetric injury accounted for 11/41 patients (27%)[2]
Crohn's diseaseUp to 43% in referral-center series; tied to active rectal inflammation[6][7]
Iatrogenic — colorectal anastomosisRVF complicates ~1.6% of low anterior resection (up to 2.2% in earlier colorectal-anastomosis series); higher with very low tumors and unsatisfactory anastomosis[1][5]
Iatrogenic — gynecologic surgeryHysterectomy (cuff into rectum), prolapse repair (especially mesh), anorectal surgery
CryptoglandularPerianal abscess eroding into vagina
Pelvic radiationCervical, endometrial, or rectal cancer treatment; median onset ~20 months after radiotherapy[8]
MalignancyDirect invasion from rectal, cervical, or vaginal cancer

Classification​

The single most operative-decision-relevant categorization:[1][9]

SimpleComplex
LocationLow (anal canal ↔ lower vagina)Mid- or high-vaginal septum
DiameterASCRS: < 2 cm; a traditional obstetric review uses < 2.5 cm[1][25]ASCRS: ≥ 2 cm (or another complex feature)[1]
EtiologyObstetric or traumaticCrohn's, radiation, malignancy, anastomotic
Tissue bedHealthyInflamed, irradiated, scarred
Prior repairNoneOne or more failed

Anatomic level is also described as low (at or near the dentate line), mid (mid-septum, uncommon), or high (upper vagina or vault, including some post-hysterectomy and anastomotic fistulas); level helps determine the operative approach.[29]

Clinical Presentation​

  • Passage of flatus per vagina: often the earliest symptom
  • Passage of feces per vagina: suggests an enterovaginal fistula; localize the tract to distinguish rectovaginal from colovaginal disease.[32]
  • Foul-smelling vaginal discharge
  • Recurrent vaginitis and UTI
  • Fecal incontinence: frequent in obstetric RVF because of concurrent sphincter damage[2]
  • Dyspareunia and significant psychosocial morbidity

Diagnostic Evaluation​

The ASCRS guideline emphasizes that the workup must define both the fistula and the sphincter complex, since sphincter status drives the choice of repair.[1]

Bedside​

  • Inspection of the perineum: scarring, deformity, external opening
  • Speculum exam: vaginal opening of the tract
  • Digital rectal exam: palpation of the tract; resting and squeeze sphincter tone; integrity assessment
  • Anoscopy or proctoscopy: rectal opening
  • Examination under anesthesia is often required to fully define the anatomy. Biopsy a suspicious fistula or adjacent lesion when carcinoma or recurrence after pelvic cancer treatment is possible, before benign reconstruction.[1][26]

Imaging​

ModalityRoleNotes
MRI pelvis (with vaginal gel)Maps the fistula and adjacent anatomyCharacterizes the tract, secondary extensions, abscess, sphincter destruction, and neoplasm; a dedicated protocol with vaginal gel and optimized planes helps define surgical anatomy[3][9]
3D endoanal ultrasound (EAUS)Used to map sphincter anatomy and defects that may affect repair selectionEAUS and MRI can be useful adjuncts; the cited EAUS–MRI comparison studied simple anal fistulas.[1][10]
Anorectal manometryQuantifies resting and squeeze sphincter pressuresComplements examination and EAUS when sphincter function may affect repair selection[1]
Vaginography / contrast enemaDefines the tract when MRI is equivocal
Proctoscopy / sigmoidoscopyHelps assess active rectal inflammation when Crohn's is suspectedElective definitive closure generally follows control of active proctitis; urgent drainage of sepsis must not wait for mucosal healing[7]

Management — ASCRS Recommendations by Indication​

1. Conservative management (Recommendation 12, Weak / 2C)​

For obstetric and minimally symptomatic benign RVF: sitz baths, perineal hygiene, infection control, and stool-bulking fiber for 3–6 months. Selected nonoperative RVF series across differing etiologies and endpoints report 52–66% fistula resolution or symptom improvement.[1][31] This window applies to an established, minimally symptomatic fistula. A fresh, directly recognized obstetric or surgical injury follows a separate timing framework: repair within 72 hours of injury, or delay up to 12 weeks once local inflammation has settled.[19]

2. Seton drainage (Recommendation 13, Strong / 1C)​

A draining seton may relieve acute inflammation, edema, or infection and provide long-term symptom relief when definitive repair is not feasible; it may improve the chance of later repair success. In Crohn's-related RVF, consider a seton when local sepsis or ongoing tract drainage needs control rather than placing one routinely before immunosuppression.[1][7]

3. Endorectal advancement flap (ERAF) — procedure of choice for most RVF (Recommendation 14, Strong / 1C)​

The guideline names endorectal advancement flap, with or without sphincteroplasty, the procedure of choice for most patients with RVF, without limiting it to simple fistulas; for recurrent or complex fistulas it separately recommends interposition (below).[1] For a low RVF, an endorectal advancement flap may cause mucosal ectropion; the guideline suggests considering a flap from anoderm and perianal skin instead.[1]

Technique:

  1. Trans-anal exposure (prone-jackknife)
  2. Full- or partial-thickness flap of rectal mucosa, submucosa, ± internal sphincter raised proximal to the fistula opening
  3. Excise or curette the tract
  4. Close the rectal opening
  5. Advance the flap distally to cover the closed defect
  6. Leave the vaginal side open to drain

Outcomes:

SettingHealing
ERAF across reported techniques41–78% (varies by etiology, operative technique and healing definition)[1]
Sphincteroplasty ± levatorplasty for obstetric RVF (Tsang: 28/35 versus 11/27 for ERAF alone); retrospective, not randomized, and not ERAF combined with sphincteroplasty80% (ERAF alone 41%)[1]
Repeat ERAF after initial failure55–93%[1]

In a low-quality network meta-analysis of obstetric RVF (32 studies, 595 patients), sphincter-repair-type operations (transvaginal or transperineal excision with layered closure, Musset procedure) had higher anatomic success than ERAF, and no randomized trial compares ERAF with sphincteroplasty.[18] Factors associated with ERAF failure include a sphincter defect on EAUS, manometric dysfunction, Crohn's disease, prior pelvic radiation, and recurrent fistula.[1] Diverting stoma is not consistently shown to improve ERAF outcomes and is decided on a per-patient basis.[1]

4. Episioproctotomy (Recommendation 15, Strong / 1C)​

A transperineal "convert and repair" technique for low RVF with anterior sphincter defect (classically obstetric or cryptoglandular). The anterior anal sphincter complex and rectovaginal septum are intentionally divided to lay open the fistula, then reconstructed in layers with sphincter repair. ASCRS states that it may be used for obstetric or cryptoglandular RVF in patients with an anal sphincter defect.[1]

  • ASCRS summarizes 78–100% healing in selected series. In Hull's 42-patient retrospective cohort, all 11 reported recurrences were among the 33 patients with RVF (22/33 without reported recurrence); none of the 9 patients with cloaca recurred at a mean 37-month follow-up.[1][27]
  • Diversion was used in 55% (Hull 2007, 23/42) to 72% (36/50 in each of two later series) and was not significantly associated with outcome in Hull 2007[1]

5. Tissue interposition flaps (Recommendation 16, Strong / 1C)​

For recurrent or complex RVF, ASCRS supports Martius or gracilis interposition, selected by anatomy, tissue availability and expertise.[1] Pastier’s retrospective cohort included 62 patients and 79 flap procedures. Success required both absence of RVF and absence of a stoma: 35% of Martius and 31% of gracilis patients met this composite immediately, rising to 69% in each group after additional procedures at median 23-month follow-up.[11] A 2024 systematic review and proportional meta-analysis of Martius flaps reported 91.4% healing for primary RVF and 94.6% for radiation-induced RVF.[12]

FlapHealingNotes
Martius flap (bulbocavernosus / labial fat pad)65–94% (individual mixed-etiology series); 77.5% pooled (recurrent); 91.4% pooled (primary); 94.6% pooled (radiation)[1][11][12]Shorter LOS than gracilis in Pastier's retrospective cohort; a 12-study Martius review (137 flaps) reported 29% pooled complications (95% CI 9–55%).[12] Diversion is individualized: ASCRS generally favors it for complex flap repairs despite limited evidence, while 27% of Martius procedures in Pastier's cohort were performed without a stoma[1][11]; one interposition option
Gracilis muscle flap50–92% (individual series); 64% pooled (20 mostly small series, 384 patients); 69% free of RVF and stoma after additional procedures at median 23 months in Pastier's gracilis arm[1][4][11]ASCRS cites 28–47% complications in two older series[1], while the 2023 pooled review found a 0–37% range across studies[4]; reported events include wound infection, thigh numbness and hematoma; sexual function is often impaired, and smoking, Crohn's disease and more than two prior repairs predicted failure while a stoma was associated with better closure[4]; may be primary interposition or salvage depending on defect and prior surgery

Smoking was a negative predictor in the Pastier cohort (p = 0.02).[11]

6. Anastomotic-related RVF (Recommendation 17, Strong / 1C)​

RVF after low anterior resection or other colorectal anastomosis usually requires a transabdominal approach.[1]

  • Initial fecal diversion or early redo: The ASCRS guideline describes diversion as the general initial step after an anastomotic RVF to allow acute inflammation and symptoms to subside; selected immediate or early postoperative RVFs may be better served by reoperation and repeat colorectal anastomosis.[1] An ASCRS-cited retrospective series of RVF after failed colorectal anastomosis reported healing with diversion alone in 6/16 (37%).[1] In a separate 24-patient post-LAR cohort, 14 of 21 patients given supplemental diversion healed without fistula suturing and one more healed with simultaneous suturing; three died before fistula status could be established.[1][5]
  • Persistent fistulas may need redo colorectal anastomosis, ERAF, or transperineal interposition. In a retrospective international cohort of women with anastomotic leakage after rectal cancer resection, one-year stoma-free survival was 29.5% among 88 women with colorectal-vaginal fistula and 48.7% among 606 without fistula; this endpoint differs from fistula closure.[30]

7. Radiation-induced RVF (Recommendation 18, Weak / 2C)​

The most challenging subset; endarteritis obliterans produces a hostile, progressive bed.[1][8]

  • Median time to radiation-induced RVF: 20 months (range 5–240) after radiotherapy[8]
  • Fecal diversion alone was the only feasible option in 96% (48/50) of patients in one series; 6/50 (12%) healed overall, including one patient who later underwent low anterior resection; fistula > 7 cm from the anal verge was associated with healing on univariate analysis (OR 18, p = 0.007), while loop ileostomy had a nonsignificant univariate result (OR 17, p = 0.08); only distance remained significant in multivariate analysis[8]
  • Martius flap for radiation RVF: in selected series, 11/12 patients and 13/14 Martius repairs achieved fistula closure; in the latter series, 6/14 remained without a colostomy after about 10 years.[1][12][34]
  • Proctectomy with coloanal anastomosis (sleeve excision or pull-through): ASCRS lists this as an option for radiation-related or recurrent complex RVF.[1] In Patsouras’s retrospective series of 34 patients with mixed complex rectal conditions, fistulas recurred in 7/28 after pull-through (21/28, 75%, without reported recurrence); four later healed, for 25/28 (89%) overall healing at median 23-month follow-up.[36] In a separate selected radiation-induced RVF cohort, no recurrence was reported among the 10/10 pull-through patients or 11/11 ultralow anterior resection patients at mean 20-month follow-up after ostomy reversal.[13]
  • Delayed coloanal anastomosis (Turnbull–Cutait): In a retrospective cohort of 78 complex RVFs, 67% followed anastomotic leakage and only 8/78 were attributed to radiotherapy. Across the mixed cohort, 63/78 (81%) achieved fistula healing with bowel continuity at median 31 months. Overall morbidity was 45%, major morbidity 23%, and anastomotic leakage 17%; 24/57 assessed (42%) reported severe LARS or retained a stoma because of poor function.[14]
  • In a small retrospective comparison of radiation-induced rectovaginal fistulas, selected restorative-resection patients had greater remission of tenesmus and perineal mucous discharge, and 3/10 (30%) underwent stoma reversal versus none after colostomy alone[15]

8. Crohn's-disease-associated RVF​

Coordinate medical treatment with gastroenterology and counsel selected patients with Crohn's-related RVF about surgical closure after control of sepsis and active rectal inflammation; ECCO 2024 rates its suggestion for rectogenital fistulas as evidence level 5.[7][16][28]

  • Infliximab has the strongest medical evidence for perianal fistulizing Crohn's disease. In ACCENT II's post hoc RVF subgroup of 25 women, after 5 mg/kg induction at weeks 0, 2, and 6, 13/29 evaluated fistulas (44.8%) were closed at week 14; among induction responders, median closure lasted 46 weeks with maintenance infliximab versus 33 weeks with placebo.[35] Select advanced therapy and any immunomodulator with gastroenterology.[7][35]
  • Antibiotics for infection control or a selected short adjunctive course; routine long-term dual antibiotics are not definitive fistula therapy
  • Drain abscesses and control sepsis before immunosuppression; use a loose seton when appropriate to maintain tract drainage
  • Elective definitive repair is favored after control of active rectal inflammation; urgent drainage or diversion for sepsis does not wait for endoscopic healing[7]
  • Diverting stoma for refractory disease; long-term success of diversion alone in perianal Crohn's is poor
  • Proctectomy / total proctocolectomy with permanent stoma in the most severe cases

Rectal sleeve advancement has been described for a low, Crohn's-related RVF: submucosal dissection begins at the dentate line and continues circumferentially and cephalad into the supralevator space, the rectum is mobilized until a tension-free anastomosis is possible, the fistula tract is cored out and closed, the vaginal defect is left open for drainage, and the distal rectum is advanced and sutured to the anoderm. Some patients require a repeat sleeve advancement to achieve healing.[24] Marchesa's circumferential transanal sleeve advancement flap healed 8 of 13 patients (62%) with severe perianal Crohn's disease at 1 year, 3 of them after an additional procedure.[22] Hull's earlier series of 35 women undergoing transanal repair of Crohn's-related anovaginal fistula, using three flap types including 5 sleeve advancements, reported healing in 19 of 35 (54%) after the index procedure and 24 of 35 (68%) after repeat surgery.[21] Parks described peranal sleeve anastomosis in four patients with post-irradiation RVF; all four fistulas closed. A fifth patient had a painful irradiation ulcer rather than RVF.[23]

In a single-center retrospective cohort of 55 women (median follow-up 30.2 months), inflammatory fistulas (Crohn's, cryptoglandular, or anastomotic) healed in 2/28 (7.1%) after index surgery and 13/28 (46.4%) by final follow-up, versus 11/24 (45.9%) and 22/24 (91.7%) traumatic fistulas (obstetric or iatrogenic); overall, 37/55 (67.3%) healed by final follow-up.[17]

Outcomes and Prognostic Factors​

FactorReported association (mostly retrospective)
Traumatic etiology (obstetric / iatrogenic)22/24 (91.7%) final healing in a 55-woman retrospective cohort (median overall follow-up 30.2 months)[17]
Inflammatory etiology (Crohn's, cryptoglandular, anastomotic)13/28 (46.4%) final healing in the same retrospective cohort (p = 0.001; median overall follow-up 30.2 months)[17]
Major procedure (gracilis, coloanal anastomosis) for failed local repairOR 6.4 for success per procedure (79 patients, 286 procedures; 72% overall success)[6]
Diverting stoma in complex casesOR 3.5 for success[6]
First surgery less than 9 months after diagnosisOR 2.3 for per-procedure success in Corte's retrospective cohort[6]
First surgery at the study institutionOR 3.2 (95% CI 1.5–6.9) for per-procedure success in Corte's retrospective cohort[6]
SmokingNegative predictor in one interposition cohort[11]
Sphincter defect, prior radiation, recurrent fistulaPredict ERAF failure[1]

Corte's 79-patient, 286-procedure retrospective cohort found associations between per-procedure success and major procedures, diversion, first surgery within 9 months of diagnosis, and first surgery at the study institution.[6]

Operative Principles​

  • Etiology drives strategy: obstetric, Crohn's, radiation, and anastomotic RVF have distinct pathways
  • Assess sphincter integrity and continence: a clinically important defect may favor concurrent sphincteroplasty or episioproctotomy
  • Control infection and inflammation first: drain, divert, and treat before definitive repair
  • Repair from the high-pressure side: the rectal advancement flap covers the rectal opening, directing intraluminal pressure away from the suture line
  • Vascularized tissue interposition is an option for recurrent or complex fistulas; select Martius, gracilis or another reconstruction by anatomy and tissue quality
  • Local transvaginal repair for a low, accessible RVF with an intact sphincter has been described: a finger in the rectum guides dissection of the posterior vaginal wall off the rectum, using an inverted-U perineal incision for a low fistula or, when the fistula is higher and the perineum is intact, an incision directly over the posterior vaginal-wall opening; the rectal defect is then closed extramucosally with 3-0 or 4-0 absorbable suture (4-0 chromic catgut in one description), followed by an imbricating layer and, when available, a perirectal-fascial layer, before the vaginal epithelium is reapproximated. Some authors describe mobilizing 1.5–2 cm around the opening, though no ideal margin has been established.[19][20]
  • Isolated obstetric rectal buttonhole tear recognized at birth: The 2026 IUGA guideline recommends transvaginal three-layer repair; approximation of the rectovaginal fascia with 2-0 or 3-0 PDS is an essential step (grade D).[33]
  • Fecal diversion depends on sepsis, symptoms and reconstruction complexity; comparative data are insufficient to define a general closure benefit
  • Smoking cessation is advisable; smoking predicted poorer outcomes in one retrospective interposition cohort[11]
  • Fibrin glue and fistula plugs are omitted from the ASCRS RVF recommendations because reported success has been prohibitively poor.[1]
  • Watch for stapler entrapment of the septum: during stapled colorectal anastomosis, rotating the device while palpating and directly viewing the posterior vaginal wall has been described as a way to detect the rectovaginal septum caught in the staple path, seen as dimpling of the vaginal wall.[24]

See Also​

References​

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2. Thayalan K, Krause H, Goh J. "A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia." Aust N Z J Obstet Gynaecol. 2022;62(2):263–267. doi:10.1111/ajo.13444

3. Expert Panel on Gastrointestinal Imaging, Levy AD, Liu PS, et al. "ACR Appropriateness Criteria® anorectal disease." J Am Coll Radiol. 2021;18(11S):S268–S282. doi:10.1016/j.jacr.2021.08.009

4. Maspero M, Otero Piñeiro A, Steele SR, Hull TL. "Gracilis muscle interposition for the treatment of rectovaginal fistula: a systematic review and pooled analysis." Dis Colon Rectum. 2023;66(5):631-645. doi:10.1097/DCR.0000000000002739

5. Zheng H, Guo T, Wu Y, et al. "Rectovaginal fistula after low anterior resection in Chinese patients with colorectal cancer." Oncotarget. 2017;8(42):73123–73132. doi:10.18632/oncotarget.17046

6. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

7. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465

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13. Karakayali FY, Tezcaner T, Ozcelik U, Moray G. "The outcomes of ultralow anterior resection or an abdominoperineal pull-through resection and coloanal anastomosis for radiation-induced recto-vaginal fistula patients." J Gastrointest Surg. 2016;20(5):994–1001. doi:10.1007/s11605-015-3040-8

14. Collard MK, Tuech JJ, Fernandez B, et al. "Delayed coloanal anastomosis for rectovaginal fistulas: insights from a multicenter cohort (GRECCAR)." Surgery. 2025;188:109767. doi:10.1016/j.surg.2025.109767

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16. Feuerstein JD, Ho EY, Shmidt E, et al. "AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease." Gastroenterology. 2021;160(7):2496–2508. doi:10.1053/j.gastro.2021.04.022

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18. Venara A, Houlet E, Poupard E, et al. "Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis." Tech Coloproctol. 2025;29(1):95. doi:10.1007/s10151-025-03133-3

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33. Sultan AH, Okeahialam NA, De Leeuw J, et al. "IUGA International Guidelines on Obstetric Anal Sphincter Injuries." Int Urogynecol J. 2026;37(8):2223–2280. doi:10.1007/s00192-026-06642-3

34. Aartsen EJ, Sindram IS. "Repair of the radiation induced rectovaginal fistulas without or with interposition of the bulbocavernosus muscle (Martius procedure)." Eur J Surg Oncol. 1988;14(2):171–177. PMID:3360159

35. Sands BE, Blank MA, Patel K, van Deventer SJ. "Long-term treatment of rectovaginal fistulas in Crohn's disease: response to infliximab in the ACCENT II Study." Clin Gastroenterol Hepatol. 2004;2(10):912–920. doi:10.1016/S1542-3565(04)00414-8

36. Patsouras D, Yassin NA, Phillips RKS. "Clinical outcomes of colo-anal pull-through procedure for complex rectal conditions." Colorectal Dis. 2014;16(4):253–258. doi:10.1111/codi.12532