Episioproctotomy for Rectovaginal Fistula
Episioproctotomy opens an accessible rectovaginal fistula through the perineum and involved anterior sphincter and septal tissues, followed by layered reconstruction. ASCRS 2022 supports its use for obstetric or cryptoglandular RVF with an anal sphincter defect . It is a selected reconstructive option that does not require dividing an intact sphincter.[1]
Related pages: ERAF ± Sphincteroplasty, Anal Sphincteroplasty, Nonoperative RVF Management and Rectovaginal Fistula.
Selection
The strongest published experience concerns low, accessible obstetric or cryptoglandular fistulas with anterior sphincter disruption, including cloaca-like perineal defects.[2][3] A prior failed repair or pre-existing incontinence can affect selection.[2][3]
Assess fistula height, tissue viability, sphincter anatomy, continence, bowel function and previous repairs. When examination does not define the sphincter defect or tract extent, consider examination under anesthesia and selected pelvic imaging; endoanal ultrasound can delineate the sphincter.[1][9] For a newly recognized obstetric RVF, ASCRS weakly recommends initial nonoperative care (low-quality evidence, 2C); its guidance describes a usual 3–6-month period to allow inflammation and infection to resolve.[1] Drain abscesses and control active inflammation before definitive reconstruction; ASCRS supports a draining seton when it facilitates control of fistula-associated infection.[1]
| Finding | Consequence for planning |
|---|---|
| Intact anterior sphincter | Favor an approach that preserves function; deliberate division adds reconstructive burden and risk. |
| Defect reachable through the perineum | Episioproctotomy may provide access for fistula and sphincter reconstruction together. |
| Cloaca-like deformity | Identify disrupted/retracted muscle remnants; an absent perineal body does not mean there is no sphincter muscle available to repair. Bilateral X-flap ano-vaginal and perineal reconstruction with sphincteroplasty is a described alternative for this deformity; see Outcomes below.[10] |
| High fistula or extensive tissue loss | Consider other exposures or tissue transfer rather than extending a local operation beyond feasible anatomy. |
| Crohn's disease or radiation damage | For Crohn's RVF, ECCO suggests medical treatment and counseling selected patients about surgical closure (EL5), with care in an experienced multidisciplinary team.[11] For radiation damage, assess tissue quality and reconstructive options separately. |
Crohn's disease is not an absolute technical prohibition. In a retrospective tertiary-center series, 8/26 episioproctotomy procedures (30.8%) healed; across all 166 patients and multiple operation types, 119 (71.7%) eventually healed at median 5.5 years.[4]
Operative Framework
Episioproctotomy differs from a limited sphincteroplasty in the amount of perineal and septal tissue that must be opened to reach the fistula. The extent of division follows the defect; it is not automatically a full-length division of every anterior layer.[1]
- Define the anatomy under adequate exposure. Identify rectal and vaginal openings, the intervening defect and available sphincter remnants. Avoid forcing a probe into a false passage.
- Open the involved perineal or septal tissues deliberately. Preserve viable tissue and identify the muscle ends that will require reconstruction.
- Prepare and close the rectal component. Debride nonviable tissue, obtain a tension-free closure and protect the lumen. Scar excision and suture configuration depend on tissue.
- Reconstruct the sphincter and perineum. Account for both external and internal sphincter injury, mobilizing enough tissue for repair while preserving its blood supply. See the sphincteroplasty page for delayed-repair variants and their limitations.[6]
- Restore vaginal and superficial coverage. Tailor closure and drainage to the wound; avoid tension and narrowing. Additional levator plication is a technique choice with uncertain independent benefit and is not an obligatory layer in every operation.
Technique as described by Hull's group
DeLeon and Hull describe the operation as performed at their institution.[9] A probe is placed through the fistula tract and the tract is unroofed, creating a defect similar to a fourth-degree obstetric laceration. When a full cloaca is present, the junction between the anorectal and vaginal epithelium is incised. The tract is debrided, and the sphincter muscles are identified laterally and mobilized enough to allow overlap.
The anorectal mucosa is repaired first with mattress sutures of absorbable material (2-0 or 3-0 polyglactin), working from proximal toward the anal verge. The mucosal edges and proximal border are difficult to see once the sphincter covers them. The internal and external sphincter are then overlapped together (vest over pants) with 2-0 PDS, typically with three to four sutures, and the free edge is secured with a second row. The vaginal mucosa is closed with mattress sutures, confirming reapproximation of the hymenal ring. It is sometimes left open to drain fluid that can collect under a tight closure.[9]
This is one institution's technique, described in a review focused on Crohn's disease. The en masse overlap of internal and external sphincter differs from IUGA guidance for acute OASI, which repairs a torn IAS separately, end-to-end.[7]
These are planning principles. No single stitch-by-stitch protocol has been validated. For acute OASI, IUGA recommends separate end-to-end repair of a torn IAS and advises against IAS overlap.[7]
Healing and Functional Outcomes
| Primary report | Findings | Interpretation |
|---|---|---|
| Hull 2007: 42 women | Nine had cloaca and 33 had RVF. All 11 reported recurrences occurred in the RVF subgroup: 22/33 with RVF had no reported recurrence (66.7%), versus 9/9 with cloaca; 31/42 overall (73.8%) had no reported recurrence. Mean follow-up was 37 months.[2] | — |
| Hull 2011: 87 women | Surgeon-selected episioproctotomy in 50 (39 healed, 78%) versus ERAF in 37 (23 healed, 62.2%); healing comparison P = 0.1. Fecal and sexual-function measures favored episioproctotomy; mean follow-up 49.2 months. | Retrospective nonrandomized comparison. It establishes neither equivalent healing nor causal superiority in function.[3] |
| El-Gazzaz 2010: 100 obstetric/cryptoglandular patients | Of 268 women who underwent RVF repair, 100 with obstetric or cryptoglandular etiology agreed to participate; 68/100 healed at mean 45.8-month follow-up. Episioproctotomy was associated with healing on unadjusted analysis but not multivariable analysis. Among 47 sexually active participants, 12 reported dyspareunia. | Mixed procedures; the 25.5% dyspareunia estimate is not episioproctotomy-specific.[5] |
| Kaiser 2008: 12 women with cloaca-like deformity | Bilateral X-flap ano-vaginal and perineal reconstruction with sphincteroplasty, without primary fecal diversion: primary healing without postoperative RVF in 9/12 (75%). Of the three recurrences, two closed spontaneously and one required diversion and a bulbocavernosus flap; all patients were satisfied with continence, function and appearance at long-term follow-up (mean 39 months).[10] | — |
ASCRS reports that in the 50-patient episioproctotomy series, preoperative FI in 25 patients fell to postoperative FI in four. Its description of 46/50 having “rare” postoperative incontinence is not the same endpoint as 92% being completely continent. Discuss residual symptoms separately from anatomical closure.[1]
What the 2025 synthesis adds
A network meta-analysis of 32 nonrandomized studies limited to obstetric RVF associated Musset and excision/layered-closure approaches with better anatomical outcomes than ERAF. Functional outcomes were too sparsely reported for pooling, and fistula characteristics and treatment selection were incompletely described. This supports attention to sphincter reconstruction when indicated, while leaving the best comparative operation uncertain.[8]
Diversion and Aftercare
Diversion is individualized according to infection, tissue quality, prior failures, wound burden and patient needs.[1] In Hull 2007, 23/42 had a stoma; no statistically significant association with healing was found in this small retrospective series.[2] In the 2011 episioproctotomy group, ASCRS reports that 36/50 had a preoperative stoma and most underwent stoma closure after fistula repair (median 3.4 months).[1][3]
After repair, manage stool consistency, pain, wound hygiene and drainage, and reassess promptly for infection or dehiscence. Individualize activity and intercourse restrictions to healing. Confirm fistula closure and assess continence before reversal of a protective stoma. Record both leakage through the vagina and anal-control symptoms; one may improve while the other persists.
Counseling
The procedure can repair fistula and sphincter disruption together, at the cost of a more extensive perineal reconstruction. Discuss persistent or recurrent fistula, residual or worsened FI, wound complications and sexual pain. Neither the reported healing range nor observational functional advantages identify the best operation for every patient.[2][5] Higher BMI and prior repairs were associated with failure in some mixed-procedure cohorts, while other small series found no significant predictors.[2][5]
References
1. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473
2. Hull TL, Bartus C, Bast J, Floruta C, Lopez R. "Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula." Dis Colon Rectum. 2007;50(1):97–101. doi:10.1007/s10350-006-0790-0
3. Hull TL, El-Gazzaz G, Gurland B, Church J, Zutshi M. "Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin." Dis Colon Rectum. 2011;54(1):54–59. doi:10.1097/01.dcr.0000388926.29548.36
4. Otero-Piñeiro AM, Jia X, Pedersen KE, et al. "Surgical intervention is effective for the treatment of Crohn's-related rectovaginal fistulas: experience from a tertiary inflammatory bowel disease practice." J Crohns Colitis. 2023;17(3):396–403. doi:10.1093/ecco-jcc/jjac151
5. El-Gazzaz G, Hull TL, Mignanelli E, et al. "Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function." J Gastrointest Surg. 2010;14(11):1758–1763. doi:10.1007/s11605-010-1259-y
6. Ong F, Phan-Thien KC. How to do it: delayed sphincteroplasty for obstetric anal sphincter injury. ANZ J Surg. 2022;92(5):1208–1210. doi:10.1111/ans.17650.
7. Sultan AH, Okeahialam NA, De Leeuw J, et al. IUGA International Guidelines on Obstetric Anal Sphincter Injuries. Int Urogynecol J. 2026;37:2223–2280. doi:10.1007/s00192-026-06642-3.
8. 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;29:95. doi:10.1007/s10151-025-03133-3. Author-name correction: 10.1007/s10151-025-03168-6.
9. DeLeon MF, Hull TL. Treatment strategies in Crohn's-associated rectovaginal fistula. Clin Colon Rectal Surg. 2019;32(4):261–267. doi:10.1055/s-0039-1683908
10. Kaiser AM. Cloaca-like deformity with faecal incontinence after severe obstetric injury—technique and functional outcome of ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty. Colorectal Dis. 2008;10(8):827-832. doi:10.1111/j.1463-1318.2007.01440.x
11. Adamina M, Minozzi S, Warusavitarne J, et al. "ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment." J Crohns Colitis. 2024;18(10):1556–1582. doi:10.1093/ecco-jcc/jjae089