Obstetric Fistula Advocacy Group

A fistula is defined as a communication between two major organs.

A Rectovaginal Fistula (RVF) is a tract or hole between the rectum and the vagina. It allows the involuntary passage of faeces from the rectum through the vagina.

Watch The Doctors TV: Rectovaginal Fistula explained

An RVF  is often the result of trauma during childbirth in situations where there is inadequate health care. Whilst it was commonly believed this only occurred in developing countries, this is no longer the case.  A decline in the standards of health care, particularly in the obstetrics arena have seen a rise in the incidence of RVF occurring during childbirth.

If  there is a large tear or episitomy or labour is allowed to go on for too long there can be a necrosis of vaginal tissue and the death of the tissue erodes into the rectum, causing a hole which becomes permanent. RVF can also occur with other diseases such as Crohns Disease and as an unintended result of surgery.

SYMPTOMS

• One of the most common symptoms of a rectovaginal fistula is the passage of pus, gas, and stool from the vagina.
• Bowel movements that are urgent, blood on the toilet paper and an inability to hold your bowel movements can also be symptoms. You may also notice inflammation of the vagina, which can result in itching, burning and a vaginal discharge which is foul smelling.
• You may notice that you get urinary tract and vaginal infections which occur frequently, or do not seem to completely resolve even with medications. The infections are caused by bacteria from your digestive tract and bowels entering your vagina.  Bladder inflammation is also common, sometimes causing frequent and painful urination.

A Recto-Vaginal Fistula can cause pain during sexual intercourse, and also pain in your perineum, vulva, and vaginal area. This pain can range from none or very mild to extremely severe, depending on the size and location of the fistula.

HOW IS IT DIAGNOSED?

Your General Practitioner may be able to diagnose the fistula by physically examining the anal or vaginal area. However, if the hole is small it may be difficult to find and an internal examination will be necessary.  An instrument called an endoscope is used to examine the rectum and lower colon using a small thin flexible tube with a light and camera.

Watch Sarah’s story on an episode of The Doctors TV.

TREATMENT?

There is a theory that some RVF’s will heal on their own within 6-12 weeks if left untreated. However I am yet to be convinced that this is true. Not one of the 60 RVF girls on our Facebook Fistula site have had a spontaneous repair and all have required surgery or multiple surgeries.

Repair of an RVF requires aggressive surgery and the goal is the remove the fistula tract and close the opening by sewing together healthy tissue around it.  The repair may require a tissue graft taken from an adjacent part of the body, or by folding a flap of healthy tissue over the fistula opening. However in the event of scarring or tissue damage then more complicated surgery is indicated.

Colostomy bag: For cases that are recurrent or complex a colostomy bag may be inserted prior to attempting surgery. The operation itself involves creating a diversion via a surgical opening in the abdomen diverting stool from the colon into the bag. This procedure allows the bowel and vagina to heal and can be done before or after surgery, depending on the needs of the surgeon. A colostomy bag can also be used if there is significant fecal contamination which would hamper the chances of a successful surgical repair.

SURGERY

Transanal Advancement Flap: this surgery involves the surgeon dissecting or lifting a portion or flap of the rectal wall adjacent to the fistula opening. This flap is then pulled down and placed over the opening and sutured into place to close the opening, allowing the fistula to heal. The opening on the vaginal side is left open for drainage purposes.

Transabdominal repair: Some RVF’s cannot be repaired by the flap method because they are located too high up in the rectum/vagina. In a transabdominal surgical repair the surgeon makes an incision in the abdomen to gain access to the fistula. The fistula tract is then located and an incision is made along the tract to divide the tissue, when this incision heals, the tissues grow together, eliminating the fistula.

Fibrin Glue: In some cases fibrin glue is used to close the fistula. This glue comprises of clotting factors fibrinogen and thrombin which together form a clot within the fistula  and helps the repair of the tract. We have had a number of ladies try this technique with no success and do not recommend this as it has a high failure rate.

Fistula Plug: This conical shaped device is made from an advanced tissue  repair graft which communicates with your body to draw healthy tissue across the plug allowing the body to repair the fistula tract. Incontinence is unlikely with plugs as the procedure does not require cutting of the sphincter muscles.

Watch Repairing a Rectovaginal Fistula

LIFE AFTER RVF

This very much depends on whether the RVF has been successfully surgically repaired. A great majority of RVF surgeries fail due to incorrect surgery techniques resulting in failed repairs and many women are forced to endure multiple surgeries, sometimes leading to even worse incontinence.

The important thing is that surgery is not attempted too early. The basic rule for fistula surgery is that the first operation has the best chance of success. Surgeons therefore should approach the repair with caution and should not attempt a repair unless they have the expertise to do so. Many of my fistula sisters have told stories of surgeons who have used them as test guinea-pigs, with no experience or expertise in this specialised surgery, their surgeries have subsequently failed. Once this happens, it is very difficult and problematic to achieve a successful repair.

Some women choose not to have a surgical repair because the risks of the surgery outweigh the symptoms. Some women find with dietary care they manage their bowel habits and alleviate their incontinence to a manageable level.

Emotionally incontinence has a profound effect on anyone suffering from an Obstetric Fistula. Many women simply do not leave the house and become house bound. They feel ashamed and dirty and are constantly worried that people can smell them.  Many women are diagnosed with Post Traumatic Stress Disorder (PTSD) and are required to seek help from a mental health care provider, some are in constant pain, develop Irritable Bowel Syndrome that makes the incontinence worse or suffer nerve damage as a result of the surgical repairs.  Many marriages do not survive, simply unable to cope with the ongoing physical and emotional health issues.