You can expect a physical exam and certain tests, depending on your needs.
Your doctor will perform a physical exam to try to locate the rectovaginal fistula and check for a possible tumor mass, infection or abscess. The doctor’s exam includes inspecting your vagina, anus and the area between them (perineum) with a gloved hand.
Unless the fistula is very low in the vagina and readily visible, your doctor may use a speculum to see inside your vagina. An instrument similar to a speculum, called a proctoscope, may be inserted into your anus and rectum to check for problems.
Tests for identifying fistulas
Your doctor may not find a fistula during the physical exam. Other tests may be needed to locate and evaluate a rectovaginal fistula. These tests can also help your medical team in planning for surgery.
- Contrast tests. A vaginogram or a barium enema can help identify a fistula located in the upper rectum. These tests use a contrast material to show the vagina or the bowel on an X-ray image.
- Blue dye test. This test involves placing a tampon into your vagina, then injecting blue dye into your rectum. Blue staining on the tampon indicates a fistula.
- Computerized tomography (CT) scan. A CT scan of your abdomen and pelvis provides more detail than does a standard X-ray. The CT scan can help locate a fistula and determine its cause.
- Magnetic resonance imaging (MRI). This test creates images of soft tissues in your body. MRI can show the location of a fistula, whether other pelvic organs are involved or whether you have a tumor.
- Anorectal ultrasound. This procedure uses sound waves to produce a video image of your anus and rectum. Your doctor inserts a narrow, wand-like instrument into your anus and rectum. This test can evaluate the structure of your anal sphincter and may show childbirth-related injury.
- Anorectal manometry. This test measures the sensitivity and function of your rectum and can give information about the rectal sphincter and your ability to control stool passage. This test does not locate fistulas, but may help in planning the fistula repair.
- Other tests. If your doctor suspects you have inflammatory bowel disease, he or she may order a colonoscopy to view your colon. During the procedure, your doctor can take small samples of tissue (biopsy) for lab analysis, which can help confirm Crohn’s disease.
Symptoms of a rectovaginal fistula can be distressing, but treatment is often effective. Treatment for the fistula depends on its cause, size, location and effect on surrounding tissues.
Your doctor may recommend a medication to help treat the fistula or prepare you for surgery:
- Antibiotics. If the area around your fistula is infected, you may be given a course of antibiotics before surgery. Antibiotics may also be recommended for women with Crohn’s disease who develop a fistula.
- Infliximab. Infliximab (Remicade) can help reduce inflammation and heal fistulas in women with Crohn’s disease.
Most people need surgery to close or repair a rectovaginal fistula.
Before an operation can be done, the skin and other tissue around the fistula must be healthy, without infection or inflammation. Your doctor may recommend waiting three to six months before having surgery to ensure the surrounding tissue is healthy and see if the fistula closes on its own.
Surgery to close a fistula may be done by a gynecologic surgeon, a colorectal surgeon or both working as a team. The goal is to remove the fistula tract and close the opening by sewing together healthy tissue. Surgical options include:
- Sewing an anal fistula plug or patch of biologic tissue into the fistula to allow your tissue to grow into the patch and heal the fistula.
- Using a tissue graft taken from a nearby part of your body or folding a flap of healthy tissue over the fistula opening.
- Repairing the anal sphincter muscles if they’ve been damaged by the fistula or by scarring or tissue damage from radiation or Crohn’s disease.
- Performing a colostomy before repairing a fistula in complex or recurrent cases to divert stool through an opening in your abdomen instead of through your rectum. Most of the time, this surgery isn’t needed. But you may need this if you’ve had tissue damage or scarring from previous surgery or radiation treatment, an ongoing infection or significant fecal contamination, a cancerous tumor, or an abscess. If a colostomy is needed, your surgeon may wait eight to 12 weeks before repairing the fistula. Usually after about three to six months and confirmation that your fistula has healed, the colostomy can be reversed and normal bowel function restored.