Rectovaginal fistulas (RVFs) are abnormal connections between the rectum and vagina, leading to the passage of gas or feces through the vaginal canal. This condition is distressing for patients, often accompanied by fecal incontinence, significantly impacting their quality of life. Dr. Steven D. Wexner, a renowned colorectal surgeon, has made significant contributions to the management of RVFs, especially those complicated by fecal incontinence.
Etiology and Diagnosis RVFs can arise from various causes, including obstetric trauma, surgical complications, radiation therapy, inflammatory bowel disease, or malignancy. Accurate diagnosis is essential for effective management, often involving a combination of patient history, physical examination, endoscopic evaluation, imaging studies like MRI or CT scans, and sometimes the use of contrast studies.
Initial Management The initial approach to managing RVFs focuses on controlling infection and inflammation. This might involve:
Antibiotic Therapy: To manage any associated infection. Bowel Rest: Using a temporary diverting colostomy to allow the fistula to settle. Nutritional Support: Ensuring the patient receives adequate nutrition, often with the help of a nutritionist. Surgical Management Primary Repair For small and simple fistulas, a direct primary repair may be attempted. This involves excising the fistulous tract and closing the defect in multiple layers. The success of this procedure depends on the size and location of the fistula, as well as the presence of any underlying conditions like Crohn's disease.
Tissue Flaps In more complex cases, tissue flaps can be used to provide additional support and promote healing. Common flaps include:
Martius Flap: Using labial fat to create a barrier between the rectum and vagina. Gracilis Muscle Flap: Utilizing the gracilis muscle from the thigh to reinforce the repair. Advancement Flaps Anorectal advancement flaps involve mobilizing a flap of rectal or vaginal tissue to cover the fistula. This technique is particularly useful in cases where primary repair is not feasible.
Fibrin Glue and Plugs Less invasive methods like fibrin glue or biologic plugs can be used to seal the fistula. These techniques are generally reserved for smaller fistulas or patients who are not candidates for more extensive surgery.
Management of Fecal Incontinence Fecal incontinence associated with RVFs presents an additional challenge. Dr. Wexner emphasizes a multimodal approach:
Pelvic Floor Rehabilitation: Including biofeedback and pelvic floor exercises to strengthen the sphincter muscles. Medications: Anti-diarrheal medications can help manage symptoms.
