Clinical Spectrum, Management, and Outcome of Rectovaginal Fistulae

Silindokuhle Revivial Sibiya, Surandhra Ramphal, Thandinkosi Madiba, Frank Anderson 

University of KwaZulu-Natal, Durban, South Africa

 

Correspondences to: Silindokuhle Revivial Sibiya; email: slindosibiya88@gmail.com

Received: 11 Oct 2021; Revised: 24 Aug 2022; Accepted: 25 Aug 2022; Available online: 12 Sep 2022

Abstract

Background

There are limited reports on rectovaginal fistulae in South Africa.

Materials and methods

This was a prospective analysis of all patients undergoing treatment for RVF at a tertiary referral hospital. Data was extracted from the database between 2006 and 2018 and analysis included demographics, aetiology, management, and outcome. The main outcome measure was healing of the fistula.

Results

Fifty patients were identified [Median age 36 (IQR 28-42) years]. HIV status was positive (31), negative (5) and unknown (14). Commonest causes were obstetric (17), perineal sepsis (14) and spontaneous (8) (Table 2). Median duration of symptoms was 34.5 months (IQR 5-72) (Diagram 1). Forty-two patients underwent 55 surgical procedures (including 14 redos). In 32 patients RVF repair was undertaken under colostomy cover and 28/42 fistulae healed after the initial repair (66.7%), final success rate was (41/42) 97.6%. Two of eight fistulae healed after non-operative management (25%).

Conclusion  

Obstetric injury was the leading cause of RVF. HIV positive patients predominated. Spontaneous fistulae were seen in immunocompromised patients. Success rate was 97.6% over a healing time of 3 months. Non-operative management led to healing in 25% of cases.

Key words: Rectovaginal fistula, fistula repair, fistula management 

Ann Afr Surg. 2022; 19(4): 200-206

DOIhttp://dx.doi.org/10.4314/aas.v19i4.7

Conflicts of Interest: None

Funding: None

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Rectovaginal fistulae (RVF) are abnormal epithelialized connections between the rectum and/or anal canal on the one end and the vagina on the other end (1). They are associated with significant distress and poor quality of life (2). They result from difficult labor, inflammatory bowel disease (IBD), neoplasms, and infections such as cryptoglandular and Bartholin gland abscess, tuberculosis, and lymphogranuloma venerium.
RVF occur as a complication of delivery or uterine evacuation usually in the absence of skilled medical staff assistance in situations where there is lack of access to high-quality obstetric care (3). Obstetric fistula is associated with several preventable risk factors, which include young age (teens) at delivery, primiparity, prolonged labor, and home delivery (3). The mechanisms of obstetric injury are prolonged obstructed labor leading to necrosis of the rectovaginal septum and third- or fourth-degree perineal tears sustained during difficult labor (3–5). The fistula is clinically apparent 1 to 2 weeks after delivery and is most often located at the level of the anal sphincters (3). Approximately 10% of immediate repairs fail leading to anorectal pelvic floor dysfunction such as anal incontinence and/or RVF (3). Surgical repair has reported success rates ranging between 69% and 80% in the African continent (5).
Obstetric causes are rare in high-income countries, but they remain prevalent in low- and middle-income countries (6). More than 2 million women worldwide have RVF, with at least 50,000 to 100,000 new cases occurring annually (6, 7). Among these, the majority are from low- and middle-income countries, which tend to be resource-poor and with ineffective health delivery systems (2, 4, 7). In sub-Saharan Africa, lifetime prevalence ranges between 0.4 and 19.2 per 1000 women of reproductive age (3, 8).
The classification of RVF is based on location, size, and etiology (1). A common classification system is based on the size and anatomic position in the vagina, as described by Zitsman and Glowacki (20) (Table 1). The anorectal part of the fistula is also classified as suprasphincteric, intersphincteric, or low/trans- sphincteric.
Although there is a plethora of data from African series reporting on RVF, there is scarce literature describing the management of this condition in the South African context. A previous report from South Africa reported on 87 genital tract fistula, and 36 (41.4%) of which were RVF (9). All were repaired transvaginally and 9.2% required stomas, two of which were permanent (9). The overall success of the initial repair was 85.1% but the RVF were not analyzed separately in this report, and the present research sought to analyze RVF as a single entity (9).

Materials and Methods

The prospective