The clinical presentation of RVF is a result of a combination of the passage of rectal content to the vagina and the underlying disease or injury. A detailed history of the underlying disease should be explored. Clinically, the escape of stool or gas from the rectum to the vagina through the fistula gives the abnormal signs and symptoms of foul-smell vaginal discharge, dyspareunia, passing air, bleeding, and passage of frank stool, especially when the patient has diarrhea. Further symptoms of complications like symptoms of cystitis or vaginitis are occasionally encountered. Symptoms of an underlying disease like rectal obstructing cancer or diverticulosis may be present.

Physical exam of the vagina, the source of the symptoms, will likely reveal irritation, erythema, swelling, discharge, stool, and possible fistula opening in the speculum exam. An office colposcopic exam may reveal more details of the vaginal epithelium and the fistula site as an indurated indentation. A rectovaginal examination may reveal signs of the underlying disease like an obstructing low rectal tumor or phlegmon, Crohn disease, or tissue atrophy from radiation.

When RVF is suspected, a workup should be started to confirm the diagnosis, assess the extent of the fistula, and identify the underlying diagnosis. In addition to history and physical examination, workup should be complemented by imaging and endoscopy if needed.

Laboratory tests to assess the baseline hematocrit, biochemical and infectious parameters are usually obtained. Signs of the overall disease impact, complications, and severity can be estimated from these tests. Further tests may be needed according to the initial assessment.

Endoscopy, like colposcopy and/or proctosigmoidoscopy (rigid or preferably flexible), may reveal the site of the fistula with the underlying disease. Signs of the underlying diseases like Crohn’s, diverticular disease, or rectal cancer are likely to be identified with endoscopy. Colposcopy can help detect cervical or vaginal cancers.

Imaging is commonly used and useful to confirm the diagnosis and identify the underlying disease. CT scan provides accurate, objective, detailed information of the fistula, the underlying disease, and the related nearby area. Rectal and intravenous contrast will outline the fistulous tract and the related structures. The presence of rectal contrast in the vagina is a confirmation of the diagnosis even if the fistulous tract itself cannot be visualized.

Further assessment includes laboratory workup to evaluate the general patient condition, underlying disease, or complications of the fistula like infection or electrolyte imbalance. Tissue biopsy from suspected masses will help to confirm malignancy and its origin.

Treating RVF involves treating the underlying disease, the fistula itself, and any related complications.[8][9] Therefore, confirming the fistula etiology should be done before planning treatment. The treatment approach depends on condition severity, acuity, presenting symptoms, patient's general condition, underlying etiology, and complications resulting from the fistula.[10]

Treatment of Crohn's disease, diverticular disease, or colorectal or gynecologic cancers should follow the principles of treating these diseases primarily. Treating RVF depends to a great extent on treating the underlying primary disease. There is more than one approach to the treatment of fistula with curative intent. In 2016, the American Society of Colon and Rectal Surgeons reviewed the approaches and developed guidelines to manage RVF.

Medical Treatment

The Conservative or non-surgical treatment approach of the symptoms and possible complications like UTI, local irritation, and site infection can be used in selected patients. This approach can be considered in high-risk patients and severe underlying disease. Medical treatment includes treating the infection and the associated symptoms, maximizing medical treatment of the underlying disease like in Crohn disease or diverticulitis, and supporting the general patient's condition. Other conservative treatment includes non-operative measures to close the fistula like fibrin glue or other occlusive measures. The success rate of these measures is not high. They are still an option to consider in high-risk patients who are not fit for surgery or failed a prior surgical approach.

Surgical Approach

Multiple operative approaches are used to treat RVF depending on complexity, recurrence, and the underlying disease.[11][12][13][14] Simple measures like draining seton in recurrent or acute infection may be used to optimize local tissue integrity and treat the infection.

The proximity of the rectal wall to the vaginal wall with minimal tissue makes repairs connecting fistula challenging. The principles of successful repair are to remove the unhealthy fistula tissue, replace with healthy tissue that has a good blood supply to enhance healing, and maintain thick interposing tissue between the rectal and vaginal walls. Following these principles (although not always possible) increase the chance of successful fistula treatment.

Fistula debridement and flaps are common surgical approaches. Advancement local endo-rectal flaps in simple RVF or gracilis regional myocutaneous flap in more complicated RVF are of the common flaps.[12][15]

In proximal or high RVF, surgical excision of the rectal wall in regimental resection is the other surgical radical approach.

• Aortitis

• Appendicitis

• Blunt abdominal trauma

• Colon cancer

• Diverticulitis

• Enterovesical fistula 

• inflammatory bowel disease 

• Large bowel disease

• Malabsorption 

• Urinary tract infection and cystitis in females

Typically patients can return to their regular routine a week or two following surgery, but it will probably be several months for complete healing to occur. These factors depend on the fistula's size and how extensive the surgical intervention was.

Rectovaginal fistula complications include fecal incontinence, associated hygiene issues, vaginal, perineal, or anal irritation, potential life-threatening abscess, and fistula recurrence.[16]

Following surgery, patients need counsel on minimizing irritation and discomfort and taking steps to promote healing. These can include:

• Washing the area only with water, or if they must use soap, use a mild, unscented variety.
• Avoid scented tampons and douches
• Allow the area to dry well before covering.
• Wear loose-fitting undergarments and clothing, preferably of cotton
• Utilize non-scented talcum powder or moisture barrier creams to keep the area dry

Management of RVF is complex and potentially tremendously challenging due to multiple factors. It requires interprofessional efforts, collaboration, assessment, and planning.[17] Prevention or early detection and treatment may save the unnecessary suffering of patients. Suspected fistula patients should be evaluated and appropriately referred to specialists. All pertinent information, including previous surgical information details, should be obtained. Proper planning and involvement of the required services are essential for successful treatment. Finally, an RVF has enormous adverse mental morbidity. Thus, these patients should be referred to a mental health counselor.