Treatment of rectovaginal fistula – only surgical
PROCTOLOGY – 2009
SURGICAL DIVISION CB 6 RZD – MOSCOW
Rectovaginal fistula – a pathological communication between the rectum and the vagina. In this case the contents of the colon – feces and gases – can enter the vagina. The most common cause of rectovaginal fistula is an injury during birth, and complications after surgical interventions in this area, neoplastic and inflammatory diseases of the rectum. Rectovaginal fistula risk in normal birth is 0.1%.
Thus, the rectovaginal fistula – is for the most part, acquired pathology. Much more rarely, such fistulas may be congenital. Congenital fistulas are mainly involved pediatricians and pediatric surgeons.
Rectovaginal fistula symptoms are often accompanied by emotional stress, as well as causing physical discomfort. Although sometimes the woman is extremely awkward to start a conversation with your doctor about this disease, it is important to conduct a thorough examination. In some cases (though rare), such fistulas may close by themselves, but generally require surgical intervention.
Rectovaginal fistula Causes
Currently, many distinguish the causes of rectovaginal fistula. The most common cause of this pathology are the generations, and the pathological. These genera are:
- Protracted labor
- The long dry period (when the discharge of water between the fetus and the birth was a long time)
- Perineal tear
Among the causes of rectovaginal fistula can also be called and inflammatory changes in the wound after interventions during delivery. A more rare cause of rectovaginal fistula formation may be an injury of the rectal wall during various operations on the pelvic organs, as well as acute spontaneous dissection of the lumen of the vagina paraproctitis (when the accumulation of pus breaks through the vagina), and traumatic injury rectovaginal septum.
Rectovaginal fistula can also be complications of diseases of rectum and colon, such as Crohn's disease, diverticulosis of the colon (especially in women after hysterectomy).
The long dry period can also be a cause of rectovaginal fistula, which is due to the fact that by passing the head waters of the fetus descends and presses the wall of the vagina to the pelvic bone to the ring. At this point, blood circulation, tissue necrosis and a fistula formed.
However, most causes of rectovaginal fistula are different, and as already mentioned, this is – abnormal births.
When non-compliance of the birth canal size of the fruit when the fruit itself is wrong, as well as some obstetric operations could occur trauma of the birth canal. At the same damaged wall of the vagina and rectum, as well as the ligament-muscular apparatus of the rectum. In such cases, is usually carried out emergency surgery. Such operations may be complicated by inflammatory complications in the intervention areas (almost 10% of cases). Among these the most frequent complications of suture failure in the wall of the intestine (ie, their difference). This complication usually lets you know about yourself in 3-5th day after the operation – from the vagina appears contents of the rectum – feces and flatus.
Typically, in this case can not help there is a desire to urgently take in this defect. But it is a mistake, as purulent wound closure, especially in this neighborhood, as the rectum, is fraught with repeated failures of the new mandatory seams. As you know, the wall of the vagina is very closely connected with the wall of the rectum, and along its entire length. The pressure in the rectum is much higher than in the vagina. Therefore, if between the gut and the vagina was formed message, it gets the contents of the intestines into the vagina, but not vice versa.
In the formation of a fistula after a week he had become "permanent" due to the fact that its edges are fused to the vaginal wall and the rectal mucosa. The final "maturation" rectovaginal fistula occurs in 3-4 months after decrease inflammation in the surrounding tissues.
Rectovaginal fistula For that occurred against the backdrop of diseases of the rectum, for example, paraproctitis or colitis, marked a few other features. In the third of the cases of fistula communication between the gut and the vagina is tubular in nature, with the progress of the fistula may be branched, with purulent streaks and pockets.
Rectovaginal fistula manifestation
Depending on the size and location of fistula, symptoms of the disease can vary from minimal to severe symptoms.
- The most common manifestation of rectovaginal fistula is a vaginal discharge of intestinal gas and feces. In addition, may occur and pus from the vagina vdeleniya.
- The presence of a permanent infection of the vagina is characterized by frequent exacerbations of inflammatory diseases of the genital tract (colpitis), and especially of the urinary tract.
- Another symptom characteristic of rectovaginal fistula is pain during sexual intercourse, which is usually associated with the presence of inflammation.
- Rectovaginal fistula for fecal incontinence are also characteristic.
- In the presence of concomitant vezikovaginalnogo fistula (communication between the vagina and the bladder) may experience leakage of urine into the vagina.
Naturally, this disease is very unpleasant for any woman. The patient is forced to hide from others his illness. Hygienic problems that are characteristic of rectovaginal fistula may even lead to family breakdown or inability of its creation, as well as significant difficulties in sexual relations with a partner. Therefore, another manifestation of the permanent rectovaginal fistulas are a variety of neuropsychiatric disorders. Joining other inflammatory diseases of the urogenital even more difficult for the disease.
Classification of rectovaginal fistula and type of
Rectovaginal fistulas can be divided into:
- low (3 cm from the edge of the anus)
- average (from 3 to 6 cm from the edge of the anus)
- high (6 cm above the edge of the anus).
Diagnosis of rectovaginal fistula
Among the methods of diagnostics rectovaginal fistula apply:
- clinical examination
- vaginal examination in the mirror
- contrast radiographic methods.
First of all, the doctor collects the history: the patient asks about the previous births of their nature, severity, amount of deferred surgical intervention in the pelvis, a woman could not stand the radiation therapy, as well as the presence of bowel disease.
Clinical examination is the examination of the vagina in the mirror. Inspection is carried out almost to the vault. In the presence of a fistula between the vagina and rectum can note the presence of the hole and the discharge from it (intestinal contents). Be sure to hold the finger vaginal research, which allows us to estimate the presence of scarring in the area of fistula.
Fistulografiya using water-soluble contrast agents and probes with a coloring matter. Usually when painting in the samples from the vaginal opening is introduced dye, after which the inspection is carried out of the lumen of the rectum by using mirrors or rectal proctoscope.
X-ray diagnostic methods are the introduction of radiopaque substance into the fistula and the further implementation of the X-ray image.
To assess the degree of concomitant anal sphincter insufficiency, as well as the volume of rumen lesions carried a mandatory definition of sphincter rektoanalnogo reflex and digital rectal examination. In some cases, resorting to instrumental methods of investigation, such as sphincterometry, electromyography or manometry.
Mandatory in the diagnosis of rectovaginal fistula is a sigmoidoscopy, and, if necessary – colonoscopy and barium enema.
Treatment of rectovaginal fistula
Treatment of rectovaginal fistula – with surgery alone. When an injury rectovaginal septum within the first 18 hours you can spend the resulting closure of messages with minimal risk of septic complications. In this case the edge of the fistula are excised, the wound is treated and then held suturing the rectal wall and levator muscles. After that sutured the defect in the wall of the vagina.
Harder for a long time for mature fistulas. In this method of surgery depends on the particular situation. It is important to take into account such factors as the cause of a rectovaginal fistula, its location, the distance from the edge of the anus, the relationship of the fistula with a muscular apparatus of the rectum, the severity of scarring, the functional state of the anal sphincter.
Note that in the process of scar in the fistula is usually applied first colostomy – on the wall of the abdomen shows part of the colon. This is done to eliminate the presence of feces in the proposed surgery. The operation of the imposition of colostomy done in 2-3 months.
Today, among the surgical treatment of rectovaginal fistulas are three types of access:
At low rectovaginal fistula (a hole when the fistula is located less than 3 cm from the edge of the anus), surgical approach depends on the cause of the disease. If the cause of fistula – acute abscess, it is used only rectal access as required to eliminate not only the fistula, but its cause – the festering anal crypt.
In other cases, surgery is usually performed relegated muco-muscular flap of the rectum. In the case of anal sphincter defect should be complemented by an operation of its correction. To do this, or is held sfinkteroplastika sfinkterolevatoroplastiki.
In half of the rectovaginal fistula, they are at the middle level (hole fistula is located at a distance of 3-6 cm from the edge of the anus). Treatment of these fistulas can be done as a perineal and vaginal access. The operation is reduced to the excision of the fistula, and in the perineal access is carried out for the semilunar incision in the perineum and vaginal same goal is achieved after excision of the triangular flap sheath with a defect. Once scar tissue is excised and the fistula, the defect in the intestinal wall sutured.
Next carried forward levatoroplastika to create a natural "spacer" between the rectum and vagina, and then suturing the defect is carried out the vagina.
In the case of an extensive process of elimination of rumen fistula and closure of the defect in the rectum and the vagina is done through so-called laparotomic access, you have done for this cut in the wall of the abdomen.
In the postoperative period is very important delay in the chair to allow the wounds to heal without infectious and inflammatory complications. For this purpose appointed a special diet with plenty of liquid food, the poor of vegetable fiber.
Some doctors believe that women who had undergone previous surgery for rectovaginal fistula is recommended for the next pregnancy to give birth to a child by caesarean section.
CENTER PROCTOLOGY Professor PROMA – GERMANY
SURGICAL DIVISION CB 6 RZD – MOSCOW
Examination and treatment in GERMANY – Institute "DIAGNOSTIX"
AID IN THE TREATMENT –