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15 Rectovaginal Fistula
283
the years 2006–2011 [23]. Anal stula may be the initial manifestation of Crohn’s disease or may occur years before or
after the diagnosis of proximal luminal disease [24]. The incidence of anal stula increases with both disease duration and
as the luminal disease distribution extends more distally in
the GI tract, with the highest incidence in patients with
Crohn’s proctitis [25, 26]. As with other etiologies of RVF, a
rst step in their management is to control associated infection (“sepsis”) if it is present. In general, this involves some
combination of antibiotics, abscess drainage, draining
seton(s), and patient-directed self-care with frequent irrigation of the healing wounds. The extent of disease should be
assessed via examination of the anus and rectum, with anoproctoscopy, and often requires sedation or general anesthesia to achieve the dual goals of thorough assessment and
minimal patient discomfort. The presence of proctitis, anal or
rectal stricture, and associated ano-perineal stula will inuence both the course of treatment and prognosis of rectovaginal stula in this setting. In terms of diagnostic imaging, MRI
may be the most useful modality and should be used selectively in cases in which the clinical examination is insufcient [27]. Once any associated infection has been controlled,
the next step is to consider if medical and/or surgical treatments are needed. Not all patients with Crohn’s RVF require
treatment [28]. Like other manifestations of Crohn’s disease,
the goal of RVF treatment is to control the symptoms of the
disease. If the patient is asymptomatic or minimally symptomatic, it may be best to avoid medical and surgical interventions. Alternatively, patients with symptomatic RVF must be
offered treatment to alleviate their symptoms.
Iniximab is an anti-TNF antibody that has been proven
effective in the treatment of stulizing perianal Crohn’s disease [14]. In a subset analysis of the ACCENT-2, a randomized prospective trial of iniximab versus placebo for the
treatment of stulizing perianal Crohn’s disease, among 25
women with RVF who were induced with iniximab, 16
(64%) responded to treatment with at least 50% closure of
their RVF tracts. These responders were then randomized to
maintenance iniximab or placebo and were assessed every
8weeks until week 52, at which point 45% and 43% of RVF
were closed in the iniximab and placebo groups, respectively [14]. While this study did not show a long-term benet
of iniximab in terms of stula healing, there was a shortterm benet as the mean duration of RVF closure was longer
in the iniximab-treated patients (45weeks vs. 25weeks). In
a 2016, a systematic review of 16 studies and 137 Crohn’s
RVF demonstrated that 63% of patients had some response
to iniximab and that 38% had a complete response, but did
not include data on the long-term results of iniximab treatment in these patients [29]. Thus, with the data available, it
may be fair to conclude that iniximab is “worth a try” in
patients with Crohn’s RVF and that it helps some patients,
but it is far from a panacea.
In the not so distant future, stula healing may be augmented by stem cell injections. There are reports of early
promising results with injections of stem cells into rectal
vaginal stula in ten patients with Crohn’s disease demonstrating a 60% healing rate [30].
The surgical treatments for Crohn’s RVF are the same as
those that are used for other causes of RVF and cover a spectrum of complexity that ranges from draining seton insertion
to proctectomy with permanent ostomy. Between these
extremes lay procedures including endorectal advancement
ap, gracilis or bulbocavernosus (Martius) ap, rectal resection with coloanal anastomosis, and others. In comparison
with non-Crohn’s RVF, the success of surgical treatment is
often lower for patients with Crohn’s and varies with the specic type of intervention [7, 31]. For example, in a study by
Pinto and colleagues from Cleveland Clinic Florida, the
overall per-procedure success of surgical interventions for
RVF was 78% and 44% for patients with non-Crohn’s and
Crohn’s RVF, respectively [7]. As with non-Crohn’s RVF,
while the initial attempt at repair is not always successful,
the majority will be healed after multiple attempts [7, 13]. A
special consideration in the surgical treatment of Crohn’s
RVF is whether the use of Crohn’s medical therapy positively or negatively impacts the success of surgical interventions. This question was evaluated by Narang and colleagues
at the Cleveland Clinics, who concluded that recent use of
anti-TNF, steroids, or immunomodulatory drugs did not negatively impact RVF healing after surgical repair [32]. Another
consideration in patients with Crohn’s RVF is the value of a
temporary diverting ostomy. As stated by Pinto and colleagues, “The inuence of a protective stoma on RVF repair
remains controversial” [7]. There is no randomized trial of
fecal diversion in RVF repair, and while retrospective studies
have had variable results in terms of the benet of diversion,
these studies are limited by selection bias [6, 7, 31].
Therefore, the Cleveland Clinic approach to temporary fecal
diversion in RVF repair, with its use in “redo repairs, technically challenging repairs, and suboptimal tissue conditions,”
seems reasonable [28]. In patients with Crohn’s RVF in
whom all else fails, the construction of a permanent ostomy
may be required for symptom and disease control. Risk factors for permanent fecal diversion in patients with perianal
Crohn’s disease include complex stula, anal stenosis, history of rectal resection, fecal incontinence, and the use of a
temporary fecal diversion [33–35].
Cryptoglandular
In retrospective studies of the surgical treatment of RVF,
anywhere from 2% to 40% of cases are classied as cryptoglandular in origin [8, 10, 21, 36]. Initial treatment in these
cases is focused on eradication of sepsis. The use of subse-
284
B. H. Gurland and J. D. Vogel
quent surgical procedures is determined on an individualized
basis with consideration of symptoms, anal sphincter integrity, and the condition of the surrounding soft tissues.
Anastomotic andOther Surgical Complications
Fistulization of a colorectal anastomosis to the vagina has
been reported to occur in as many as 10% of women who
undergo low anterior resection [3, 37, 38]. When this occurs,
fecal diversion is generally recommended as the initial step
to facilitate resolution of the acute inammation and associated infection. In some cases, diversion alone may result in
healing. In 2005, Kosugi reported that 6 of 16 (37%)
colorectal anastomotic-vaginal stulas treated with diversion
alone healed within a period of 6months [37]. Persistent stulas were treated with neo-colorectal anastomosis, endorectal advancement ap, or gluteal-fold ap interposition. Other
iatrogenic causes of RVF include rare occurrences after stapled hemorrhoidopexy or stapled transanal rectal resection
(STARR) [4].
Radiation Injury
Radiation-related RVF occur after the use of radiation to
treat cervical cancer and other pelvic malignancies. In a
recent review by Zelga and colleagues, RVF developed anywhere from 5months to 20 years after radiation treatment
with a median interval of 20 months [39]. While in their
series, the majority of patients with long-term follow-up
were maintained with fecal diversion; other studies have
demonstrated high rates of stula resolution with the use of
a bulbocavernosus ap [40, 41] or rectal resection with colo-
anal anastomosis [42].
Evaluation ofPatient withRVF
RVF clinical evaluation begins with a thorough history of the
illness: information about the duration of symptoms, the
nature and volume of vaginal discharge, number and consistency of day and night bowel movements, the patient’s ability to defer defecation and atus, and if they have experience
fecal incontinence. The use of pads to control drainage and
the number of pad changes per day may be helpful in quantifying the amount of drainage from the stula. Inquiries about
the presence of urinary symptoms such as pneumaturia or
fecaluria are also important and may help uncover the presence of an associated enterovaginal stula. The patient’s past
medical, surgical, and childbirth history should be assessed
to nd clues of the etiology of the stula and if prior attempts
were made to repair the stula. Awake examination in the
surgery clinic is an important step in evaluation of the stula.
Inspection of the anoperineum includes an evaluation of the
integrity of the perineal body and if there are scars in this
area that resulted from an episiotomy or sphincter laceration
repair. Inspection and digital examination of the anorectum
and vagina are useful to assess the internal and external anal
sphincter and the location and size of the RVF.Vaginoscopy
and anoproctoscopy may also be useful to obtain information
about the location and size of the stula and if there is a stricture, proctitis, or other mucosal abnormalities of concern. If
sufcient information about the anatomy of the stula cannot be obtained during awake examination, an exam under
sedation or general anesthesia should be considered. The
“tampon test,” in which the patient inserts a tampon or gauze
pad into her vagina, leaves it in place for several hours, and
then removes and inspects it for fecal staining, is an occasionally useful test to conrm the presence or absence of a
RVF [18]. This test may also be modied and used during
awake or sedated examination for the same purpose. This is
done by carefully inserting a clean gauze or lap pad into the
vagina and then by instilling a dilute Betadine solution into
the rectum with a 60cc syringe or similar instrument. The
pad in the vagina is then removed and inspected to see if
there is Betadine staining.
Diagnostic imaging is used selectively in the evaluation of
RVF to dene the trajectory and number of tracts and to determine if there are undrained uid collections or local pathology. To obtain this information, magnetic resonance imaging
(MRI) is the preferred imaging modality [43, 44]. CT imaging may also be used, but limitations in its ability to provide
sharp contrasts between pelvic soft tissues make this modality relatively inferior to MRI.Fluoroscopic studies, including
rectal contrast enema, are useful to evaluate a colorectal anastomosis for patency or stula, while vaginography has been
shown to have high sensitivity for detection of RVF [45].
Endoluminal ultrasound may also have a role in the evaluation of RVF, particularly for examination of the anal sphincter, but has limits in terms of its readability and limited view
of the surrounding anatomy [44, 46]. Endoscopic evaluation
of the rectum and colon may be considered in cases in which
Crohn’s disease or radiation injury is the suspected etiology
of the stula. Consultation with urologist and/or gynecologist
may be needed in patients with suspected coexistent rectourethral or enterovesical stula or in cases in which gynecological interventions are needed. In patients in whom surgery is
planned and an ostomy is considered, preoperative site marking and education is advised [47].
15 Rectovaginal Fistula
Surgical Techniques
There are excellent review articles which describe the surgical
techniques for RVF [18, 48]. A distal anovaginal or rectovaginal stula can be surgically approached through the perineum,
vagina, or rectum. For patient with anal sphincter injuries, decient perineal tissue, or gaping introitus, a perineal approach is
preferred (Figs.15.1 and 15.2). However, if the perineum and
sphincters are intact, the stula can be repaired through the rectum or vagina avoiding the trauma associated with a perineal
incision. Traditionally, colorectal surgeons prefer a transanal
approach both based on their experience and comfort level with
operating in the rectum and the philosophy that focusing the
repair on the high-pressure zone of the rectum would lead to
better stula healing. However, no one specic surgical technique has been found to be superior, and stula healing rates
range from 50% to 85% depending on the case series and
patient characteristics [1, 49, 50]. There are situations where
avoiding anal sphincter stretching with retractors is advantageous, and we recommend that the colorectal surgeon consider
transvaginal approaches in appropriate cases.
285
Fig. 15.2 A stula probe is in place through the vagina and rectum in
this very distal stula. Endoanal ultrasound conrms an anterior anal
sphincter defect. A perineal approach with episioproctotomy is performed to repair the stula and sphincter defect
Preoperative considerations include smoking cessation,
weight loss, diabetes control, and improving bowel consistency and frequency. We recommend mechanical bowel
preparation, but many authors prefer only an enema clean
out and a single dose of perioperative antibiotics. It is
important to discuss the possibility of postoperative dyspareunia and changes in bowel function associated with the
repair. Postoperative complications may include infection,
bleeding, and perineal sepsis. Breakdown of the perineal
skin is common, and some surgeons leave the perineal skin
loose to heal by secondary intention. The use of drains is
surgeon dependent. Vaginal packing at the end of the procedure is selectively inserted as a pressure dressing to help
with hemostasis. A short course of oral postoperative antibiotic is used by some surgeons but is not in our practice.
Women undergoing local repairs are usually discharged
the following morning with no dietary restrictions and on
a stool softener or mineral oil to lubricate the stool.
Perineal wound care involves a peri-bottle and handheld
shower but tub soaking is avoided. Patients are restricted
from sexual activity, tampon use, excessive leg stretches,
and strenuous activities until their 6-week postsurgical
visit.
Fig. 15.1 This woman suffered from an obstetric injury several years
prior. A probe is placed from the vagina through the perineum and from
the perineum to the anus. This woman will benet from a perineal
approach to reconstruct her perineum. Her underlying sphincter injury
will be addressed with an overlapping sphincter repair
Perineal Approach
Episioproctotomy
Episioproctotomy is our preferred approach for women with
sphincter or perineal injuries (Fig. 15.3) [51]. This technique involves opening the fistula tract and creating a
defect similar to a fourth degree perineal laceration. The
286
Fig. 15.3 Episioproctotomy. (https://doi.org/10.1007/000-339)
B. H. Gurland and J. D. Vogel
tum until healthy pliable tissue is appreciated. Meticulous
hemostasis is obtained throughout the procedure. The rectal
mucosa is approximated with running 3-0 absorbable sutures.
The levators and rectovaginal septum are approximated, but
deep suture bites and unnecessary tension are avoided which
can lead to levator spasm and dyspareunia. The sphincter
muscles are overlapped and secured with mattress sutures.
The vaginal mucosa is approximate with a running locking
3-0 absorbable suture. The hymenal edges are identied and
aligned. The transverse perineal muscles are repaired and the
perineal skin is loosely approximated. Success rates are
reported from 64% to 100% [50].
Transverse Perineal Repair
An incision is made transversely through the perineal body,
and dissection is carried out proximal to the stula tract. The
vaginal and rectal wall are mobilized and the stula tract
edges are excised. Closure of the rectal wall is performed in
two layers. The rectovaginal septum and levators are approximated in the midline, and the vaginal epithelium is closed
(Fig.15.5).
Fig. 15.4 The patient is in lithotomy position and the stula tract was
opened over the probe. Allis clamps hold the edges of the perineal skin.
Anterior sphincter scar is visualized in the midline, and the sphincter
complex will be mobilized laterally to perform overlapping sphincter
repair
patient is positioned in either lithotomy or prone position. A
longitudinal incision is made over the probe to create a cloacal defect (Fig.15.4). Skin aps are created on either side to
mobilize the external sphincter laterally. The stula tract
edges are excised, and complete debridement of the stula
tract or granulation tissue is performed. The plane between
the rectum and vagina is mobilized in the rectal vaginal sep-
Transrectal Approaches
Endorectal advancement ap (ERAF) technique has been
well described in the literature, and this is by far the most
common approach in the colorectal literature. A curvilinear
incision is made nearly 180 degrees just distal to the stula
opening in the anal canal. The ap of mucosa, submucosa,
and rectal wall is dissected off the rectovaginal septum.
Mobilization of the rectal wall is performed proximal to the
stula to avoid tension on the repair. The stula tract is
excised and the opening is closed with absorbable suture.
The ap is trimmed and approximated to the distal cut end
(Fig.15.6). The vaginal or perineal openings are left open to
heal by secondary intention. Overall success rates are
reported at 43–93% [1, 31, 50, 52, 53].
Rectal Sleeve Advancement
Rectal sleeve advancement can be used in select situations
when the distal rectum is diseased but the proximal rectum is
normal such as with Crohn’s disease, radiation, or prior surgical procedure. Starting at the dentate line, a mucosectomy
of the mucosa and submucosa is performed, and dissection is
taken cephalad proximal until healthy tissue is encountered.
Mobilization of the rectum is 90–100%. The healthy proximal rectum is brought down without tension and sutured to
the neodentate line. This repair is typically considered in
patients where the only other option is total proctocolectomy
or permanent fecal diversion [54].
ab
15 Rectovaginal Fistula
287
Fig. 15.5 Episioproctotomy. (a) ap of mucosa and submucosa is
raised. A longitudinal incision is made along the perineum opening the
skin, transverse perineal muscles, sphincter complex or midline scar, and
rectovaginal septum and vaginal epithelium so that the stula is com-
Vaginal Approach
pletely opened. (b) The stula tract and granulation tissue have been
excised and the muscle layers identied and mobilized. A layered repair
is performed. (Reprinted with permission, The Cleveland Clinic Center
for Medical Art & Photography © 1999–2020. All Rights Reserved)
Tissue Transposition Repairs
For more complicated repairs (such as prior failed attempts,
Transvaginal repair is least commonly reported in the
colorectal literature (Fig. 15.7). Advantages of vaginal
approach are avoiding extensive mobilization of diseased
rectum and avoiding sphincter stretch associated with
anal retractors and tissue trauma associated with rectal
aps. Transvaginal approach is favored in patients with
active Crohn’s disease in the rectum, and studies have
shown that endovaginal aps produce similar outcomes to
endorectal aps [55]. The vaginal advancement ap consists of raising a posterior ap of vagina over the stula.
The rectal and vaginal orices of the stula are identied and repaired with absorbable sutures. The levator ani
muscles are approximated in the midline. The vaginal ap
is advanced over the repair. Alternative techniques are
described in the literature involving coring out the stula tract, freshening up the edges, and creating a apless
transvaginal RVF repair with healing rates of 67% in 15
patients [56].
Crohn’s, and radiation-induced stula), tissue transposition
with muscle or pedicled adipose has been shown to be effective. The interposition of healthy well-vascularized tissue
between the stula layers increases bulk and obliterates dead
space.
The Martius ap is harvested from the labia and includes
fat and bulbocavernosus muscle. The posterolateral vascular
pedicle which originates from a branch off the internal
pudendal artery is preserved, and the ap is rotated and interposed between the cut and closed edges of the RVF
(Fig.15.8). Success rates for this procedure range from 60%
to 100% [57, 58].
The gracilis muscle interposition offers a greater bulk of
healthy vascularized tissue. The muscle is harvested from the
thigh and then passed through a tunnel from the proximal
aspects of the thigh toward the perineum and then positioned
between the rectum and vagina. Overall success rates are
reported from 53% to 92% [59, 60].
288
ab
cd
B. H. Gurland and J. D. Vogel
Fig. 15.6 Endorectal advancement ap. (a) ap of mucosa and submu-
cosa is raised. (b) Adequate mobilization of the ap is performed to
avoid tension. (c) Approximation of the lateral edges of the muscular
layer over the stula as an additional layer for reinforcement. (d) The
ap is sutured in place
15 Rectovaginal Fistula
289
Bioprosthetic Products
There have been several biosynthetic products developed for
stula tract closure. The biological matrix is thought to promote inammatory response and scar formation while minimizing dissection and trauma. Success rates are low ranging
from 20% to 35%, and the initial enthusiasm for bioprosthetic material has diminished [6].
Abdominal Approaches
For RVF originating in the middle third of the rectum or
upper portion of the vaginal or in patients with severely damaged tissue following surgery or radiation, an abdominal
approach is warranted. When the patient has a high stula
Fig. 15.7 Vaginal approach. (https://doi.org/10.1007/000-338)
with healthy tissue anterior dissection between the rectum
and vagina, excision of the stula tract and interposition of
omentum have been reported with satisfactory success rates
[61]. In most cases, resection of the diseased rectum with
anastomosis at a lower level is necessary [62, 63]. This can
be performed with two main techniques: an immediate anastomosis or delayed coloanal anastomosis (Turnbull-Cutait).
When the distal rectal tissue is normal, an immediate anastomosis is performed. However, the Turnbull- Cutait is reserved
for situations when there are other stulous connections or
an internal opening close to the suture line [64].
Circumferential sutures are placed at the neodentate line.
The proximal bowel is prolapsed out of the anus and wrapped
in gauze for 5–7days at which point the patient returns to the
operating room for amputation of the prolapsed rectum and
suture xation to the neodentate line [65, 66]. Temporary
fecal diversion is highly recommended in the setting of
abdominal procedures and radiation. Permanent colostomy
should be considered in patients with severe radiation injury.
Conclusion
RVF are uncommon but can pose a very challenging problem. The colorectal surgeon is likely to encounter the
most complicated cases. A thorough understanding of the
disease process and surgical options are imperative to provide the patient with the best opportunities for stula
healing.
Fig. 15.8 Martius ap. The
fat pad is dissected from the
labia and then the ap is
rotated and interposed
between the rectal and vaginal
stula. (Reprinted with
permission, The Cleveland
Clinic Center for Medical Art
& Photography © 1999–2020.
All Rights Reserved)
290
B. H. Gurland and J. D. Vogel
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Pilonidal Disease andHidradenitis
Suppurativa
AnuradhaR.Bhama andBradleyR.Davis
16
Key Concepts
• Pilonidal disease is an acquired chronic, infectious disease typically of the natal cleft with an unknown etiology,
thought to be due to a combination of environmental and
patient-specic factors.
• The treatment for pilonidal disease should not result in
worsening of quality of life than the disease itself. Incision
and drainage for acute infections is mandatory, but further
surgical treatment should be individualized.
• Several operative strategies exist for the treatment of pilonidal disease; surgeons should be familiar with the various options available, though no single option has proven
superior.
• Wound care following pilonidal excision can have a major
impact on quality of life and several nonoperative treatment strategies exist.
• Hidradenitis suppurativa (HS) is a chronic, relapsing,
inammatory skin condition that typically occurs after
puberty. The primary clinical presentation is painful
inamed nodules in the apocrine gland-bearing regions
that progress to abscesses, sinus tracts, and scarring.
• The overall disease burden is disproportionate to the estimated prevalence, and patients with HS not seen and evaluated by dermatologists and surgeons may not get timely
and appropriate treatment.
• Therapy is initially medical and consists of antibiotics
both orally and topically as well as immune modulators to
manage the chronic inammation.
• Surgery is an important treatment for both acute abscess
formation and painful scarring and deformity. Excision
A. R. Bhama
Department of Colon and Rectal Surgery, Cleveland Clinic,
Cleveland, OH, USA
B. R. Davis (
Department of Surgery, Atrium Health,
Charlotte, NC, USA
e-mail: Bradley.R.Davis@atriumhealth.org
*)
with primary closure and skin grafting can result in cure
for patients with recalcitrant disease.
Pilonidal Disease
Introduction
Pilonidal disease is a chronic, suppurative condition, typically of the sacrococcygeal natal cleft, that can present from
quiescent and asymptomatic disease to an active and purulent infection. Clinical descriptions date as far back as the
1850s, yet this disease process continues to challenge clinicians today. The ideal treatment for this condition remains a
dilemma, and classic techniques are still frequently utilized
for treatment while newer techniques are explored. Pilonidal
disease can result in signicant quality of life impairment for
the patient, but treatments for the disease can be equally frustrating, not infrequently resulting in chronic open wounds
requiring extensive wound care with prolonged healing periods. When caring for patients with pilonidal disease, it is
important to remember that the treatment of the disease
should not be more debilitating than the disease itself.
The terms “pilonidal cyst,” “abscess,” “sinus,” and “disease” are often used interchangeably. In the setting of an
infection of the pilonidal sinus or cyst, the term “abscess” is
most appropriate. In general, this spectrum of pilonidal conditions can be referred to as “pilonidal disease.” There is a
multitude of nonsurgical and surgical treatment options
available for pilonidal disease that can be employed at various stages of disease severity. The plethora of literature compares procedures, with variable success and recurrence rates
where no single procedure outshines the others. As such, it is
important to have an understanding of the assorted options
available to patients during any stage of their disease process, from the initial stage of diagnosis to recurrent disease
several years after denitive surgical treatment.
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