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306 The ASCRS Manual of Colon and Rectal Surgery
Kraske Laterosacral Approach
• This approach provides excellent exposure without division
of the sphincter mechanism. The need to excise two to three
sacral segments as well as the nerves, muscles, and ligaments
around them pose a disadvantage.
York Mason (Trans-Sphincteric) Approach
• This approach affords a rapid, bloodless exposure through
fresh territory and allows for complete separation of the urinary and fecal streams.
Transanal Endoscopic Microsurgery
• This highly specialized technique allows for a meticulous twolayer closure of the rectal wall and may be combined with
transurethral fulguration of the opposite urethral opening of
the fi stula.
Cystectomy and Ileal Conduit
• Cystectomy and ileal conduit may be considered for those
patients with a low probability of success in resolving the fi stula
or in maintenance of urinary continence.
Appendix: Practice Parameters for Treatment of
Fistula-in-Ano
Prepared by the Standards Task Force, American Society of Colon and
Rectal Surgeons
Acute Suppuration (Abscess)
Presentation and Management
An abscess should be drained in a timely manner; lack of fl uctuance is
not a reason for delay in treatment. If the abscess is superfi cial, it may
be drained in the offi ce setting using a local anesthetic. If the patient
13. Benign Anorectal: Abscess and Fistula 307
is too tender to permit examination and drainage, then these measures
should be undertaken in the operating room. Antibiotics may have a role
as adjunctive therapy in special circumstances, including valvular heart
disease, immunosuppression, extensive cellulitis, or diabetes. Location
of the abscess should be documented. If possible, anoscopy should be
performed to reveal the primary site of infection. Patients should notify
the physician if pain recurs after abscess drainage.
Chronic Suppuration (Fistula)
Physical Examination
Inspection and palpation form the basis of the initial evaluation. Specifi cally, external (secondary) openings are sought, because their relationship to the anal canal provides a clue to the origin of the abscess-fi stula.
Anoscopy may be useful to identify an internal opening. If clinically
indicated, proctosigmoidoscopy or colonoscopy may be suggested to
exclude more proximally located infl ammatory disorders with which fi stulas can be associated.
Radiographic Evaluation
Ultrasound, fi stulography, computed tomography, and magnetic resonance imaging are not routinely indicated in the initial evaluation of
fi stulas but may be helpful in identifying an occult cause of recurrent
fi stula.
Treatment
Simple Fistulas May Be Treated by Fistulotomy. Fistulotomy is preferred
to fi stulectomy, because the former technique does not involve excision
of the sphincter. Primary fi stulotomy is appropriate in cases of intersphincteric and low transsphincteric fi stulas. Exceptions may include an
anteriorly based transsphincteric fi stula in a female, a diabetic patient,
or a patient with a weakened sphincter. Patients with irritable bowel
syndrome or increased stool frequency may require staged fi stulotomy
with a seton.
Recurrent Abscess-Fistula/Incontinence. Repeat fi stulotomy can be
used in treatment of recurrent fi stula. If the patient with a recurrent
308 The ASCRS Manual of Colon and Rectal Surgery
fi stula has symptomatic incontinence, then a physiologic investigation
may be warranted.
Selective Complex Fistulas May Require Treatment Other Than
Fistulotomy. These indications include (1) high transsphincteric fi stula, (2) extrasphincteric fi stula, (3) anterior fi stulas in females, (4)
patients with coexisting infl ammatory disease, (5) patients with
immunosuppressive disease such as human immunodefi ciency virus,
(6) elderly patients with poor sphincter function, (7) uncertainty by
the surgeon of level of fi stula in relation to sphincter, (8) multiple
simultaneous fi stulas, and (9) patients with multiple prior sphincter
surgeries or injuries. Either seton placement or advancement fl ap closure should be considered. The seton may be used in either a cutting or
draining manner, depending on the clinical situation and the patient’s
underlying condition.
Special Considerations
Rectovaginal Fistulas
For a traumatic (postobstetric) fi stula, a 3- to 6-month waiting period
after injury is generally useful to promote fi brosis of the injured muscle. A fi stulotomy is not generally used if it results in undue amounts
of sphincter division. Treatment alternatives include transanal or transvaginal advancement fl ap closure, closure of the rectovaginal septum,
conversion to a complete perineal laceration with layered closure,
sphincteroplasty, and muscle interposition.
Radiation-Associated Fistulas
Interposition fl ap or transabdominal approaches have the highest success
rates, depending on the level of the fi stula.
High Fistulas
For some surgeons, the transabdominal approach is more familiar and
involves division of the fi stula with layered closure and interposition of
omentum. Alternatively, an anterior resection or coloanal anastomosis
may be considered.
13. Benign Anorectal: Abscess and Fistula 309
Suprasphincteric Fistulas
Treatment requires an appreciation that the tract involves the entire
external sphincter complex and the puborectalis muscle. Useful treatment
options include division of the internal sphincter with concomitant seton
placement, excision and drainage of the tract with closure of the internal
opening, and advancement fl ap closure.
Horseshoe Fistula
The internal opening and postanal (or deep anterior anal) space should
be drained with or without a seton. The horseshoe portion of the fi stula
should be curetted and counterdrained rather than unroofed.
Human Immunodefi ciency Virus Infection
Large open wounds and sphincter division should be avoided. In general,
minimally immunocompromised patients can undergo standard fi stulotomy, whereas patients with higher degrees of immunosuppression should
undergo placement of a noncutting (draining) seton.
Crohn’s Disease
Initial management should be directed at resolving rectal infl ammation.
Such medical management may include antidiarrheals, topical enemas,
antibiotics, suppositories, or systemic steroids and/or immunosuppressive
agents. Fistulotomy is a reasonable alternative in most cases of intersphincteric or low transsphincteric fi stulas. More complex fi stulas can be treated
with drainage, seton placement, or fl ap closure based on the patient’s level
of continence or extent of concomitant intestinal disease. Ultimately, a
temporary or permanent stoma may be indicated.
Reprinted from Dis Colon Rectum 1996;39(12):1361–1372. Copyright © 1996. All rights reserved. American Society of Colon and Rectal
Surgeons.
14. Benign Anorectal:
Rectovaginal Fistulas
A. Etiology
• Obstetric injury is the most frequent cause of acquired
rectovaginal fi stulas but infection and other forms of trauma
may also result in these fi stulas. After an obstetric injury, the
fi stula may be manifest immediately but more frequently appears
7–10 days after delivery. Fistulas occur most often after a third- or
fourth-degree laceration. Inadequate repair, breakdown of the
repair, or infection may result in fi stula formation.
• In developed nations, rectovaginal fi stulas occur after 0.06–0.1%
of vaginal deliveries.
• Disease processes may also cause rectovaginal fi stulas. Cryptoglandular infection may result in an abscess spontaneously
draining into the vagina resulting in a fi stula.
• Rectal and gynecologic malignancies may result in fi stulas as a
result of local extension of the tumor or secondary to treatment
with radiotherapy.
• Women with infl ammatory bowel disease, Crohn’s disease
more frequently than ulcerative colitis, may develop rectovaginal fi stulas.
• Operative trauma may also result in a rectovaginal fi stula. Complications of rectal or vaginal surgery usually result in fi stulas
opening low in the rectum. High fi stulas are most frequently
complications of low stapled colorectal or ileoanal anastomoses.
• Pouch vaginal fi stulas are reported in 3–12% of patients. The
mechanism is usually that a portion of the posterior vaginal
wall is included in the anastomosis or that an abscess secondary
to an anastomotic leak drains into the vagina.
D.E. Beck et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery, 311
DOI: 10.1007/978-0-387-73440-8_14, © Springer Science + Business Media, LLC 2009
312 The ASCRS Manual of Colon and Rectal Surgery
• Fistulas have also been reported after vaginal dilatation of a
radiated vaginal cuff, fecal impaction, viral and bacterial infection
in human immunodefi ciency virus patients and sexual assault.
B. Evaluation
• There are two primary goals in the evaluation of women with
possible rectovaginal fi stulas: identifi cation of the fi stula site
and assessment of the surrounding tissue. The type of investigation
required varies with the underlying etiology of the fi stula.
Identifi cation of Fistula Site
• In most women with complaints consistent with a rectovaginal
fi stula, the site can be readily identifi ed on examination. Visual
examination may show the dark red rectal mucosa contrasting
with the pale mucosa of the vagina. A dimple may be palpable
in the anterior midline on rectal examination.
• The rectal opening is frequently visible on anoscopy.
• A methylene blue test may confi rm the presence of a communication and aid in locating the site. During this test, a vaginal
tampon is inserted and then the patient is given an enema colored
with methylene blue. If the patient retains the enema, staining
on the tampon is highly suggestive of a rectovaginal fi stula.
• Alternatively, saline can be instilled in the vagina with the
patient in the lithotomy position. The rectum is then insuffl ated
with air and the vagina observed for bubbles.
• Radiographic tests may help identify an elusive fi stula. One
option is vaginography. The examination is performed by
instilling contrast into the vagina.
– The technique has a sensitivity of 79–100% for the detec-
tion of the fi stula tract.
– Vaginography is most helpful for colovaginal and enter-
ovaginal fi stulas; it is less useful for low rectovaginal
fi stulas.
• Computed tomography scans may identify the fi stula tract and
characterize the surrounding tissue.
• Both magnetic resonance imaging (MRI) and ultrasound are
used to identify fi stulas with reasonable specifi city and low
sensitivity.
14. Benign Anorectal: Rectovaginal Fistulas 313
Assessment of Local Tissue
• The second goal of evaluation is to determine the etiology
and to assess the surrounding tissue. The necessary tests are
determined by the suspected etiology of the fi stula.
• If the mechanism of injury is childbirth, the patient with a fi stula
is at signifi cant risk of a sphincter defect.
• Ultrasound or MRI should be done to assess the anal sphincter.
• One study found that 100% of women presenting with a rectovaginal fi stula after a delivery had a sphincter defect.
• Multiple perianal fi stulas suggest Crohn’s disease as the etiology.
Evaluation of the intestinal tract by colonoscopy and contrast
studies is indicated in patients with known or suspected infl ammatory bowel disease. One must be careful to consider the
patient’s obstetric history even if she carries the diagnosis of
Crohn’s disease.
• Biopsy of a detectable mass should be done for suspected
malignancy.
• It is critical that recurrent carcinoma be distinguished from
irradiation injury. In patients with a history of malignancy
treated by radiation, examination under anesthesia with biopsies
is often necessary. Two series report an approximately 50%
incidence of recurrent cancer on biopsies of these fi stulas.
C. Classifi cation
• A variety of classifi cation systems exist for rectovaginal fi stulas.
Most systems classify by size, location, and etiology.
• Daniels classifi ed fi stulas by their location along the rectovaginal septum as low, middle, or high.
– The rectal opening is at the dentate line and the vaginal
opening just inside the vaginal fourchette in low fi stulas.
– The vaginal opening is at or near the cervix in high fi stulas.
Middle fi stulas are located between high and low fi stulas.
– This system is useful in that high fi stulas are more likely
to require laparotomy; perineal approaches are appropriate for most low and middle fi stulas.
• Saclarides argues that a classifi cation system based on etiology
is the most useful for the treating physician. A system determined by etiology would take into consideration the state of
314 The ASCRS Manual of Colon and Rectal Surgery
the surrounding tissue both anatomically and functionally as
well as the health of the patient.
• None of these systems have been tested to see whether they are
predictive of outcome but a strong case can be made that etiology
is the best guide to patient management.
D. Conservative Management
• For women with small fi stulas and minimal symptoms, medical management is appropriate. Optimizing the patient’s bowel
function, particularly controlling diarrhea, is benefi cial. Unfortunately, for the majority of women with rectovaginal fi stulas,
the symptoms are intolerable.
E. Surgical Techniques
Local Repairs
General Considerations
• A local repair is appropriate for the fi rst or second repair in
women with rectovaginal fi stulas and intact sphincter muscles.
Fibrin Sealant
• Most studies that include rectovaginal fi stulas report discouraging results of 0–33% success in very small numbers of patients.
Advancement Flaps
• Advancement fl aps may be approached transrectally, vaginally, or through the perineum. An advantage of the transanal
approach is direct access to the rectal side of the fi stula which
is the high pressure side (Fig. 14.1 ).
• The literature contains many case series of endorectal advancement fl aps (Table 14.1 ).
• Lowry and colleagues reported a success rate of more than
80% in fi rst and second repairs but only 55% in patients with
two prior repairs.
14. Benign Anorectal: Rectovaginal Fistulas 315
Fig. 14.1. Endorectal advancement fl ap.
316 The ASCRS Manual of Colon and Rectal Surgery
Table 14.1. Results of endorectal advancement fl aps.
Author Year
Greenwald and
Hoexter
Hoexter et al. 1985 15 100 Repair as above
Wise et al. 1991 40 85 15 concomitant
Lowry 1991 85 78 25 concomitant
Kodner et al. 1993 71 93 Unknown no.
Khanduja et al. 1994 16 100 Patients without
MacRae et al. 1995 28 29 50% obstetric, previous
Mazier et al. 1995 19 95 67% simple
Watson and Phillips 1995 12 58 Ultimate success 83%,
Tsang et al. 1998 27 41 All obstetric
Hyman 1999 12 91 Etiology not reported
Joo et al. 1998 20 75 Ultimate success, all
Baig et al. 2000 19 74 7 concomitant
Mizrahi et al. 2002 32 56 Mixture of etiologies
Sonoda et al. 2002 37 43 Mixture of etiologies
Zimmerman et al. 2002 21 48 6 concomitant
1978 20 100 Tract excised, layered
No. of
patients
Success
(%) Comments
closure under fl ap
sphincteroplasty
sphincteroplasty
sphincteroplasty
incontinence
failed repairs
25% stomas
Crohn’s
sphincteroplasty
sphincteroplasty
12 labial fl ap
transposition
• Sonoda and colleagues also found that a diagnosis of Crohn’s
disease was associated with a higher failure rate in their study
of 105 endorectal advancement fl aps.
• Success rates of 84–100% are reported with vaginal fl aps.
• Anocutaneous fl aps are an option for distal rectovaginal or
anovaginal fi stulas.
Rectal Sleeve Advancement
• An alternative transrectal approach is a rectal sleeve advancement
involving mobilization of the distal rectum and advancement
to cover the fi stula.
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