Rectovaginal fistula
A rectovaginal fistula (RVF) is an abnormal connection between the rectum (the lower part of the bowel) and the vagina. Because of this opening, gas, mucus or even stool can pass from the bowel into the vagina.
Rectovaginal fistulas can be classified by where they sit:
• Low: just above the anus — often related to childbirth injury.
• Mid-vaginal: the most common location after pelvic surgery.
• High: near the top of the vagina — often related to surgery or radiation.
What causes a rectovaginal fistula?
• Childbirth injury — a deep tear that involves the anal sphincter and rectum can heal abnormally or undiagnosed injury can result an RVF
• Pelvic surgery — hysterectomy, prolapse repair, low rectal surgery and stapled haemorrhoidectomy.
• Inflammatory bowel disease — particularly Crohn’s disease.
• Pelvic radiotherapy — often presents 6–24 months (or longer) after treatment.
• Cancers of the rectum, cervix or vagina
• Severe infection or abscess in the pelvis
What are the symptoms of rectovaginal fistula?
Symptoms depend on the size and location of the fistula, but typically include:
• Passing wind (gas) from the vagina
• Brown discharge, mucus or stool coming from the vagina
• An unpleasant smell that does not improve with washing
• Recurrent vaginal or bladder infections
• Pain during sex or a feeling of pressure in the pelvis
• Skin irritation around the vulva
Even a tiny fistula can cause significant distress — many women describe the social and emotional impact as worse than the physical symptoms. You are not alone, and effective treatment is available
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How is a rectovaginal fistula diagnosed?
History and examination
Your specialist will ask about childbirth, previous surgery, cancer treatment, bowel symptoms and the pattern of leakage. A gentle vaginal and rectal examination is performed, sometimes with a small speculum.
Bedside tests
• Tampon-and-dye test: a coloured fluid is gently placed in the rectum while a tampon sits in the vagina. Staining of the tampon confirms a connection.
• Anoscopy and proctoscopy: a short scope is used to inspect the inside of the rectum.
What investigations might I need?
• MRI of the pelvis: the most useful test — it shows the fistula tract, the relationship with anal sphincter, and any inflammation or tumour around it.
• Endoanal or transvaginal ultrasound: assesses the anal sphincter, especially after childbirth injury.
• Colonoscopy: used to look for inflammatory bowel disease or cancer.
• Examination under anaesthetic (EUA): sometimes the easiest way to map the tract is in theatre, where biopsies can also be taken if needed.
• Anorectal manometry: measures sphincter strength when continence is a concern.
How is a rectovaginal fistula treated?
Non-surgical management
Some very small, recent fistulas heal on their own. While waiting, treatment focuses on:
• Treating any infection
• Optimising stool consistency with diet and gentle laxatives
• Skin protection and pelvic floor physiotherapy
• Treating underlying conditions such as Crohn’s disease
• Smoking cessation if you are smoking - this can impact the tissue healing process
Surgical repair of fistula
Most rectovaginal fistulas require surgery. The choice of operation depends on the cause, location and tissue quality. If you are a smoker, Dr Yong strongly recommend you to quit smoking for at least 3 months before considering surgery
• Transvaginal rectovaginal fistula repair : the fistula tract is excised vaginally and repaired in layers to ensure watertight closure.
• Perineoplasty / sphincteroplasty: used when there is also damage to the anal sphincter after childbirth.
• Martius fat-pad/Singapore flap: healthy tissue from the labia is brought in to reinforce a complex repair.
• Abdominal or laparoscopic/robotic repair: reserved for high or complex fistulas — sometimes a resection of bowel is required (performed in conjunction with colorectal surgeon)
• Temporary stoma (ileostomy or colostomy): occasionally needed for radiation-related or very complex fistulas to allow healing before definitive repair.
Reported success rates range from 60–90% depending on the cause; results are best for non-radiated, non-Crohn’s fistulas.
What is recovery like after rectovaginal fistula surgery?
• Hospital stay is typically 2-3 nights for vaginal/perineal repairs, longer if a stoma or bowel resection is needed.
• A low-residue diet and stool softeners are usually recommended for several weeks.
• No intercourse, tampons or strenuous exercise for around 6–12 weeks.
• Follow-up examinations confirm the repair has healed before normal activities resume.
Disclaimer: This information is intended as a brief guide to rectovaginal fistula management. Dr Yong will be able to provide a more specific assessment and advice before making any decision on further treatment.