Management of Rectovaginal and Vesicovaginal Fistulae

Initial Assessment and Etiology Determination

The American Gastroenterological Association recommends performing proctosigmoidoscopy to assess rectosigmoid inflammation in suspected IBD-related fistulae, as active inflammation dramatically affects surgical outcomes 4, 5
Obtain pelvic MRI to define fistula anatomy and identify associated abscesses or collections, as recommended by the European Society of Gastrointestinal Endoscopy 1
Rule out malignancy before any treatment, as malignant fistulae require oncologic resection, never local repair, and anti-TNF therapy is contraindicated, according to the National Comprehensive Cancer Network 6

The European Crohn’s and Colitis Organisation recommends never initiating anti-TNF therapy before draining abscesses, as this increases mortality 1, 6, 7
Treat intra-abdominal or pelvic abscesses with IV antibiotics plus radiological drainage, as suggested by the Infectious Diseases Society of America 1

The American Gastroenterological Association recommends initiating combination therapy with infliximab plus an immunosuppressor (azathioprine, 6-mercaptopurine, or methotrexate) as first-line treatment for enterovaginal and enterovesical fistulae in Crohn's disease 1, 6
Medical therapy achieves complete response in 65.9% of enterovesical fistulae, making it the appropriate initial approach, according to the Crohn’s and Colitis Foundation 6

Surgery is indicated when bowel obstruction, ureteral obstruction, or recurrent urinary tract infections develop, as recommended by the Society of Surgical Oncology 6
Surgical repair should only occur after achieving endoscopic mucosal healing of the rectosigmoid colon, according to the European Society of Gastrointestinal Endoscopy 6

The American Society of Colon and Rectal Surgeons recommends that surgical treatment should only be attempted in the absence of active rectosigmoid inflammation 4, 5
Never perform fistulotomy for rectovaginal fistulae due to sphincter injury risk, as suggested by the International Continence Society 4, 5
Infliximab achieved 45% closure at week 14 in clinical trials for IBD-related RVF, according to the National Institute of Diabetes and Digestive and Kidney Diseases 1

Do not perform local repair procedures on malignant fistulae, as these are contraindicated and will fail; oncologic resection is required, according to the National Comprehensive Cancer Network 6
Do not discontinue immunosuppressors after achieving closure with infliximab, as maintenance combination therapy is essential to prevent recurrence, as recommended by the Crohn’s and Colitis Foundation 6
Do not initiate anti-TNF therapy without first excluding and draining abscesses, as this worsens sepsis, according to the Infectious Diseases Society of America 1, 6, 7
Do not attempt surgical repair of IBD-related fistulae with active rectal inflammation, as wait for mucosal healing is necessary, as suggested by the European Society of Gastrointestinal Endoscopy 4, 5, 6