Management of Rectovaginal Fistulas

Initial Evaluation and Management

Imaging studies, such as MRI or endoanal ultrasound, are recommended to define fistula anatomy and identify any associated abscesses, as suggested by the European Society of Coloproctology 1
Examination under anesthesia (EUA) is mandatory for complex fistulas to assess the tract, identify internal openings, and drain any sepsis, according to the European Society of Coloproctology 1
Endoscopy is recommended to evaluate for underlying inflammatory bowel disease, particularly Crohn's disease, as suggested by the American Gastroenterological Association 2
Control of sepsis is essential, and drainage of any associated abscess is the first priority, followed by placement of a loose, non-cutting seton for complex fistulas to establish drainage and prevent recurrent abscess formation, as recommended by the European Society of Coloproctology 1
Active rectal inflammation should be treated medically before attempting surgical repair, according to the American Gastroenterological Association 2 and the European Society of Coloproctology 1

Rectal inflammation should be controlled medically before attempting definitive surgical repair, as recommended by the American Gastroenterological Association 2 and the European Society of Coloproctology 1
Asymptomatic low anal-introital fistulae do not require surgical treatment, as suggested by the European Society of Coloproctology 1
Symptomatic fistulas generally require intervention, according to the European Society of Coloproctology 1
Fistulotomy should be avoided for rectovaginal fistulas due to high risk of sphincter injury, as recommended by the American Gastroenterological Association 2

Definitive surgical repair should be delayed until all sepsis has been drained, any active inflammation has been controlled medically, and the patient's nutritional status is optimized, as recommended by the European Society of Coloproctology 1
Premature surgical repair leads to high failure rates, according to the American Gastroenterological Association 2
The initial medical treatment for enterovesical fistulas includes antibiotics (ciprofloxacin 500 mg twice a day) and anti-TNF therapy (infliximab) in combination with immunomodulators (azathioprine or 6-mercaptopurine), reserving surgery for refractory cases or those with associated complications, as recommended by the European Crohn’s and Colitis Organisation 3

Ciprofloxacin should be administered at a dose of 500 mg orally twice a day for 7-14 days 4
Metronidazol can be used as an alternative or in combination with ciprofloxacin at a dose of 400 mg three times a day 5
Azathioprine should be administered at a dose of 1.5-2.5 mg/kg/day, with a complete response in 13% and partial response in 24% of cases 3
6-Mercaptopurina can be used as an alternative at a dose of 0.75-1.5 mg/kg/day 3, 5
Infliximab should be administered as an induction regimen of 5 mg/kg at weeks 0, 2, and 6, followed by maintenance every 8 weeks, with a complete response in 17% and partial response in 30% of cases 3, 5, 2
Medical treatment can achieve complete closure of the fistula in 65.9% of cases of enterovesical fistulas, and approximately 35.1% of patients can avoid surgery in the long term with adequate medical treatment 3

The European Crohn’s and Colitis Organisation recommends a step-up approach to the management of enterovesical fistulas, starting with medical therapy and reserving surgery for refractory cases or those with associated complications 3
Antibiotics alone have limited long-term benefit and should be considered as adjunctive therapy 3
Immunomodulator therapy has a slow onset of action and is more useful for maintaining fistula closure than for initial reduction 2
Infliximab has been shown to be effective in controlled trials for reducing the number of draining fistulas and maintaining that reduction 2
Surgery is likely to be necessary in cases of sigmoidovesical fistulas or those with associated complications such as intestinal obstruction, abscess formation, or ureteral obstruction 3
The treatment of enterovesical fistulas should be individualized and discussed in multidisciplinary meetings 3