S3-Leitlinie: Rektovaginale Fisteln (ohne M. Crohn). AWMF-registriernummer: 088/004

Abstract

Rectovaginal fistulas represent a rare condition and most have a traumatic origin. The most important causes are childbirth trauma, local infections and interventions concerning the rectum. Rectovaginal fistulas due to chronic inflammatory intestinal diseases will not be dealt with in these guidelines.The diagnosis of rectovaginal fistula is made from the clinical history and examination. Other pathological alterations should be excluded by additional examinations (e.g. endoscopy, endosonography and multislice imaging). An assessment of sphincter function is recommended for planning the operative approach (question of simultaneous sphincter reconstruction).A persistent rectovaginal fistula can as a rule only be successfully treated by surgery. A variety of surgical approaches with low evidence level have been described. The most common is the transrectal approach with endorectal suture. Transperineal access is the first choice for simultaneous sphincter reconstruction. Recurrent fistulas can be closed by the interpositioning of autologous tissue (Martius flaps, gracilis muscle transposition). In recent studies closure has also been presented with the inclusion of biomaterials. For fistulas in a more distal position abdominal procedures can also be applied.Placement of a stoma is more often necessary for rectovaginal fistulas than for anal fistulas. Depending on the etiology (in particular rectum resection) a stoma will already have been placed during the primary operation in some patients. The indications for stoma placement should principally be based on the extent of the local defect and the resulting strain on the individual woman affected. Due to the low evidence level these guidelines can only have a descriptive character. Recommendations for diagnostics and treatment are predominantly based on the clinical experiences of members of the guideline group and cannot be completely covered by the available literature. © 2012 Springer-Verlag.