Congenital Recto-Vestibular Fistula and Recto-Vaginal Fistula

Recto-vestibular fistulas and recto-vaginal fistulas are types of anorectal malformations (ARMs) that affect females.

A recto-vestibular fistula is the most common anorectal malformation seen in female patients. The condition is characterized by a connection between the rectum and the vaginal vestibule, at the lower aspect of the vaginal opening. The condition can cause feces and gas to exit the vaginal vestibule.

A congenital recto-vaginal fistula is a rare type of ARM characterized by the abnormal connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula.

Symptoms

Symptoms include:

  • Feces passing from the vagina
  • Gas passing from the vagina
  • Pus passing from the vagina
  • Repeated urinary tract or vaginal infections
  • Vaginal discharge that smells bad
  • Irritation around the area

A recto-vestibular fistula is most often congenital, and the symptoms are similar to those of a recto-vaginal fistula.

Additional symptoms patients may notice include:

  • Vulvar inflammation that occurs shortly after birth
  • Feces leaking from the vaginal vestibule

Adult patients with the condition also may experience pain during sexual intercourse.


Causes and Risk Factors

Congenital recto-vaginal and recto-vestibular fistulas are both found exclusively in female patients. The cause of congenital anorectal malformations is unknown, although environmental factors such as drug use during pregnancy may play a part.

Diagnosis

When infants are born with the condition, the physical exam will include examination of the anus and vagina to make sure both are open and in the correct position.

Proper diagnosis of anorectal malformations has greatly improved with the use of diagnostic imaging tools such as magnetic resonance imaging (MRI) , which allow the medical team to view the fistula. Additionally, abdominal X-rays and abdominal ultrasounds may be done to aid in diagnosis.

Treatments

For recto-vestibular fistulas, Posterior Sagittal Anorectoplasty (PSARP) is most common treatment. To correct this malformation, PSARP may be performed in a single operation, or a multistage procedure. The first step of the multistage treatment strategy is a temporary colostomy. With a colostomy, the large intestine is redirected through an opening in the abdominal wall to allow stool and intestinal mucus to pass into a collection bag. The second stage is the posterior sagittal anorectoplasty, also known as a “pull-through” procedure, which creates the new anal opening separating the fistula from the vaginal opening. The third stage will be closure of the colostomy, once the pull-through is fully healed, so that feces exits the body through the new anus.

The goal of surgery is to separate the rectal fistula from the vaginal vestibule, thereby creating a channel for elimination of fecal waste and maintaining as much bowel control as possible. Due to the nature of both the condition and the surgery, however, bowel control still may be difficult to achieve.

Treatment for recto-vaginal fistulas includes either posterior sagittal anorectoplasty, as described above, or a minimally invasive (laparoscopic) pull-through procedure. The procedure involves disconnecting the abnormal fistula from vagina to the rectum, and then bringing the rectum down to a newly created anal opening precisely positioned within the sphincter muscle complex.

The knowledgeable staff in the Cedars-Sinai Pediatric Bowel Management Program, Pediatric Surgery Services, will work with each patient to determine the best treatment option.