Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas

Figures & data

Table 1 Classification of Rectovaginal Fistulas

Fistula	Rectovaginal-II (Low RVF)	Rectovaginal-I (High RVF)
Definition	Fistula connecting anus and vagina or vicinity of vagina	Fistula connecting rectum and vagina
Primary difference	Does NOT pass through or involve the rectovaginal septum but involves anal sphincter	Pass through or involve rectovaginal septum.
Length of the tract	Variable (can be long or short) but longer than RVF	Very short (width of the rectovaginal septum, which is approximately 2–4mm)
Opening in anorectum	Mostly anterior midline, but can open anywhere, including posterior midline.	Anterior Midline
Opening in vagina	Any place in and around the vagina, may open in the posterior midline, lateral wall, introitus, near introitus,	Posterior Midline
Causes	Perianal abscess rupturing inside anus and vagina (near vagina) Bartholin cyst inadvertently drained through the anus Others	Injury to the rectovaginal septum during difficult labor (delivery) Other
Management	Like anal fistulas (fistulotomy in low fistulas and sphincter-sparing procedure in high fistulas)	Like conventional rectovaginal fistulas
Prognosis	High healing rates>90% if treated like anal fistulas	High morbidity, notorious for surgical management (healing rate: 41–78%).

Figure 1 The schematic diagram of the female pelvis (sagittal section) showing the rectovaginal septum (yellow dotted line), type-I rectovaginal fistula (involving rectovaginal septum) (blue color), and type-II rectovaginal fistula (not involving rectovaginal septum) (red color).

Table 2 Garg Incontinence Scoring (GIS) system

Incontinence type	Weight	Frequency			Maximum score
		Never (points)	Occasional (points) (≤ 1 episode/ wk)	Common (points) (> 1 episode/ wk)
Solid	8	0	1	2	16
Liquid	8	0	1	2	16
Urge	7	0	1	2	14
Flatus	6	0	1	2	12
Mucus	6	0	1	2	12
Stress	5	0	1	2	10
TOTAL					80

Notes: Reprinted from Garg P, Sudol-Szopinska I, Kolodziejczak M, Bhattacharya K, Kaur G. New objective scoring system to clinically assess fecal incontinence. World J Gastroenterol. 2023;29(29):4593–4603. Creative Commons.¹¹ Score in a cell = Weight for that incontinence type × frequency points. For example, a person with occasional liquid incontinence would have an 8×1 = 8 score. Maximum possible score = 80 (total incontinence), minimum score possible = 0 (no incontinence).

Figure 2 The graph of preoperative and postoperative anal manometry in a 25-year-old female patient who underwent fistulotomy for rectovaginal fistula with no rectovaginal septum involvement (RVF-II) fistula.

Table 3 Demography and Fistula Characteristics

Parameter	N=27
Age	35.2± 9.2
Recurrent fistula	11 (40.7%)
Associated abscess	8 (29.6%)
Multiple tracts	23 (85.2%)
Horseshoe tracts	13 (48.2%)
Anterior	25 (92.6%)
Posterior	2 (7.4%)
Involving <1/3 of External Anal Sphincter (Underwent Fistulotomy)	19
Involving >1/3 of the External Anal Sphincter (Underwent a sphincter-saving procedure-TROPIS)	8
Fistula healed	22/24 (91.7%)
Not healed	2/ 24 (8.3%)

Abbreviation: TROPIS, Transanal opening of intersphincteric space.

Figure 3 A 33-year old female patient with anterior horseshoe, anterior anal fistula and a RVF-II fistula. She underwent a fistulotomy. Upper panel: Schematic diagram of coronal (left side) and axial sections (right side). Middle panel: Preoperative magnetic resonance imaging - Axial sections: T2 weighted (left side) and Short Tau Inversion Recovery (STIR) (right side) (yellow arrows showing fistula tract). Lower panel: Postoperative magnetic resonance imaging- 3 months after surgery - Axial sections: T2 weighted (left side) and Short Tau Inversion Recovery (STIR) (right side showing the complete healing of the fistula.

Figure 4 A 36-year old female patient with posterior horseshoe anal fistula and an RVF-II fistula opening in the left posterior vagina. She underwent the TROPIS procedure. Upper panel: Schematic diagram of coronal (left side) and axial sections (right side). Middle panel: Preoperative magnetic resonance imaging - Axial sections: T2 weighted (left side) and Short Tau Inversion Recovery (STIR) (right side) (yellow arrows showing fistula tract, green arrows showing fistula tract opening into vagina). Lower panel: Postoperative magnetic resonance imaging- 2 months after surgery - Axial sections: T2 weighted (left side) and Short Tau Inversion Recovery (STIR) (right side showing the complete healing of the fistula.

Table 4 Change in Objective Incontinence Scores (Garg Incontinence Scores) After Surgery

Type of Incontinence	Number of Patients		Significance (p-value)
	Pre-Operative	Postoperative
Urge (n)	2	5	Not significant (p=0.065) (Fisher exact test)
Flatus (n)	1	3
Mucous (n)	0	0
Stress (n)	0	0
Liquid (n)	0	0
Solid (n)	0	0
Mean Incontinence scores	1.05 ± 3.30	3.11 ± 4.55	Not significant (p=0.0604) (Student’s t-test)

Table 5 Change in Anal Manometry After Surgery

Parameter	Pre-Operative	Postoperative	Significance (p-value)
RESTING anal pressure (Mean)	25.6 ± 14.5	30.8 ± 17.2	Not significant (p=0.53)
Peak SQUEEZE anal pressure (Mean)	64.6 ± 32.9	65.3 ± 37.9	Not significant (p=0.11)
Peak COUGH anal pressure (Mean)	63.6 ± 38.1	63.0 ± 29.7	Not significant (p=0.95)

Garg P, Sudol-Szopinska I, Kolodziejczak M, Bhattacharya K, Kaur G. New objective scoring system to clinically assess fecal incontinence. World J Gastroenterol. 2023;29(29):4593–4603. doi:10.3748/wjg.v29.i29.4593

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