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Rectovaginal Fistula – Causes, Symptoms, Treatment

Rectovaginal fistula (RVF) is defined as an epithelium-lined abnormal communication between rectum and vagina. It is reported to represent approximately 5% of all anorectal fistulas [rx]. For affected women, the passing of air and secretions or stool from the rectum through the vagina represents a psychosocial burden that, of course, increases with the diameter of the fistula. RVF can result in recurrent infections of the vagina or lower urinary tract. In terms of etiology, various types of RVF are distinguished. Principal causes are obstetric trauma or iatrogenic trauma following procedures in the perineal and pelvic region. RVF can also arise as a result of local inflammations or tumors.

Rectovaginal fistulas (RVFs) are abnormal epithelial connections between the rectum and vagina [rx], leading to the passage of rectum content into the vagina, which causes both physiological and psychological suffering to female patients. So far, RVFs remain a challenging pathological condition owing to the high failure rate of surgical repair. RVs are usually caused by congenital malformation, obstetric injury, trauma, perianal sepsis, Crohn’s disease or are iatrogenic. Spontaneous healing of a fistula is rare and surgical repair is the main treatment for RVF.

Rectovaginal fistula (RVF) is defined as an abnormal communication between the anterior wall of the rectum and the posterior wall of the vagina. It’s said to be high when it’s above the anal sphincter [^rx]. RVs are classed according to their location from the anorectal sphincter complex: ano-vaginal, recto-vaginal, and reservoir/vaginal.

Types of Rectovaginal Fistula

Classification of anal fistulas is based on anatomy, specifically about the sphincter complex. In 1976, Dr. Parks published a paper describing a classification system for anal fistulas that is still widely used today. Four types were described: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric.[7] Appropriate classification is essential for adequate treatment and conservation of the external anal sphincter to preserve fecal continence.

Intersphincteric (45%) – The fistula penetrates through the internal sphincter but spares the external sphincter.
Transphincteric (30%) – The fistula passes through both the internal and external sphincters.
Suprasphincteric (20%) – The fistula penetrates through the internal sphincter and then extends superiorly in the plane between the sphincters to pass above the external sphincter before extending to the perineum. This classification includes horseshoe abscesses.
Extrasphincteric (5%) – This fistula is very rare. It forms a connection from the rectum to the perineum that extends laterally to the internal and external sphincter. These can be the most difficult to treat due to the need to preserve the sphincter complex.

The classification of the fistula is often diagnosed during an exam under anesthesia in the setting of a simple fistula. Evaluation of complex fistulas, including recurrent disease and fistulas in the setting of perianal Crohn’s disease, may benefit from pre-operative imaging. MRI, endoanal ultrasound, epistolography, and CT are all proven to contribute to an accurate diagnosis, with MRI being the most sensitive (>90%). A combination of two imaging modalities increases the diagnostic accuracy to 100%.[rx]

Causes of Rectovaginal Fistula

RVF formation results as a complication of an underlying disease, injury, or surgical event.[rx][rx] Diseases of the vagina or the pelvic organs can be complicated with a persistent connection between the rectum and vagina. The common causes of rectovaginal fistula are[rx]:

Obstetric-related injury – This is the most common etiology of traumatic RVF, and probably for all RVs.[rx] This includes third- and fourth-degree lacerations during vaginal delivery.
Surgical procedure – Surgical interventions that cause unrecognized vaginal or rectal injury, insufficient tissue thickness between the two organs, or ischemia of the tissue may result in perforation and fistula formation through the damaged tissue.
Diverticular disease – Complex diverticular disease is a common cause of fistula connecting to an intra-abdominal organ like the bladder and vagina.[rx] Erosion of the diverticular wall with inflammation and abscess can extend, involve, and erode the adjacent organ walls resulting in a fistulous connection. An occasional increase in the luminal pressure on either side of the fistula and the continued inflammatory process will maintain the fistula patent.
Crohn’s disease – Chronic inflammatory bowel diseases, especially Crohn’s disease, is a well-known cause of intestinal fistulization.[rx] Crohn’s is a transmural disease that involves the entire thickness of the bowl, making an extension to and involvement of adjacent tissues and organs very common.
Malignancy – Cancer of the intestine or adjacent organs is a known cause of bowel perforation and fistulization. RVF can result from vaginal, cervical, or, more commonly, rectal cancer that involves the entire wall thickness and extends to the adjacent vagina. These fistulae are also called malignant fistulae.
Radiation [rx] – Radiation causes long-term chronic tissue inflammation with poor healing and repair processes. Therefore, fistulae caused by radiation manifest after a lag period from radiation exposure.
Non-surgical injuries and foreign bodies – Injuries in trauma or a foreign body can result in a non-healing abnormal connection with the vagina.
Injuries during childbirth. Delivery-related injuries are the most common cause of rectovaginal fistulas. This includes tears in the perineum that extend to the bowel, or an infection of an episiotomy — a surgical incision to enlarge the perineum during vaginal delivery. These may happen following a long, difficult, or obstructed labor. These types of fistulas may also involve injury to your anal sphincter, the rings of muscle at the end of the rectum that help you hold in stool.
Cancer or radiation treatment in your pelvic area. A cancerous tumor in your rectum, cervix, vagina, uterus, or anal canal can result in a rectovaginal fistula. Radiation therapy for cancers in these areas can also put you at risk. A fistula caused by radiation usually forms within six months to two years after treatment.
Surgery involving your vagina, perineum, rectum, or anus. Prior surgery in your lower pelvic region, such as removal of your uterus (hysterectomy), in rare cases, can lead to the development of a fistula. The fistula may develop as a result of an injury during surgery or a leak or infection that develops afterward.

There are several causes that are abbreviated in the mnemonic “FRIEND” (Foreign body, Radiation, Inflammation, Epithelization, Neoplasm, Distal obstruction). These are known causes of non-healing in fistulous diseases. They should not be mixed with the primary or underlying causes of fistula formation.

Symptoms of Rectovaginal Fistula

Depending on the fistula’s size and location, you may have minor symptoms or significant problems with continence and hygiene. Signs and symptoms of a rectovaginal fistula may include:

Passage of gas, stool, or pus from your vagina
Foul-smelling vaginal discharge
Recurrent vaginal or urinary tract infections
Irritation or pain in the vulva, vagina, and the area between your vagina and anus (perineum)
Pain during sexual intercourse

Diagnosis of Rectovaginal Fistula

A helpful, commonly used acronym for remembering the factors that make fistula formation favorable and unlikely to spontaneously regress is “FRIEND.” The acronym is remembered easily with the mnemonic “the friends of the fistula.”

F – Foreign body
R – Radiation
I – Inflammation or infection
E – Epithelialization of the fistula tract
N – Neoplasm
D – Distal obstruction

History and Physical

The clinical presentation of RVF – is a result of a combination of the passage of rectal content to the vagina and the underlying disease or injury. A detailed history of the underlying disease should be explored. Clinically, the escape of stool or gas from the rectum to the vagina through the fistula gives the abnormal signs and symptoms of foul-smell vaginal discharge, dyspareunia, passing air, bleeding, and passage of frank stool, especially when the patient has diarrhea. Further symptoms of complications like symptoms of cystitis or vaginitis are occasionally encountered. Symptoms of an underlying disease like rectal obstructing cancer or diverticulosis may be present.
Physical exam of the vagina – the source of the symptoms, will likely reveal irritation, erythema, swelling, discharge, stool, and possible fistula opening in the speculum exam. An office colposcopic exam may reveal more details of the vaginal epithelium and the fistula site as an indurated indentation. A rectovaginal examination may reveal signs of the underlying disease like an obstructing low rectal tumor or phlegmon, Crohn disease, or tissue atrophy from radiation.

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Evaluation

When RVF is suspected – a workup should be started to confirm the diagnosis, assess the extent of the fistula, and identify the underlying diagnosis. In addition to history and physical examination, workup should be complemented by imaging and endoscopy if needed.
Laboratory tests – to assess the baseline hematocrit, biochemical and infectious parameters are usually obtained. Signs of the overall disease impact, complications, and severity can be estimated from these tests. Further tests may be needed according to the initial assessment.
Endoscopy, – like colposcopy and/or proctosigmoidoscopy (rigid or preferably flexible), may reveal the site of the fistula with the underlying disease. Signs of the underlying diseases like Crohn’s, diverticular disease, or rectal cancer are likely to be identified with endoscopy. Colposcopy can help detect cervical or vaginal cancers.
Imaging – is commonly used and useful to confirm the diagnosis and identify the underlying disease. CT scan provides accurate, objective, detailed information of the fistula, the underlying disease, and the related nearby area. Rectal and intravenous contrast will outline the fistulous tract and the related structures. The presence of rectal contrast in the vagina is a confirmation of the diagnosis even if the fistulous tract itself cannot be visualized
Contrast tests – A genogram or a barium enema can help identify a fistula located in the upper rectum. These tests use a contrast material to show the vagina or the bowel on an X-ray image.
Blue dye test – This test involves placing a tampon into your vagina, then injecting blue dye into your rectum. Blue staining on the tampon indicates a fistula.
Computerized tomography (CT) scan – A CT scan of your abdomen and pelvis provides more detail than does a standard X-ray. The CT scan can help locate a fistula and determine its cause.
Magnetic resonance imaging (MRI) – This test creates images of soft tissues in your body. MRI can show the location of a fistula, whether other pelvic organs are involved or whether you have a tumor.
Anorectal ultrasound – This procedure uses sound waves to produce a video image of your anus and rectum. Your doctor inserts a narrow, wand-like instrument into your anus and rectum. This test can evaluate the structure of your anal sphincter and may show childbirth-related injury.
Anorectal manometry – This test measures the sensitivity and function of your rectum and can give information about the rectal sphincter and your ability to control stool passage. This test does not locate fistulas but may help in planning the fistula repair.
Transvaginal ultrasound – During this test, a wand-like instrument is inserted into your anus and rectum, or into your vagina. An ultrasound uses sound waves to create a picture from inside your pelvis.
Methylene enema – A tampon is inserted into your vagina. Then, a blue dye is injected into your rectum. After 15 to 20 minutes, if the tampon turns blue, you have a fistula.
Barium enema – You will get a contrast dye that helps your doctor see the fistula on an X-ray.
Computerized tomography (CT) scan – This test uses powerful X-rays to make detailed pictures inside your pelvis.
Magnetic resonance imaging (MRI) – This test uses strong magnets and radio waves to make pictures from inside your pelvis. It can show a fistula or other problems with your organs, such as a tumor.

Treatment of Rectovaginal Fistula

Medications

Your doctor may recommend a medication to help treat the fistula or prepare you for surgery:

Antibiotics. If the area around your fistula is infected, you may be given a course of antibiotics before surgery. Antibiotics may also be recommended for women with Crohn’s disease who develop a fistula.
Infliximab. Infliximab (Remicade) can help reduce inflammation and heal fistulas in women with Crohn’s disease.

Surgery

Most people need surgery to close or repair a rectovaginal fistula.

Before an operation can be done, the skin and other tissue around the fistula must be healthy, without infection or inflammation. Your doctor may recommend waiting three to six months before having surgery to ensure the surrounding tissue is healthy and see if the fistula closes on its own.

Surgery to close a fistula may be done by a gynecologic surgeon, a colorectal surgeon or both working as a team. The goal is to remove the fistula tract and close the opening by sewing together healthy tissue. Surgical options include:

Sewing an anal fistula plug or patch of biologic tissue into the fistula to allow your tissue to grow into the patch and heal the fistula.
Using a tissue graft taken from a nearby part of your body or folding a flap of healthy tissue over the fistula opening.
Repairing the anal sphincter muscles if they’ve been damaged by the fistula or by scarring or tissue damage from radiation or Crohn’s disease.
Performing a colostomy before repairing a fistula in complex or recurrent cases to divert stool through an opening in your abdomen instead of through your rectum. Most of the time, this surgery isn’t needed. But you may need this if you’ve had tissue damage or scarring from previous surgery or radiation treatment, an ongoing infection or significant fecal contamination, a cancerous tumor, or an abscess. If a colostomy is needed, your surgeon may wait eight to 12 weeks before repairing the fistula. Usually, after about three to six months and confirmation that your fistula has healed, the colostomy can be reversed and normal bowel function restored.

Surgical treatment of RVF was performed by a urologist surgeon having more than 30 years of experience, particularly in vesicovaginal fistula repair by Falandry and Martius techniques. The mean follow-up duration was 12.6 months.

Martius technique

Under spinal or general anesthesia, the patient is placed in the modified lithotomy position. Vaginal valves allow endo-vaginal exposure. Saline or better Xylocaine with epinephrine may be injected in the rectovaginal septum to facilitate dissection and hemostasis. Vaginal excision starts with excision of the vaginal fistula orifice and continues obliquely down and to the left without injury to the anal sphincter. The anteroposterior incision is made on the relief of the left labia majora.

Then, the rectovaginal septum is dissected from both sides over a width of about 4 cm to facilitate the passage of the labial adipose flap. After abrasion of the intra-rectal fistula orifice, the rectal wall is repaired transversely using absorbable 4-0 PDS sutures. From the labial incision, subcutaneous dissection is performed to create a sufficiently wide tunnel between the two incisions. The labial adipose flap is passed through the created tunnel to cover the front rectal mucosa.

Several separate absorbable 4-0 PDS sutures allow keeping in place the adipose flap. Careful hemostasis is done. Finally, the vaginal mucosa is closed using 3-0 PDS, and the wound using a nonabsorbable 3-0 separate suture with a Redon drain placed in the tunnel and adipose harvest site.

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Falandry technique

This intervention is conducted under spinal or general anesthesia and involves taking a skin flap from the inner side of the left labium majus which will be inserted in the rectovaginal. The incision isolates a labial skin flap of 4–5 cm long and 1.5–2 cm wide with a sufficiently long meso so as to reach the vaginal cavity without tension [rx, rx]. The time of exposure of the fistula and the creation of a subcutaneous tunnel between the labial and vaginal incisions are similar to those described above in the previous technique. The skin graft is mobilized beside the fistula by the subcutaneous tunnel and then attached to the rectal mucosa with an absorbable separate 4-0 PDS suture [rx]. Vaginal mucosa and labial skin closured is done after careful hemostasis.

Treatment According To Location

The treatment of an anal fistula depends on the location of the fistula as well as precipitating factors. Most fistulas are treated surgically, through a variety of different procedures depending on external and internal sphincter involvement. Complex fistulas, particularly those caused by Crohn’s disease, are treated medically. The most common options will be discussed in detail.

Fistulotomy – Fistulotomy entails opening the fistula tract and possibly dividing the sphincter muscle. This surgical treatment is very effective for simple fistulas with minimal sphincter involvement resulting in healing in 90% of properly selected patients.[rx] Marsupialization of the fistulotomy edges has proven to decrease bleeding and improve post-operative pain control.[rx]
Endorectal advancement flap – This procedure is technically more challenging than fistulotomy. The endorectal advancement flap procedure involves closure of the internal opening of the tract, debridement of the tract, and mobilization of anorectal mucosa to cover the defect. The sphincter is not divided during this procedure but can be compromised during the flap with reports of incontinence up to 35%.[rx] The results of healing vary significantly between studies but are reported between 66% to 87%.[rx][rx] Failure is associated with Crohn’s disease, malignancies, and a history of previous repair attempts.[rx][rx]
Seton placement – Seton drain placement is often reserved for complex fistulas and used in a two-stage technique. Initial placement is used to gain source control, while the second stage often includes fistulotomy. Setons can be classified as ‘draining’ or ‘cutting.’ A draining seton is placed through the fistula tract and tied loosely in place to maintain long term drainage. Many materials can be used, including vessel loops, sutures, or newly available drain devices. A cutting seton is tied tightly around the fistula tract to slowly divide the sphincter complex as it can be tightened over time. This allows for the slow division of the sphincter with a decreased risk of incontinence. A completion fistulotomy would then be performed. This two-staged technique will allow for complete healing of the fistula in 94% of patients.[rx] The rate of fecal incontinence following seton placement varies but has been documented as high as 12%.[rx]
LIFT – The ligation of intersphincteric fistula tract (LIFT) procedure can be used for the treatment of simple and complex fistulas with an average success rate of 71%.[rx] The procedure involves the identification of the internal opening with suture ligation of the intersphincteric portion of the fistula. The tract and infected gland are then excised and the wound debrided with curettage. No portion of the external sphincter is divided, so fecal incontinence is rare. The LIFT procedure can be performed following seton placement as part of a two-stage technique.[rx]
Fibrin plug and glue – A fibrin plug is a treatment option that involves a collagen matrix used to block or plug the internal opening of the fistula tract. The treatment is appealing as it does not involve dissection or division of the sphincter complex and therefore, should not contribute to incontinence. Unfortunately, the treatment is less than 50% successful in the treatment of fistula-in-ano.[rx] Similarly, fibrin glue has also been trialed to promote the healing of fistula tracts. This also preserves sphincter function but has low success rates varying from 14% to 69%.[rx][rx] Both have been initially discarded as ineffective, but more recent studies have involved a combination of surgical fistula treatment in combination with fibrin plugs and fibrin glue, which may develop into a viable treatment option following more research.[rx]
Medical management – Antibiotics are often unnecessary in the setting of an uncomplicated and drained rectal abscess. Instead, antibiotics are reserved for immunocompromised patients, those with systemic signs of illness and the presence of cellulitis at the abscess. HIV patients may benefit from wound cultures and antibiotics.[rx] Medical management should also be considered in Crohn patients. Infliximab, a TNFa monoclonal antibody, has demonstrated a fistula closure rate of 36% following 54 weeks of treatment.[rx] If medical treatment is unsuccessful, a staged fistulotomy may be necessary.

Surgical procedures

The treatment of rectovaginal fistulas presents a special surgical challenge. The majority of the fistulas are high transsphincteric to extrasphincteric, so that division alone is generally inadequate.

The results for the surgical treatment of rectovaginal fistula have been compiled in evidence tables that are published with the complete German text [rx]. Most studies report on a mixed patient group, and the respective data are not always analyzed separately. Breakdown by surgical techniques and different etiologies often results in small patient groups that are therefore only considered case reports.

Endorectal closure – The endorectal closure technique essentially corresponds to the flap technique in high anal fistulas [rx], [rx]. The more recent studies paint a differentiated picture, with healing rates ranging from 41% to 100%. Realistic success rates are probably between 50% and 70%. The various etiologies are generally not differentiated, but it is likely that the results are much better for postpartum fistulas in younger women than for radiogenic fistulas in older patients. In some studies, simultaneous anal sphincter reconstruction is performed, so that no sharp distinction can be drawn to transperineal procedures. The two studies that compare the results with and without anal sphincter reconstruction reveal a trend toward better results for reconstruction [rx], [rx]. No relevant information is available on secondary recurrence and influence on continence.
Transvaginal closure – Very few publications are available on the transvaginal approach. Among the 11 identified publications, seven are case reports. Two papers [rx], [rx] use case reports describing a combined laparoscopic-transvaginal procedure in higher rectovaginal fistulas. In summary, no recommendations can be made regarding this procedure on the basis of currently available literature.
Transperineal closure – Another treatment option is the transperineal approach, where the rectum is first separated from the vagina via a perineal incision. Following the separate adaptation of the mucosa, sphincter, and vaginal mucosa, the rectovaginal septum is augmented through the adaptation of the levator muscle. Especially in patients with postpartum sphincter lesions, sphincteroplasty can be performed in the same session [rx], [rx]. Herein lies the key advantage of this procedure [rx]. This illustrates the relevance of preoperative examination with respect to incontinence and sphincter lesions. In the case of corresponding abnormalities, simultaneous anal sphincter reconstruction is recommended [rx]. A disadvantage of this procedure is the relatively extensive surgical trauma (perineal wound) with the risk of impaired wound healing. The results of the few larger retrospective studies do not allow definitive conclusions to be drawn.
Martius procedure – The Martius procedure uses a pedicled flap of adipose tissue from the labia majora [rx]. The interposition of well-vascularized tissue is intended to separate and protect the vaginal from the rectal sutures. A special technique consists of the interposition of the bulbocavernosus muscle [rx]. Overall, the Martius flap operation is a rare procedure. We were able to analyze 14 papers, some of which were case studies. The procedure is primarily used in case of recurrences. High cure rates are reported in selected patient groups.
Gracilis interposition – Augmentation of the rectovaginal septum can also be achieved by unilateral or bilateral interposition of the gracilis muscle A special technique consists of the interposition of the bulbocavernosus muscle [rx]. In general, gracilis interposition is much more complex and invasive than the Martius flap operation. The goal of the procedure is to strengthen the rectovaginal septum by interposing the well-vascularized muscle following direct closure of the corresponding fistula orifices. Like Martius-procedure the gracious interposition is primarily used in case of recurrences. High cure rates are reported in selected patient groups [rx], especially in patients with Crohn’s disease.
Miscellaneous procedures – The so-called sleeve anastomosis is a special and highly invasive procedure. It is based on mobilization and resection of the distal rectum. Reanastomosis, usually via a transanal manual suture, is performed following removal of the fistula-bearing or destroyed area. The procedure is primarily used in patients with significant rectal wall defects due to chronic inflammatory bowel disease or following radiation therapy. Another procedure consisted in treatment with autologous stem cells [rx]. The successful treatment of rectovaginal fistula using a circular stapler is another special treat, which has only been published in one case report [rx].
The interposition of biomaterials – Treatment results using fibrin adhesive, fistula plug, or biomembrane have also only been published in the form of case reports, and highly divergent success rates of between 0% and 100% are reported. For the purpose of this guideline, the value of biomaterials, which are increasingly used, cannot be assessed at this point in time.
Abdominal techniques – Higher fistulas can also be treated by resection of the affected part of the intestine with primary rectal anastomosis using conventional [rx] or laparoscopic techniques [rx]. It is difficult to differentiate this technique from the treatment of colovaginal fistulas in cases of diverticular disease. Only one publication reports on a larger patient group [rx], with cure rates of nearly 100% in various etiologies.

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Perioperative management

Wound management and perioperative complications

Complications following rectovaginal fistula surgery are generally similar to those following other anal procedures [rx]. Plastic reconstruction of fistulas is associated with a risk of local infection with secondary suture dehiscence. In most cases, suture dehiscence is associated with the persistence of the fistula.
Relevant postoperative complications include dyspareunia resulting from vaginal stenosis or scar formation [rx]. It is reported to arise in up to 25% of sexually active patients [rx], [rx].

Postoperative return to a normal diet

The follow-up treatment after complex anal procedures is subject to the ongoing controversy. There is general consensus that avoiding the passage of stool through the fresh wound benefits the healing process. This particularly applies to avoiding strong pressing, especially after sphincter sutures. No definitive studies on this topic are currently available. The same is true for the role of perioperative and/or postoperative antibiotic prophylaxis.

Ostomy

While ostomy is rarely required in the context of anal fistula surgery [78], the rate is much higher in rectovaginal fistulas, although no relevant studies are currently available. Ostomy is primarily indicated in case of extensive destruction of the anal canal with resulting fecal incontinence.
In general, the decision must be made on the basis of the local and individual situation. Depending on the etiology (esp. rectal resection), a stoma may already be in place in some of the patients as a result of the primary surgery. In all other cases, the decision on secondary stoma creation must be made on an individual basis. The personal physical and psychological burden on the patient resulting from the local inflammation and the extent of secretion through the fistula is an important consideration in the decision process. Particularly in case of postoperative dehiscence, a major burden can result, for instance, due to enlargement of the defect following fistula excision.

Continence

Please refer to the anal fistula guideline [rx], [rx] regarding the role of incontinence. The premises described in that guideline also apply to anovaginal and rectovaginal fistulas. Rectovaginal fistulas regularly involve the entire sphincter apparatus, so that pure division is always associated with relevant incontinence. Simultaneously, there is a risk of the formation of a cloaca. Incontinence resulting from the treatment of rectovaginal fistula plays a subordinate role in the literature since “healing” is the primary focus. The simultaneous reconstruction of sphincter lesions can improve continence.

Lifestyle and home remedies

Good hygiene can help ease discomfort and reduce the chance of vaginal or urinary tract infections while waiting for repair. Other home remedies for people living with a rectovaginal fistula include:

Wash with water – Shower or gently wash your outer genital area with just warm water each time you experience vaginal discharge or passage of stool.
Avoid irritants – Soap can dry and irritate your skin, but you may need a gentle unscented soap in moderation. Avoid harsh or scented soap and scented tampons and pads. Vaginal douches can increase your chance of infection.
Dry thoroughly – Allow the area to air-dry after washing, or gently pat the area dry with a clean cloth or towel.
Avoid rubbing with dry toilet paper – Pre-moistened, alcohol-free, unscented towelettes or wipes or moistened cotton balls are a good alternative.
Apply a cream or powder – Moisture-barrier creams protect irritated skin from liquid or stool. Nonmedicated talcum powder or cornstarch also may help relieve discomfort. Ask your doctor to recommend a product. Be sure the area is clean and dry before you apply any cream or powder.
Wear cotton underwear and loose clothing – Tight clothing can restrict airflow and worsen skin problems. Change soiled underwear quickly. Products such as absorbent pads, disposable underwear or adult diapers can help if you’re passing liquid or stool, but be sure they have an absorbent wicking layer on top.

References

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Rectovaginal Fistula – Causes, Symptoms, Treatment

Rectovaginal Fistula – Causes, Symptoms, Treatment

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