Rectovaginal fistulae in Crohn's disease: a management paradox

Much has been written about the management of rectovaginal fistulae in Crohn's disease (CD), but there remains little or no consensus on the optimal therapeutic approach. This retrospective case review examined treatment and clinical outcome of women presenting with rectovaginal fistula between 1985 and 1995 in an attempt to clarify treatment guidelines.

A total of 48 case notes was reviewed. Significant symptoms and signs were noted at presentation in 73% and 65% of women, respectively, and fistula classification revealed; three (6%) superficial, 36 (76%) transphincteric, six (12%) suprasphincteric and three (6%) unclassified.

Fifteen patients were initially treated conservatively, of whom 73% were eventually rendered asymptomatic and none required proctectomy. Of the remaining 33 fistulae, 12 were treated by laying open or seton insertion, 13 by local repair using transperineal proctotomy or advancement flaps, two by defunctioning alone, and six by proctectomy. Eighty-three percent of patients undergoing laying open or seton insertion, 77% following local repair and 50% following stoma were eventually rendered asymptomatic. The proctectomy rates were 42%, 15%, and 50% in these three groups, respectively.

The results of this study suggest that in the absence of significant symptoms, conservative management provides a good chance of fistula healing without need for proctectomy. However, if symptoms dictate the need for intervention, local repair provides a similar chance of success with a lower ultimate need for proctectomy than laying open or seton. Despite these broad generalities, this study highlights the difficulties we have in advising patients with proctovaginal fistulae in CD.