What are the guideline sources, guidelines and references for Rectovaginal fistula ?
Guideline sources The following summarized guidelines for the evaluation and management of rectovaginal fistula are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2022), the American College of Radiology (ACR 2021), the British Society of Gastroenterology (BSG 2019), the American College of Gastroenterology (ACG 2018), and the Association of Gynecologists in Germany (BVF/BCD/DGAV/DDG/DGVS/DGGG/BDC/DGU/DGK/AGUB/CACP 2012). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Etiology: Recognize that the majority of rectovaginal fistulas are caused by obstetric trauma (postpartum rectovaginal fistula), and other less common causes include chronic IBD (particularly Crohn's disease), low anterior rectal resection, hemorrhoid or pelvic floor surgery, particularly when using staplers or foreign materials, local infections, particularly cryptoglandular infections and Bartholin gland abscesses, foreign body erosion. Recognize that preoperative and postoperative radiochemotherapies are risk factors for the development of postoperative fistulas. https://web.pathway.md/diseases/rec9N6wwyqmiVbFJC 1/3 6/24/23, 2:57 PM Rectovaginal fistula Pathway 2. Classification and risk stratification Classification: recognize that there is no generally accepted classification of rectovaginal fistulas. E Show 2 more 3. Diagnostic investigations Clinical assessment: Elicit patient history and perform clinical examination for the diagnosis of rectovaginal fistula. Recognize that patients typically report air, mucus, and possibly stool discharge through the vagina. E Assess for any perineal defects for treatment planning. E Evaluation of anal sphincter: Assess sphincter function in a clinical examination (digital exam, possibly incontinence score) and consider obtaining manometry and EUS for surgical planning of patients with rectovaginal fistulas. E Assess for fecal incontinence and anal sphincter lesions in patients with postpartum rectovaginal fistulas. B Diagnostic imaging: As per ACR 2021 guidelines, consider obtaining pelvic MRI without and with IV contrast or pelvic CT with IV contrast as the initial imaging in patients with suspected rectovaginal fistula. C As per DGAV 2012 guidelines, consider obtaining the following additional investigations before surgical intervention, especially in case of unclear findings: colonoscopy and pelvic CT or MRI - to rule out accompanying pathologies (especially malignancies) EUS - to help confirming sphincter lesions. E 4. Medical management Non-operative management: As per ASCRS 2022 guidelines, offering nonoperative management for the initial care of patients with obstetrical rectovaginal fistula, and consider offering in patients with other benign and minimally symptomatic fistulas. B As per BSG 2019 guidelines, manage patients with IBD and enterovaginal fistula jointly with medical control of inflammation and surgical resection. B As per ACG 2018 guidelines, consider initiating infliximab in patients with Crohn's disease and rectovaginal fistula. B https://web.pathway.md/diseases/rec9N6wwyqmiVbFJC 2/3 6/24/23, 2:57 PM Rectovaginal fistula Pathway 5. Surgical interventions Endorectal repair: perform endorectal advancement flap repair, with or without sphincteroplasty, as the procedure of choice in most patients with rectovaginal fistulas. B Transperineal repair: consider performing episioproctotomy to repair obstetrical or cryptoglandular rectovaginal fistulas in patients with anal sphincter defects. B Transabdominal repair: Consider performing transabdominal repair for the treatment of patients with rectovaginal fistulas resulting from colorectal anastomotic complications. B Consider performing completion proctectomy with or without colonic pull-through or coloanal anastomosis for the treatment of radiation-related or recurrent complex rectovaginal fistula. C Tissue interposition: consider performing gracilis muscle or bulbocavernosus (Martius) flap repair in patients with recurrent or otherwise complex rectovaginal fistula. B Seton placement: consider placing a draining seton to facilitate resolution of acute inflammation or infection associated with rectovaginal fistulas. B References 1. Wolfgang B Gaertner, Pamela L Burgess, Jennifer S Davids et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1;65 8 964 985. Open 2. Andreas Ommer, Alexander Herold, Eugen Berg et al. German S3 Guideline: rectovaginal fistula. Ger Med Sci. 2012;10 Doc15. Open 3. Expert Panel on Gastrointestinal Imaging: Angela D. Levy, MD, Peter S. Liu et al. ACR Appropriateness Criteria Anorectal Disease. ACR. 2021. Open 4. Lamb CA, Kennedy NA, Raine T et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec;68 Suppl 3):s1-s106. Open 5. Lichtenstein GR, Loftus EV, Isaacs KL et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018 Apr;113 4 481 517. Open 6. Vogel JD, Johnson EK, Morris AM et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec;59 12 1117 1133. Open https://web.pathway.md/diseases/rec9N6wwyqmiVbFJC 3/3