Colovaginal Fistulas: Presentation, Evaluation, and Management.

Objective: The objective of this study was to review a single institution's experience with colovaginal fistulas to provide guidance toward identification and management of this problem.

Methods: Patients with colovaginal fistulas treated by 2 senior surgeons between January 1, 1990, and June 31, 2011, were identified. A retrospective chart review was then performed to determine presenting characteristics and history, evaluation for the fistulas, and treatment outcomes.

Results: Nineteen patients were identified. The mean age was 63.5 years and median parity of 2. 37% complained of flatus per vagina, 89% reported stool per vagina, and 68% noted vaginal discharge. Ninety-five percent had previously undergone hysterectomy. The fistulas were identified at the left vaginal apex in 90% of the subjects. Self-reported history and/or operative findings suggested diverticulitis as the most common etiology (79% of the subjects). All subjects underwent sigmoid resection with primary anastomosis, with complete symptom resolution in 84%.

Conclusions: Patients with colovaginal fistulas commonly present for primary evaluation by gynecologists. A triad of symptoms and history should trigger a high index of suspicion for colovaginal fistulas: (1) complaints of stool or flatus per vagina or foul-smelling vaginitis resistant to treatment, (2) previous hysterectomy, and (3) history of diverticulitis. The fistulas can often be visualized on speculum examination at the left vaginal apex. Rolling the patient from left to right lateral decubitus positions during a contrast enema study can improve its sensitivity. Repair of colovaginal fistulas via rectosigmoid resection and primary reanastomosis is safe and effective. We recommend multidisciplinary management involving colorectal surgery and gynecology.