A rectovaginal fistula is an abnormal passage between the rectum and the vagina. Because of this connection, gas, stool, or infected discharge may pass through the vagina. The condition can be physically distressing and also socially and psychologically burdensome. Although many patients delay seeking care because the symptoms feel embarrassing, early evaluation is important both to identify the cause and to plan appropriate treatment. ^[1][3]

A rectovaginal fistula is often not a disease in isolation but the result of another underlying process. Severe childbirth tears, Crohn disease, pelvic surgery, radiation therapy, infections, and pelvic cancers can all lead to fistula formation. For that reason, treatment is not just about “closing the tract”; it also involves understanding why it developed in the first place. ^[1][2][3]

What are the symptoms?

The most characteristic symptom is passage of gas or stool through the vagina. In some patients the leakage is intermittent and small in amount; in others, vaginal contamination with stool, foul odor, irritation, and hygiene difficulty are much more prominent. The size and location of the fistula can directly influence symptom severity. ^[1][2]

Recurrent vaginal infections, urinary tract infections, perineal irritation, pain during intercourse, and a persistent wet sensation may also occur. Some people additionally have fecal incontinence related to associated anal sphincter injury. In other words, the clinical picture is not limited to vaginal discharge alone; bowel control and pelvic floor function matter as well. ^[1][2]

What causes it?

Birth trauma is one of the best-known causes. Third- and fourth-degree perineal tears, difficult delivery, forceps or vacuum-assisted birth, and infected suture lines all raise risk. If anal sphincter injury is also present, the chance of both fistula and loss of bowel control becomes higher. ^[1][3]

Inflammatory bowel disease—especially Crohn disease—is another major cause. In Crohn disease, deep intestinal inflammation and ulceration can lead to fistula formation. In such cases surgery alone may not be enough; control of the underlying inflammation is essential for healing. ^[1][2]

Pelvic radiation, cancers, and pelvic operations can also lead to fistulas. Radiation may impair blood supply and tissue repair, sometimes resulting in fistula formation months or even years later. Surgical tissue injury, anastomotic leakage, or postoperative infection may create similar risk. ^[1][2]

How is it diagnosed?

Diagnosis begins with a careful history and pelvic examination. The clinician asks when the symptoms started, how much stool or gas leakage occurs, whether there was childbirth trauma, prior surgery, inflammatory bowel disease, or radiation exposure. Pelvic and rectal examination help determine the likely location of the fistula and the condition of surrounding tissues, although not every fistula is obvious on routine examination. ^[2][3]

When the diagnosis is not clear on exam, dye tests, endoscopic evaluation, or imaging may be used. In some patients, a more detailed assessment under anesthesia is needed. This can be especially valuable in small or complex fistulas because it helps define the entire tract, detect associated infection, and guide surgical planning. ^[2][3]

How is it treated?

Treatment depends on the cause, size, location, tissue health, and any associated disease. Some small fistulas may close after infection and inflammation are brought under control, but many require surgical repair. In general, it is better to plan treatment when the tissues are in the best possible condition for healing rather than operating too early in an inflamed field. ^[1][2]

Before surgery, management may include treating infection, reducing inflammation, and providing temporary drainage if needed. In patients with Crohn disease, failure to control active inflammation before intervention can increase the risk of recurrence. Multidisciplinary planning involving gastroenterology, gynecology, and colorectal surgery may therefore be necessary. ^[2][3]

Repair may involve removing the fistula tract, closing healthy tissue layers separately, and sometimes using flaps or grafts. In more complex cases, a temporary colostomy may be considered to divert stool away from the repair site and allow healing. ^[2][3]

When should you seek care?

High fever, severe pelvic pain, foul heavy discharge, sudden worsening of leakage, new abdominal pain, or concern about breakdown after surgery all warrant medical attention without delay. In the postpartum period, waiting with a “maybe it will pass” mindset may be unsafe. ^[1][2]

Management is highly individualized; there is no single operation or single drug plan that suits every patient. The safest course is to seek specialist evaluation despite the understandable embarrassment of the symptoms. ^[1][2][3]

FAQ

Can a rectovaginal fistula close on its own?

Some small fistulas may close when surrounding infection and inflammation settle, but many cases require surgical repair. ^[1][2]

Is passing gas through the vagina normal after childbirth?

No. It should be evaluated, especially after severe perineal tears or difficult delivery. ^[1][3]

Why can treatment be more difficult in Crohn disease?

Because active inflammation makes healing harder and increases recurrence risk. ^[1][2]

Does every rectovaginal fistula require a colostomy?

No. It is used only in selected complex or high-risk cases. ^[2][3]

Which symptoms require urgent evaluation?

High fever, severe pain, foul discharge, major bleeding, or concern that a repair has broken down should be assessed promptly. ^[1][2]