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Imaging and Surgical Management
of Anorectal Vaginal Fistulas
Wendaline M.VanBuren, MD
Amy L. Lightner, MD
Sarasa T. Kim, MD
Shannon P. Sheedy, MD
Madeline C.Woolever
Christine O. Menias, MD
Joel G. Fletcher, MD
Abbreviations: ARVF = anorectal vaginal fis-
tula, IPAA = ileal pouch–anal anastomosis
RadioGraphics 2018; 38:1385–1401
https://doi.org/10.1148/rg.2018170167
Content Codes:
From the Department of Radiology (W.M.V.,
S.P.S., M.C.W., J.G.F.), Department of Surgery
(A.L.L.), and School of Medicine (S.T.K.), Mayo
Clinic, 200 First St SW, Rochester, MN 55905;
and Department of Radiology, Mayo Clinic,
Scottsdale, Ariz (C.O.M.). Recipient of a Certifi-
cate of Merit award for an education exhibit at the
2016 RSNA Annual Meeting. Received June 26,
2017; revision requested September 27 and re-
ceived December 15; accepted December 21. For
this journal-based SA-CME activity, the authors,
editor, and reviewers have disclosed no relevant
relationships. Address correspondence to
W.M.V. (e-mail: vanburen.wendaline@mayo.edu).
©
RSNA, 2018
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■Describe how MRI compares with
other imaging modalities for detection of
complex fistulas.
■■Identifythe causes and imaging find-
ings of ARVFs.
■■Discuss medication versus surgical
management for simple and complex
fistulas on the basis of their causes and
locations.
See rsna.org/learning-center-rg.
1385
GASTROINTESTINAL IMAGING
Anorectal vaginal fistulas (ARVFs) can result in substantial morbid-
ity and potentially embarrassing symptoms in adult women of all
ages. Despite having what may be obvious clinical manifestations,
the fistulas themselves can be difficult to identify with imaging.
MRI is the modality of choice for the diagnosis and characteriza-
tion of ARVFs. A dedicated protocol involving the use of vaginal
gel and optimized imaging planes with respect to the vagina, as well
as an understanding of the MRI pelvic floor anatomy, is crucial for
reporting surgically relevant details. Ancillary findings such as post-
surgical changes, inflammation, abscess, sphincter destruction, and
neoplasm are well evaluated. Vaginography, contrast enema, endo-
scopic US, and CT can be highly useful complementary diagnostic
examinations. The entities that result in ARVFs may be obstetric,
inflammatory (eg, Crohn disease and diverticulitis), neoplastic, iat-
rogenic, and/or radiation induced. Surgical management is heavily
dependent on the cause and complexity of the fistulizing disease,
which are related to the location of the fistula in the vagina, the type
and extent of fistula branching, the number of fistulas, sphincter
tears, inflammation, and abscess.
©
RSNA, 2018 • radiographics.rsna.org
Introduction
Anorectal vaginal fistulas (ARVFs) are abnormal communications
between the vagina and the lower portion of the gastrointestinal
tract. The treatment options for ARVFs are heavily dependent on the
type and extent of anatomic involvement and the underlying causes.
Clinical Manifestations
The symptoms and presentations of patients with ARVFs vary
widely. These patients range from those who are surprisingly asymp-
tomatic to others who have a vaginal discharge, painful vaginitis,
bleeding, and/or skin ulcerations. A malodorous vaginal discharge
is not uncommon and is worse with loose bowel movements. Fecal
urgency and incontinence may be reported.
Obstetric trauma is the most prevalent cause of trauma-related
and likely all ARVFs (1–3). Other causes include inflammatory
disease such as Crohn disease or diverticulitis (4,5), malignancy,
Bartholin abscess, and side effects of treatment such as radiation
therapy. These fistulas can also result from iatrogenic conditions such
as those related to ileal pouch–anal anastomosis (IPAA); failed repair
of third- and fourth-degree lacerations of the perineum; episiotomy
infections; difficult hysterectomies; procedures involving the poste-
rior vaginal wall, perineum, anus, or rectum; pessary treatment (6);
and various mesh repairs (7). However, the classifications of ARVFs
based on their location, size, and cause have not been shown to cor-
relate with outcomes.
1386  September-October 2018 radiographics.rsna.org
TEACHING POINTS
■■ Low, or anovaginal, fistulas occur below the dentate line and
involve the anal sphincter complex. These fistulas often in-
volve the lower half of the vagina. As nearly half of patients
with ARVFs may have incontinence, MRI and endoscopic
US are essential. Typical causes of anovaginal ARVFs include
Crohn disease, IPAA, and obstetric trauma.
■■ High, or rectovaginal, fistulas occur above the dentate line
and are usually larger. These fistulas often involve the poste-
rior vaginal fornix. Typical causes include radiation, ulcerative
colitis, diverticulitis, and cancer.
■■ Systematic imaging assessment of the vagina, anorectum,
and fistula often enables identification of the entity that is re-
sponsible for the ARVF. An understanding of the anatomy and
cause of the fistula is essential for guiding appropriate medica-
tion and surgical treatment.
■■ Use of a dedicated MRI protocol with a phased-array coil, vag-
inal gel, a small field of view, and multiplanar fast spin-echo
T2-weighted imaging sequences facilitates the identification
of ARVFs and their causes.
■■ ARVFs remain notoriously difficult to treat despite advance-
ments in medication and surgical therapies. There are mul-
tiple surgical options, largely because no one option is par-
ticularly effective in facilitating complete healing. Small low
(distal) fistulas are often amenable to local repairs, whereas
complex fistulas due to radiation or Crohn disease might re-
quire multiple interventions, concurrent medical and biologic
therapies, or even fecal diversion.
Differential Diagnosis
Anal and perianal processes that result in fe-
cal soiling include differential considerations for
ARVF such as fistula-in-ano, perianal abscess, and
other causes of anal incontinence. The presence
of a vaginal discharge may raise the differential
possibility of infection rather than ARVF. Symp-
toms and physical examination results are often
helpful in the diagnostic evaluation. Once an
ARVF is suspected, a radiologic investigation can
be performed to identify the fistula and help triage
patients to medication management, a minimally
invasive technique, or a more involved procedure
such as tissue graft placement or bowel resection.
ARVF Classification
The management of ARVFs is based on the loca-
tion in which they occur. Low, or anovaginal,
fistulas occur below the dentate line (Figs 1, 2)
and involve the anal sphincter complex. These
fistulas often involve the lower half of the vagina.
As nearly half of patients with ARVFs may have in-
continence, MRI and endoscopic US are essential
(8). Typical causes of anovaginal ARVFs include
Crohn disease, IPAA, and obstetric trauma.
High, or rectovaginal, fistulas occur above the
dentate line (Figs 3, 4) and are usually larger.
These fistulas often involve the posterior vaginal
fornix. Typical causes include radiation, ulcerative
colitis, diverticulitis, and cancer. The anus should
be well interrogated to ensure absence of con-
comitant sphincter involvement.
Pelvic Floor Anatomy
MRI has long been established as an excellent
means of evaluating anorectal disease (9,10) and
delineating the complex anatomy of the female
perineum (11). The female perineum is a dia-
mond-shaped structure that contains a complex
network of muscles, ligaments, and fasciae (11)
(Fig 1). The perineum contains the distal two-
thirds of the urethra, the vagina at the level of the
introitus, and the anal canal. In the sagittal plane
(Fig 1a, 1b), the vagina is J shaped, with the
lower part of the vagina immediately posterior
and adjacent to the urethra. The T2-hypointense
perineal body, which is a fibromuscular mass in
the midline perineum at the junction of the anal
and urogenital triangles, separates the lower part
of the vagina from the anal sphincters. The uro-
genital diaphragm helps to support the intrinsic
muscles of the urethral sphincter mechanism, in-
cluding the compressor urethra and urethrovagi-
nal sphincter. The perineal body aids in urinary
continence, but it merges posteriorly with fibers
from the external sphincter and merges superi-
orly with fibers of the levator muscle of the anus
and the rectovaginal septum (11). The upper part
of the vagina lies immediately anterior to the rec-
tum when the rectovaginal septum is intact.
The anal sphincter complex comprises several
muscular layers (Fig 1a). The external sphincter
is a striated muscular outer layer that extends
inferiorly from the subcutaneous anal sphincter,
which lies below the internal sphincter, to the
anorectal junction, where its fibers are in con-
tinuity and inseparable from the puborectalis
muscle superiorly. The internal sphincter is a
smooth muscular layer that is in continuity with
the circular muscle of the rectum. It forms the in-
ner portion of the anal sphincter complex and is
slightly hyperintense compared with the external
sphincter. Anovaginal fistulas occur between the
sphincteric complex and lower part of the vagina.
Rectovaginal fistulas occur above the level of the
sphincters (Fig 3a) and may extend to the upper
or lower part of the vagina.
Imaging Assessment
Systematic imaging assessment of the vagina,
anorectum, and fistula often enables identification
of the entity that is responsible for the ARVF. An
understanding of the anatomy and cause of the fis-
tula is essential for guiding appropriate medication
and surgical treatment (Table 1). After a fistula is
detected, it should be categorized as anovaginal or
rectovaginal, with a description of the locations of
the fistula openings in the anorectum and vagina
RG  •  Volume 38  Number 5 VanBuren et al  1387

Figure 1.  Normal pelvic floor anatomy. (a) Sagittal illustration shows the normal anatomy. (Reprinted, with permission, from
Mayo Foundation for Medical Education and Research.) (b) Sagittal T2-weighted MR image shows gel distending the rectum (R)
and vagina (V). DL = dentate line, ES = external sphincter, IS = internal sphincter, U = urethra. (c) Axial illustration shows the normal
anatomy. (Reprinted with permission, from Mayo Foundation for Medical Education and Research.) (d, e) Axial T2-weighted MR
images obtained with an endorectal coil. ES = external sphincter, ICL = ileococcygeal component of levator plate, IS = internal sphinc-
ter, LV/I = lower region of vagina at the introitus, PR = puborectalis muscle, U = urethra, UGD = urogenital diaphragm, V = vagina.

Figure 2.  Crohn disease in a 21-year-old woman with a Hartmann pouch, who underwent end colostomy
owing to perforation during dilation of a sigmoid stricture. (a) Sagittal T2-weighted MR image shows a hyper-
intense fistula tract (arrow) between the anus and the lower region of the vagina. Note the decreased conspicu-
ity of the fistula without use of vaginal gel. The rectum () is inflamed, and there is perirectal fat proliferation
(arrowhead), which is probably secondary to chronic inflammation. (b) Axial T2-weighted MR image findings
confirm the presence of a wide opening (arrow) in the anterior anus; the opening extends to the lower region
of the vagina. Gynecologic reconstruction was not possible owing to the rectal inflammation, and proctectomy
and end colostomy were recommended. Crohn disease often manifests with complex fistulas and proctitis.
Medication management was no longer an option, given the extensive disease.
1388  September-October 2018 radiographics.rsna.org

Figure 3.  Illustrations of the relevant anatomy and repair of rectovaginal ARVFs. A, Sagittal-view drawing and inset illustrate
the location of a rectovaginal fistula, which is a fistula above the dentate line that communicates with the posterior vaginal wall.
(Anovaginal fistulas develop below the dentate line.) B, Sagittal-view drawing and inset illustrate the multiplicity and branching
pattern of fistulas, which complicate the management and healing processes. C, Sagittal-view drawing illustrates the use of a drain-
ing seton for treatment of a rectovaginal fistula. D, Sagittal-view drawing and insets illustrate the use of sutures to repair the rectal
wall layers. E, Sagittal-view drawing and inset illustrate the temporary use of a fistula plug to promote healing. (Reprinted, with
permission, from Mayo Foundation for Medical Education and Research.)

Figure 4.  Post–radiation therapy

findings in a 61-year-old woman
with cervical cancer, who pre-
sented with flatulence from
the vagina and pneumaturia.
(a) Sagittal T2-weighted MR im-
age shows a high (rectovaginal)
fistula (arrow). Identifying a fis-
tula is easy when the vagina is
filled with gel. (b) On the axial
T2-weighted MR image, the dis-
tention of the tract is well seen.
As seen on this image, gel in the
rectum also may be useful. High
fistulas generally occur above
the perineal body such that the
sphincter mechanism is left intact.
Treatment is highly dependent on
the patient’s symptoms and comorbidity. A vesicovaginal fistula also was present (not shown). The patient was treated with pelvic
exenteration, a sigmoid conduit with bilateral ureterosigmoidostomy, and end sigmoid colostomy.
RG  •  Volume 38  Number 5 VanBuren et al  1389

Table 1: Critical Fistula-related Features to Assess and Report

Feature
Presence and anatomic classification of the fistula (anovaginal or rectovaginal), vaginal
location (upper or lower region)
Branching or number of fistulas, associated ramifications, degree of fistula distention
Sphincteric assessment: tear, other fistulas, sphincteric involvement, exclusion of abscess
Rectal inflammation or mass
Prior therapy: presence of setons or drains, IPAA, radiation therapy, hysterectomy

(ie, upper or lower region of vagina). Branching
tracts or ramifications should be described. The
wall of the fistula is generally thin and hypointense
owing to fibrous tissue, and suspicion for underly-
ing tumor should be raised if there is surrounding
soft tissue (Fig 5). In addition, the location of any
setons should be reported (Fig 3).
If an anovaginal fistula is present, the associated
sphincter tears and/or masses, as well as any other
perianal or intersphincteric horseshoe fistulas,
should be described. Associated perianal ab-
scesses should be detailed. The rectum should be
examined for findings of proctitis, including wall
thickening, intramural edema, and hyperenhance-
ment, that may be related to Crohn disease or
radiation proctitis (Fig 2). The presence of a rectal
or vaginal mass should be excluded. Unilateral or
bilateral puborectalis atrophy or tear is probably a
sign that the patient has undergone prior obstet-
ric injury, which can be associated with sphincter
damage. The sigmoid colon should be separated
from the vagina, and findings of diverticulitis, such
as intramural edema and pericolonic inflammation
or fluid, should be described if they are present.
If a J pouch with ileoanal anastomosis is present,
the location of the anus, rectal cuff, blind end of
the J pouch, and anastomosis should be identi-
fied, with the anastomosis generally demonstrating
metallic artifact. It should be recognized that most
J pouches are created by using automatic staplers,
which leave approximately 1 cm of the lower rec-
tum (ie, rectal cuff) intact (12).
MR Imaging
MRI has evolved to have a critical role in the
evaluation of perianal fistulas (13). In addition
to enabling identification of a fistula, MRI can
be used to assess the regional anatomy, sphinc-
ter integrity, relationship of the fistula to the
dentate line, fistula complexity and multiplicity,
presence of abscess, and associated disease. In
a retrospective study (14) to evaluate endolu-
minal MRI, the modality had a positive predic-
tive value of 92% for delineating the location of
ARVFs. However, use of a targeted MRI proto-
col (Table 2), systematic review of the imaging
findings, and reporting of pertinent information
are key to rendering a correct diagnosis.
Use of a dedicated MRI protocol with a
phased-array coil, vaginal gel, a small field of
view, and multiplanar fast spin-echo T2-weighted
imaging sequences facilitates the identification
of ARVFs and their causes. The fistulas can be
adequately visualized at 1.5- and 3.0-T MRI.
However, 3.0-T imaging is preferred owing to an
increase in the available signal-to-noise ratio and
the capability for subsequent higher-resolution
imaging (15). A dedicated phased-array torso coil
should be used in all instances. The gel insertion
technique, imaging coverage, and section orienta-
tion stay the same, regardless of the magnetic field
strength. The vagina should be adequately dis-
tended with up to 60 mL of water-soluble US gel
inserted into the vaginal vault via a catheter and
syringe. Vaginal distention can be reduced in the
postradiation setting. All imaging planes should be
oriented with respect to the vagina, as visualized
on sagittal T2-weighted MR images. An in-plane
resolution of approximately 1 3 1 mm is ideal for
aiding visualization of the smallest fistulas, with a
maximal section thickness of 4 mm (Fig 2).
Anovaginal (low) fistulas are generally col-
lapsed, small, and short. They have a complex
trajectory and are frequently missed at initial im-
aging assessment. An endoanal coil may obscure
the fistula opening. The vagina, unlike the rectum,
can be maximally distended, with the distention
facilitating delineation of the vaginal wall and
communicating fistula, occasionally causing filling
of a collapsed tract with gel. Although the use of
rectal gel also may be helpful, it does not facilitate
the same pressure effect as vaginal gel. Despite
necessitating a small sacrifice in some anatomic
details of the sphincter anatomy, the use of vaginal
gel (Fig 1b) rather than an endoluminal coil (Fig
1d) nearly always improves visualization of an
anovaginal fistula tract (16,17). If proctocolectomy
and J pouch creation with ileoanal anastomosis
have been performed, insertion of a small-caliber
catheter into the anus, across the IPAA, is often
helpful for delineating important surgical ana-
tomic features. With dynamic examinations such
1390  September-October 2018 radiographics.rsna.org

Figure 5.  Crohn colitis in a 44-year-old woman who was presumed to also have perianal disease owing
to a vaginal discharge, which was initially and erroneously interpreted at MRI to indicate a perianal fistula.
(a) Sagittal fat-saturated T2-weighted fast spin-echo MR image shows a fluid-filled fistula (arrows) posterior
to the lower region of the vagina and introitus (arrowhead). (b, c) Axial fast spin-echo T2-weighted MR
images show an intermediate-signal-intensity soft-tissue mass (arrows in b) involving the anterior portions
of the internal and external sphincters and extending inferiorly into the perianal fat, with internal enhance-
ment (arrows in c), as well as increased signal intensity at b = 400 sec/mm2 (top inset in c) and associated
restricted diffusion (bottom inset in c) at diffusion-weighted imaging. These findings were believed to rep-
resent malignancy with a tumor fistula. Biopsy revealed squamous cell carcinoma. The patient subsequently
underwent chemoradiation with proctectomy, which led to a complete disease response.

as defecating proctography, fistula tracts can be
distended during simulated defecation (Fig 6b).
Given the complex orientation of female pelvic or-
gans and the often confounding pelvic floor laxity,
multiple imaging planes are required for visualiza-
tion of ARVFs (Fig 7).
The MRI appearances of pelvic fistulas have
been described as those of linear or branch-
ing T2-hyperintense tracts that communicate
between the low-signal-intensity interface of the
outer vagina and the bowel adventitia (18) (Fig
4). The signal intensity of a fistula can also vary
greatly and depends on the chronicity of the fis-
tula and the presence of internal fluid or granula-
tion tissue, inflammation, and/or tumor. Chronic
or trauma-induced fistulas may have low signal
intensity owing to a lack of active inflammation,
or they may have low T1 and T2 signal intensity
because they contain air or feces (Figs 8–10).
Dedicated perineal MRI is the method of
choice for detection and imaging assessment of
ARVFs. However, numerous other correlative im-
aging methods with complementary advantages
may be used to detect ARVFs. These modalities
are described in the sections that follow.
Fluoroscopy
Conventional fluoroscopic evaluation of the
vagina, or vaginography (Fig 11a), involves the
insertion of a catheter into the vagina, with the
RG  •  Volume 38  Number 5 VanBuren et al  1391

Table 2: Basic Parameters Used to Perform 3-T MRI Sequences

Contrast-
Fat-sup- enhanced Fat-suppressed
T2-weighted pressed T2- T2-weighted T1-weighted T1-weighted
Parameter FSE weighted FSE FSE DW EP 3D Dixon SPGR
Matrix 416 × 224 416 × 224 416 × 224 128 × 128 288 × 288 320 × 256
Section thickness (mm) 3.5 3.5 3.5 5.0 2.6 3.5
Intersection spacing (mm) 0.5 0.5 0.5 0 0 0.5
Repetition time (msec)/ 6000/85 6000/85 6000/85 2800/59 7.9/1.2 175.0/4.1
echo time (msec)
No. of signals acquired Three Three Three Eight Two Two
FOV (mm) 220 220 220 240 280 220
Orientation Sagittal Oblique axial Oblique axial Oblique Oblique Sagittal
and oblique Axial Axial
coronal
Bandwidth (Hz) 41.67 41.67 41.67 250.00 142.86 31.25
Note.—All MRI sequences were performed with a 24-cm field of view (FOV) body coil and vaginal gel. DW EP =
diffision-weighted echo planar, FSE = fast spin echo, SPGR = spoiled gradient echo, 3D = three dimensional.

Figure 6.  Findings in a woman 8 months postpartum with a grade 4 episiotomy injury. (a) Axial T2-weighted MR image obtained
with endorectal coil placement shows a full-thickness tear (arrow) in the internal anal sphincter at the 12-o’clock position. (b) Sagittal
proctographic MR image shows two fistulas (arrowheads) to the vagina, which became widely patent during simulated defecation
at MR proctography. (c) Axial fat-suppressed T2-weighted MR image shows how narrow even the upper anovaginal fistula lumen
(arrow) is at rest. The patient underwent overlapping sphincteroplasty and ileostomy.

balloon inflated within the vagina to create the
necessary filling pressure and distention. An-
teroposterior and oblique projections should be
obtained with an adequately small field of view.
High-quality spot-film exposures are necessary
to visualize small tracts. Although the use of
barium contrast material may enable delinea-
tion of the fistula, water-soluble contrast material
may be preferred, given the complexity of the
fistula and the potential for peritoneal spill (19).
At our institution, water-soluble enema examina-
tions and vaginography are performed by using
a mixture of one part iohexol (Omnipaque 300;
GE Healthcare, Milwaukee, Wis) and one part
water, 300 mL of each, for a total of 600 mL.
Variability in contrast medium, techniques, and
user experience may account for the wide range
of diagnostic performance (between 40% and
100%) with vaginography (20). In addition, the
occlusion balloon has been known to occlude low
fistulas (21,22). Fluoroscopic evaluation through
the anus is the preferred imaging technique to
perform within 1 year after a J pouch is created to
exclude a leak at the surgical anastomosis, and it
may be helpful in patients with known rectovagi-
nal fistulas. If an ARVF is not initially visualized
at vaginography, enema examination may be
helpful for demonstrating the fistula.
Computed Tomography
Although CT is not the modality of choice for
ARVF assessment, rectal contrast material or gas
tracking toward the vagina may suggest a fistula
and prompt further evaluation. CT frequently
facilitates the identification of fistulas associated
with diverticulitis (Fig 11b), which may extend to
1392  September-October 2018 radiographics.rsna.org

Figure 7.  Multiplanar identification of an ano-

vaginal fistula in a 44-year-old woman with peri-
anal and small-bowel Crohn disease. (a) Sagittal
T2-weighted MR image shows a thin hyperin-
tense tract (arrowhead) between the anus and
the lower region of the vagina. Many rectovagi-
nal and anovaginal fistulas are missed on MR im-
ages because the anus and vagina often do not lie
within a single imaging plane. As these fistulas can
be subtle, critical anatomic information must be
obtained in other planes once they are detected.
(b) Axial fat-saturated T2-weighted MR image
shows transsphincteric disruption (arrowhead) at
the 12-o’clock position. (c) Coronal T2-weighted
MR image shows the length of the fistula (arrow-
head) and can help in defining the trajectory of
the tract. Low (anovaginal) fistulas are below the
dentate line and usually involve the anal sphincter
complex.

Figure 8.  Extreme perianal Crohn disease, with complete sphincter destruction, in a 63-year-
old woman. (a) Sagittal T2-weighted MR image obtained after ileostomy shows a large ARVF ()
with a “cloaca” effect and little to no inflammation. (b) Axial T2-weighted MR image shows a
large defect () containing debris and gas. Note the frank leakage of rectal contrast material
(arrowhead) posteriorly in the absence of sphincter function. The perineum was nonrepairable.
These are the sequelae of multiple anterior transsphincteric fistulas with destruction of the
perineal body and external openings to the base of the labia. Previous attempted treatments
included the use of setons and Penrose drains.
RG  •  Volume 38  Number 5 VanBuren et al  1393

Figure 9.  Rectal adenocarcinoma invading the vagina in a

57-year-old woman. (a, b) Sagittal (a) and axial (b) T2-weighted
MR images show a heterogeneous predominantly T2-hyperintense
rectal mass invading the middle to upper region of the vagina and
thus causing an enormous fistula (). The patient underwent ra-
diation therapy. (c) Subsequently obtained axial T2-weighted MR
image shows a marked treatment response in the tumor (arrow).
Persistence of the fistula resulted in a loss of substantial portions
of the right lateral and anterior rectal walls, with destruction of
the vagina and right piriformis muscle. Permanent diverting colos-
tomy was recommended; however, the patient selected inconti-
nence rather than diversion.

Figure 10.  Passage of stool from the vagina in a 59-year-old woman who underwent chemoradiation for treatment of cervical can-
cer. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a high fistula (arrow). (c) Water-soluble enema radiograph shows
contrast material leakage into the upper posterior vaginal vault through a large rectovaginal fistula (arrow). Fistulas in the setting of
malignancy must be sampled at biopsy to exclude residual or recurrent cancer. Diversion, often for at least 6 months, can enable the
inflammation in the surrounding tissue to resolve. Permanent colostomy is often the best option if the patient is elderly and/or has
comorbid conditions, substantial sphincter damage, and/or fecal incontinence. Surgical repair is considered in the appropriate set-
ting, and if the fistula is high, interposition through the abdomen may be considered. If there is a stricture or severe radiation damage
in the rectum, rectal resection with reconstruction may be performed.

the bladder or vagina, and not infrequently it de-
picts perianal Crohn disease. If the fistula is siz-
able, a defect may be seen. Increased conspicuity
of the fistula may be possible with use of oral and
intravenous contrast media. Suspected tracts that
are not clearly delineated at vaginography may
be identified at CT, with water-soluble contrast
material in the vagina. CT remains a practical
means of evaluating possible ARVFs in those who
are not candidates for MRI (23). At CT, fistulas
1394  September-October 2018 radiographics.rsna.org

Figure 11.  Colovaginal fistula in a 73-year-old woman with acute diverticulitis. (a) Oblique water-solu-
ble contrast material–enhanced vaginogram shows a catheter and a balloon inflated in the vagina, with
filling of an extraluminal fistula (arrow) that extends to the sigmoid colon. (b) Sagittal CT image shows
tissue (arrowhead) in the region of the suspected fistula; fluoroscopy was required to confirm the pres-
ence of the fistula. The tissue was divided by means of transanal flap repair.

also appear as extraenteric tracts connecting the
anorectum or sigmoid colon to the vagina. Air
within the otherwise collapsed vagina is sugges-
tive of a fistulous communication; however, it
may be incidental.
Endoluminal US
In small patient cohorts, endoluminal US per-
formed with a transrectal probe has had positive
predictive values similar to those of MRI (14).
Although endoluminal US facilitates excellent
sphincter evaluation, it enables limited evalua-
tion of other entities in the pelvis. The small field
of view may limit visualization of longer or more
complex tracts, especially those seen with Crohn
disease, which may extend into the ischioanal
fossa or supralevator space. Some groups have
advocated the use of hydrogen peroxide to eluci-
date side tracts and fluid collections (24).
Causes and Imaging
Findings of ARVFs
Obstetric Injury and Prior Therapy for
Gynecologic Malignancies
Obstetric injury is the most common cause of
acquired ARVFs, with a fistula generally manifest-
ing 7–10 days after delivery as a result of third- to
fourth-degree laceration, inadequate repair, or
subsequent repair breakdown (Figs 6, 12). There
is a higher incidence of these cases in developing
countries owing to prolonged labor that causes
necrosis of the rectovaginal septum. Radiologic
imaging has a vital role in establishing the site,
course, and complexity of ARVFs and yields cru-
cial information for optimal presurgical planning.
ARVFs can also occur in association with ad-
vanced-stage gynecologic malignancy and the re-
lated surgical and radiation treatments. MRI is the
modality of choice for local staging of gynecologic
malignancies and detection of fistula formation.
Surgery is often required for management of
obstetric ARVFs; however, these fistulas may
close spontaneously during the early postpartum
period. Proper presurgical assessment of the
sphincter anatomy and function, as well as confir-
mation of the absence of infection or induration
in the surrounding tissue, is necessary before sur-
gery. Often there is an associated perianal abnor-
mality, such as perianal intersphincteric fistula,
abscess, and/or sphincter defects, that requires
sphincteroplasty to close the fistula and repair the
sphincter defect (25). Depending on the mode of
repair selected, subsequent deliveries may need to
be performed by means of cesarean section.
Inflammatory
Crohn Disease.—Crohn disease is the second
most common cause of ARVFs after obstetric
trauma and probably the most common type of
ARVF detected at imaging. Crohn disease–related
ARVFs represent about 9% of Crohn disease–re-
lated fistulas and are difficult to detect and treat
(4,5). With the peak patient age at Crohn disease
onset being 15–30 years, proper management
can help prevent long-term effects on the devel-
opmental, sexual, reproductive, and psychologic
health of young and reproductive-age women.
Early methods used for detection of Crohn
disease–related ARVFs included CT, with 60%
accuracy; vaginography, with 79% sensitivity;
and proctography, with an even lower sensitivity
of 35% (22,26,27). MRI has been proven to be
RG  •  Volume 38  Number 5 VanBuren et al  1395

Figure 12.  Fistula formation in a 28-year-old woman who underwent sphincteroplasty for a fourth-de-
gree vaginal tear. (a) Sagittal T2-weighted MR image obtained with use of vaginal and rectal gel shows a
persistent anovaginal fistula (arrow) from the middle and upper regions of the anus to the middle region
of the vagina, in the area of surgery. (b) Axial fat-suppressed T2-weighted MR image shows no inflamma-
tion (dashed oval). (c) Coronal T2-weighted MR image shows intact puborectalis muscles (arrowheads),
which are an important finding. (d) Axial gradient-echo MR image is useful for depicting artifact (arrow)
in the area of attempted surgical repair, which is sphincteroplasty in this case.

the most effective for the diagnosis of ARVFs,
with an accuracy approaching 100% (25). Ac-
cording to a relatively recent global consensus
statement (28), owing to these considerations,
MRI is considered the reference-standard imag-
ing modality for examination of perianal Crohn
disease. However, the detection of ARVFs is of-
ten challenging, with careful inspection required
to detect fistula tracts that are iso- or hypoin-
tense owing to the absence of active inflamma-
tion (Fig 8). Even with active inflammation, the
signal of the fistula at T2-weighted MRI is only
slightly hyperintense, with minimal gadolinium-
based contrast material enhancement on axial
two-dimensional, fat-saturated, spoiled gradient-
echo MR images (17). Furthermore, as an ARVF
heals, the T2 signal intensity and gadolinium en-
hancement decrease. Use of techniques such as
US gel insertion in the vagina is helpful when in-
vestigating findings that are clinically suspicious
for an ARVF. Finally, an intentional search for
Crohn disease–related postoperative pouch-vag-
inal fistulas also is important, as these tracts can
be difficult to identify and can arise at, above, or
below the site of the anastomosis (17,29).
Perianal fistulas associated with Crohn disease
tend to be more complex, with increased branch-
ing and horseshoe ramifications or abscesses.
In addition, Crohn disease–related fistulas are
frequently associated with Crohn proctitis, which
complicates the situation because definitive surgi-
cal therapy cannot be performed until the proctitis
is under control. If the proctitis persists, multimo-
dality therapy is administered and includes seton
placement, generally in conjunction with antibiotic
and biologic therapies (17). The anatomy and
localization of branching ramifications have a large
role in deciding the treatment. Ultimately, the
management of ARVFs depends on the magnitude
of symptoms, degree of patient discomfort, level
of Crohn disease activity, and height of the fistula.
For closure of a Crohn disease–related ARVF, a
combination of medication (infliximab) and surgi-
cal management is recommended.
It should also be recognized that patients with
Crohn disease are at increased risk for malignancy
1396  September-October 2018 radiographics.rsna.org

Figure 13.  Vaginal cancer in a 70-year-old woman who did not appear for im-
aging follow-up until 2 years after the diagnosis. (a, b) Axial contrast-enhanced
CT (a) and PET/CT (b) images show a large vaginal mass (dashed circle) invading
the right pelvic side wall and the rectum. Pathologic analysis revealed invasive
squamous cell carcinoma, and definitive radiation therapy was administered. Two
years later, the patient had hemorrhaging from the vagina and a mucous fistula.
(c) Sagittal MR image of the pelvis shows a rectovaginal fistula (dashed oval). A
left-sided intersphincteric perianal fistula (not shown) also was present.

owing to chronic colorectal inflammation and the

use of immunosuppressive medications. Thus,
imaging findings of soft tissue involving the fistula,
anus, or rectum should prompt endoscopic assess-
ment and potentially biopsy (Fig 5).

Diverticulitis.—ARVFs usually arise as a result of

microperforations of inflamed diverticula (Fig 11).
ARVFs are seen in 2% of diverticulitis cases at sur-
gery and most often involve the sigmoid colon ow-
ing to its proximity to the vagina (30). Among the
internal fistulas seen with diverticulitis, colovesical
fistulas are the most common, with some investi-
gators suggesting that the uterus has a protective
role in women. Colovesical fistulas are followed in
frequency by colovaginal, coloenteric, and colout-
erine fistulas (31,32). Urgent surgical intervention
is rarely indicated; however, diverticular fistulas
generally do not resolve spontaneously. Therefore,
an elective one-stage procedure involving resection
and primary anastomosis is feasible in the majority
of cases, with lower morbidity. Infrequently, when
the inflammation is severe or there is concurrent
active perforation, two-stage procedures involving
fecal diversion are necessary.
Radiation
Radiation-induced ARVFs are a major cause of
morbidity in patients with cancer who are under-
going therapy. Although the tumors themselves
may result in tissue destruction that results in fis-
tulas (33), radiation-induced fistulas can be large
and may not be repairable with surgery (Fig 13).
These fistulas occur within 6 months to 2 years
and are believed to result from tissue necrosis
secondary to obliterative endarteritis, with pos-
sible superimposed proctitis and ulceration of the
anterior rectal wall (34). Fistulas occurring after
radiation therapy must be analyzed with biopsy
to exclude recurrent or residual tumor. Radia-
tion for treatment of cervical cancer is one of the
most prevalent causes of these fistulas (Fig 10),
with rectovaginal fistulas arising in nearly 8%
of patients (23). The incidence of fistula forma-
tion increases with higher doses of radiation and
without the protective barrier of the uterus in the
setting of hysterectomy (35). The morbidity as-
sociated with fistulizing disease is one of the rea-
sons that most cervical cancer regimens include
hysterectomy or radiation therapy, but not both.
Ileal Pouch–Anal Anastomosis
IPAA is not the standard of care for patients with
Crohn disease, but it is sometimes performed in
patients who are initially believed to have ulcer-
ative colitis and later present with findings of
Crohn disease. IPAA is a surgery that involves sub-
total proctocolectomy, creation of an ileal reservoir
or pouch, and an anastomosis between the pouch
and anus (36). A pouch-vaginal fistula can arise as
a postoperative complication, or it may result from
unsuspected Crohn disease. Crohn disease is more
likely to be the cause if the fistulas manifest more
than 6–12 months after surgery, the fistulas are
complex or branching rather than simple, and/or
the internal opening is away from the actual anas-
RG  •  Volume 38  Number 5 VanBuren et al  1397

Figure 14.  Crohn disease, complex branching fistulas, and an IPAA pouch–vaginal fistula in a 34-year-
old woman. (a, b) Axial fat-suppressed T2-weighted (a) and sagittal T2-weighted (b) MR images show a
hyperintense fistula tract (arrow) from the anal portion of the pouch, extending to the lower left region
of the vagina. (c) Coronal T2-weighted MR image shows a perianal abscess (arrowhead). While IPAA is
not the standard of care for patients with Crohn disease, treatment is sometimes based on an initial pre-
sumption of ulcerative colitis. The fistula can be the result of postoperative complications or unsuspected
Crohn disease. Crohn disease is more likely if the fistula occurs more than 6–12 months after surgery, the
fistula is complex or branching, or the internal opening is away from the anastomosis. In this case, the
fistula is away from the anastomosis and occurred years after surgery, with complex or branching fistulas
and an abscess.

tomosis or suture lines of the pouch (37). After
IPAA, careful assessment of MR images should be
performed to identify the pouch-anorectal anasto-
mosis, rectal cuff, and anus, as vaginal fistulas seen
in this setting may arise from the anus (raising
suspicion for perianal Crohn disease), inflamed
rectal cuff (raising suspicion for Crohn disease),
anastomosis (potentially indicating delayed recog-
nition of leak), or pouch itself (raising suspicion
for Crohn disease of the pouch) (Fig 14).
fistula in a patient with Crohn disease who has
suspected or prior perianal disease (Fig 5). Any
tissue thickening must be carefully sampled with
biopsy and interrogated, as patients who have this
thickening are at increased risk for malignancy
secondary to immunosuppressive medication use
and chronic inflammation. Rapid expansion of
the fistula tract, regional desmoplastic reaction,
and diffusion restriction may be helpful MRI
features that indicate a suspicious process.

Malignancy Iatrogenic Causes

Rectal, uterine, cervical, and vaginal cancers may
have marked regional extension, placing patients
with these neoplasms at risk for ARVFs (34).
These advanced-stage tumors usually are aggres-
sive, with destruction of tissue planes resulting in
highly symptomatic disease and tissue destruc-
tion (Fig 9). Malignancy can also occur within
a chronic preexisting fistula, or it may mimic a
Postoperative leaks, which can lead to abscess
formation, place patients at risk for ARVF devel-
opment (Fig 15). The surgical trauma itself may
directly result in a fistula. Colorectal anastomo-
ses performed with a stapler may cause ARVFs
if the vagina is inadvertently incorporated into
the procedure (34). The key to the diagnosis is
somewhat temporal, as leaks and abscesses will
1398  September-October 2018 radiographics.rsna.org

Figure 15.  Rectovaginal fistula and leakage in a 52-year-old woman after low anterior resec-
tion for rectal cancer. Sagittal CT image of the pelvis acquired with iodinated contrast material
in the vagina (a) and sagittal T2-weighted MR image acquired by using vaginal gel (b) show
a fistula (arrow) to the rectum and a presacral fluid collection ().

be evident early in the postoperative course and
patients may become newly symptomatic. CT is
often useful as a primary means of assessing for
free fluid or a fluid collection. Occasionally there
may be a tract, which is possibly gas filled, com-
municating with the vagina. Fluoroscopy or MRI
is useful for further evaluation (38).
Surgical Management
ARVFs remain notoriously difficult to treat despite
advancements in medication and surgical thera-
pies. There are multiple surgical options, largely
because no one option is particularly effective
in facilitating complete healing (39). Small low
(distal) fistulas are often amenable to local re-
pairs, whereas complex fistulas due to radiation
or Crohn disease might require multiple interven-
tions, concurrent medical and biologic therapies,
or even fecal diversion. The choice of surgical
technique depends on the degree of anal sphincter
involvement, the underlying diagnosis, and the
surgeon’s and/or patient’s preference. It is impor-
tant to counsel the patient regarding the potential
need for multiple surgeries to achieve long-term
success and clearly articulate the potential lack of
effectiveness with multiple interventions.
Before undergoing any definitive repair for an
ARVF, the patient needs to be examined for any
signs or symptoms of perianal sepsis. If perianal
sepsis is present, it should be controlled, most
often with use of setons placed in the fistula tract
for drainage. Once the sepsis has been controlled,
typically within 6 weeks, a more definitive repair
can be conducted.
Local approaches, including transanal, trans-
vaginal, and transperineal techniques, may be
attempted in the setting of simple low fistulas.
One of the simplest and least invasive approaches
is to use fibrin glue and/or plugs, with both used
to fill the fistula tract and seal it. Although these
methods are simple and pose minimal risk to
the sphincter mechanism, healing rates are poor.
The most common transanal repair is endorectal
advancement flap placement, whereby the rectal
tissue is used to cover the internal opening of the
fistula. A U-shaped flap of mucosa, submucosa,
and circular muscle is raised proximally 4–5 cm
and brought down over the anorectal opening
of the fistula (Fig 3). The flap is then sutured in
one to two layers with absorbable sutures, and
the vaginal opening is left open to drain (40–42).
A similar repair can be performed with a trans-
vaginal approach, whereby a flap of vaginal tissue
is raised and used to cover the vaginal opening,
and the rectal and vaginal defects, as well as the
vaginal flap, are closed with absorbable sutures.
An approach involving the placement of anocuta-
neous flaps, which are rarely used, is an alterna-
tive way of addressing an extremely distal fistula.
A flap of anoderm or perianal skin is created and
lifted retrograde into the anal canal (43).
Ligation of the intersphincteric fistula tract
(LIFT) is a procedure that involves dissecting
into the intersphincteric space, identifying the
fistula tract, and ligating the tract on either side
(44). This approach can be used for low fistulas
that pass through an intact sphincter complex.
When a bioprosthetic graft is placed between the
rectum and vagina in combination with the LIFT
procedure, healing rates are improved.
Transperineal repairs are designed to place tis-
sue or prosthetic material between the rectal and
vaginal openings. The most commonly used tis-
sue interposition grafts are bulbocavernosus and
gracilis muscle grafts. Both of these grafts can be
used to close large defects, facilitating neovascu-
larity, dead-space filling, and enhanced granula-
tion tissue formation. The use of bulbocavernosus
RG  •  Volume 38  Number 5 VanBuren et al  1399

Figure 16.  Drawings illustrate the creation of a Martius modified labial fat pad flap, or Martius flap.
(a) After the fistula is ligated, a Martius flap is created by making an incision on the labium majus pu-
dendi to expose the fat pad underneath. Gentle dissection to free the fat pad is performed while stay-
ing lateral to the bulbocavernosus and ischiocavernosus muscles. (b) A tunnel connecting the pedicle
of the fat pad to the vaginal opening is formed with blunt dissection, and the flap is gently transferred
through. A catheter is present in the urethra. (Reprinted, with permission, from Mayo Foundation for
Medical Education and Research.)

muscle or the labial fat pad is called Martius flap

Figure 17.  Drawings illlustrate gracilis flap repair. The vagina
is reconstructed by using the gracilis muscle, with the patient
in the lithotomy position. (Reprinted, with permission, from
Mayo Foundation for Medical Education and Research.)
creation (Fig 16) (45). The perineum is dissected
to identify the plane and fistula tract between
the rectum and vagina, and the fistula tract is
ligated. The bulbocavernosus muscular fat pad is
harvested from either labium majus pudendi, de-
pending on the vascular supply from the perineal
branch of the pudendal artery, and then trans-
posed through a subcutaneous tunnel to separate
the vaginal and rectal walls. Success rates of up to
100% have been reported in the setting of Mar-
tius flap creation with fecal diversion.
A gracilis flap repair is performed with the
patient in the modified lithotomy position (Figs
17, 18). An incision is made posterior to the
vaginal introitus, and the rectovaginal septum
is entered. A dissection is performed to iden-
tify and ligate the fistula tract. The harvested
gracilis muscle (Fig 17) is then passed through
a subcutaneous tunnel between the perineal and
thigh incisions. The muscle is then interposed
between the rectum and vagina and sutured in
place (Figs 17, 18). To facilitate healing, diver-
sion with a temporary ostomy is recommended.
Healing rates of up to 100% have been achieved
with this technique (46).
Recently, mesenchymal stem cells have been
used increasingly to treat perianal Crohn disease.
Owing to the favorable healing rates seen, some
groups are beginning to design clinical trials to
test mesenchymal stem cell–based therapies for
rectovaginal fistulas. This treatment most often
involves the direct injection of cells, with an
1400  September-October 2018 radiographics.rsna.org
Figure 18.  Gracilis flap repair. (a) Pho-
tograph shows the left thigh of a patient
in the modified lithotomy position, with
mobilization of the gracilis muscle ().
(b) The muscle is advanced by way of a
transperineal approach, interposed be-
tween the rectum and vagina, and su-
tured in place with use of an incision at
the rectovaginal septum (arrow). All steps
are performed through the vagina.
exceedingly low risk of injury to the anal sphinc-
ter complex. Data collected within the next few
years should shed light as to whether this may be
a more optimal surgical approach (47,48).
Conclusion
The diagnosis and management of ARVFs
are complex and vary greatly according to the
cause of the fistula. MRI performed by using
a dedicated protocol is the modality of choice
for primary assessment, as it can yield details
regarding the number of tracts, their anatomic
locations, and complicating features such as
abscess, inflammation, sphincter destruction,
and neoplasm. Vaginography, CT, and endo-
scopic US also may aid in the identification of
fistulas; however, each of these examinations
has limitations. Because ARVFs can be difficult
to identify and treat, it is important for radiolo-
gists to apply the modalities necessary to report
those details regarding ARVFs that may alter the
surgical management.
Acknowledgments.—The authors acknowledge the assis-
tance of Sonia Watson, PhD, in editing the manuscript and
Brent Warndahl, RT, for contributions regarding the MRI
techniques.
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