Rectovaginal fistulas are an abnormal connection between the rectum and vagina. In patients with recurring or persistent rectovaginal fistulas, a Martius repair can be utilized to correct the abnormality. This technique was first described in 1928 by Heinrich Martius, a German Ob/Gyn.


  • Obstetric complications (most common cause)
    • Third- or fourth-degree laceration repair dehiscence (breakdown of repair appears 1 – 2 weeks after delivery)
    • Unrecognized vaginal laceration during operative vaginal or precipitous delivery (instrumentation injury appears immediately)
  • Inflammatory bowel disease
    • Crohn disease (common)
    • Ulcerative colitis is less common since it isn’t transmural
  • Infection
    • Cryptoglandular abscess (commonly located in anterior aspect of anal canal)
    • Lymphogranuloma venereum
    • Tuberculosis
    • Bartholin gland duct abscess
    • HIV
    • Diverticular disease
  • Previous surgery in anorectal area
    • Hemorrhoidectomy
    • Low anterior resection
    • Excision of rectal tumors
    • Hysterectomy
    • Posterior vaginal wall repairs
  • Pelvic radiation therapy
  • Neoplasm
    • Invasive cervical or vaginal cancer
    • Anal or rectal cancer
  • Trauma
    • Intraoperative
    • Coital


  • Epithelial-lined communication between the rectum and vagina


  • Occasional passage of flatus through the vagina
  • Continuous drainage of stool through the vagina
  • Recurrent bladder or vaginal infections
  • Rectal or vaginal bleeding
  • Obstetric etiologies may present with gross fecal incontinence 
  • Infectious or inflammatory etiologies may present with abdominal cramping and fevers

Physical exam

  • Undrained abscess or purulent perineal drainage
  • Location of fistula in relation to sphincter muscles and pelvic floor should be noted as this can affect the repair technique
  • Palpable fistula tract 
  • Air bubbles at fistula’s vaginal opening after filling te vagina with water (done if initial examination doesn’t reveal readily seen fistula)


  • Consider imaging and other etiologies if rectovaginal fistula is not identified on exam
  • Exam under anesthesia
  • Barium enema
  • CT with IV and rectal contrast


  • Repair of rectovaginal fistulas from obstetric injury tends to be more successful compared to other etiologies
  • Surgical repair
    • Depending on etiology, such as inflammatory, recommended 3 – 6 months after disease onset (to decrease inflammation in tissues and increase likelihood of a successful repair)
    • Draining seton, antibiotics, or fecal diversion are considered depending on size, location, and etiology of the fistula 
    • Repair techniques
      • Endorectal advancement flap
        • Most popular surgical repair
        • Fistula tract excision and closure of rectal portion of the fistula with a vascularized mucosal flap
      • Transperineal repairs
        • Episioproctotomy with layered closure
        • Transperineal repair with levatorplasty
        • LIFT procedure
        • Sphincteroplasty
      • Tissue transposition repairs
        • Labial fat pad interposition (Martius flap)
        • Gracilis muscle interposition
      • Transvaginal repairs
      • Transabdominal repairs


  • Fecal incontinence
  • Vaginal, perineal, or anal irritation
  • Abscess
  • Fistula recurrence

Differential Diagnoses

  • IBD
  • Colon cancer
  • Large bowel disease
  • Malignancy
  • Surgical complications