Clinical Scorecard: Standardized Examination Under Anesthesia for Rectovaginal Fistulae: The St Mark’s Protocol
At a Glance
Category
Detail
Condition
Rectovaginal fistulae (RVFs)
Key Mechanisms
Fistulous communication between rectum and vagina causing vaginal defaecation, flatus, discharge; arises from obstetric trauma, Crohn’s disease, surgery, radiation, malignancy
Target Population
Patients with suspected or confirmed rectovaginal fistulae, including those with ambiguous imaging or persistent symptoms
Care Setting
Day-case surgical setting under general anaesthesia
Key Highlights
Five-stage EUA protocol: inspection, intraoperative endoanal ultrasonography, probing, insufflation with bubble test, and methylene blue dye test
Intraoperative endoanal ultrasonography enhances anatomical delineation and correlates with preoperative MRI where expertise permits
Protocol aids diagnosis, assessment of healing, and intraoperative decision making including timing of definitive repair
Guideline-Based Recommendations
Diagnosis
Perform systematic proctovaginal inspection under anaesthesia to identify fistulous openings and related pathology
Use intraoperative endoanal ultrasonography to assess sphincter integrity and fistula tract anatomy when available
Employ probing with Lockhart-Mummery or lacrimal probes to confirm patency of small or occult fistulae
Conduct insufflation and bubble test with vaginal irrigation and rectal air insufflation to detect fistulous communication
Apply methylene blue dye test rectally with vaginal packing to confirm persistent fistulae
Management
Use EUA findings to guide operative decision making including timing and extent of repair
Document findings comprehensively with photographic or video capture where appropriate
Monitoring & Follow-up
Repeat EUA to assess healing after conservative or surgical management in patients with persistent symptoms
Risks
Potential false negatives with imaging modalities necessitate EUA for definitive diagnosis
Care to avoid cross-contamination during dye testing
Patient & Prescribing Data
Patients undergoing evaluation for rectovaginal fistulae including those with complex or recurrent disease
EUA protocol facilitates accurate diagnosis and assessment of fistula healing, optimizing timing and approach for surgical repair
Clinical Best Practices
Position patient in lithotomy under general anaesthesia for optimal access
Use appropriate retractors (Parks vaginal, Eisenhammer rectal) for thorough inspection
Incorporate intraoperative endoanal ultrasonography where local expertise is available
Perform systematic five-stage protocol to maximize diagnostic yield
Seal vaginal introitus carefully during methylene blue dye test to prevent contamination
Document findings with images or video to support clinical decision making
