Anogenital and rectovaginal fistulas are abnormal connections between the lower gastrointestinal tract and the vagina. Other causes of fistulas, which occur most frequently after obstetric trauma, include radiation damage, Crohn's disease, and difficult hysterectomies due to deep infiltrative endometriosis (1). Rectovaginal fistulas can be classified as low and high fistulas according to their location above or below the dentate line. Patients usually present with complaints of gas or stool retention and foul-smelling discharge from the vagina. Patients should also be questioned simultaneously for gas and stool incontinence. In this way, an idea will be obtained as to whether the external anal sphincter is affected. Patients with suspected fistula should definitely be evaluated with a vaginal examination. If necessary, a methylene blue test can be performed (2). Since the symptoms are generally intolerable, surgical treatment is usually recommended (3). It is recommended to start a liquid diet 24-48 hours before surgery, to give prophylactic antibiotics 30 minutes before surgery, and to perform mechanical bowel cleansing the night before (3). The surgical technique will vary depending on whether the sphincter enters the planned excision area of the fistula tract. If the sphincter is intact, simple fistulectomy is recommended. If necessary, a modified Martius graft can be placed perioperatively. The patient should be kept under close follow-up with stool softeners and a liquid diet postoperatively.

In this video, we present the surgical management of a patient who developed a rectovaginal fistula following silver nitrate treatment for a Bartholin gland abscess. Initial primary repair was unsuccessful, and the fistula was subsequently addressed with surgical reconstruction using a Martius flap.

A 37-year-old patient with a history of 5 vaginal births, who underwent 3 abscess drainage at an external center due to recurring Bartholin's abscess, and after the abscess drainage due to the fourth recurrence, a Silver Nitrate stick was applied to the cyst, and the patient applied to us after a foul-smelling and stool-like discharge from the vagina that started 1 month after the procedure. A gynecological examination revealed two fistula-like mouths in the Batholin lodge on the right side of the vulva. Transrectal methylene blue was administered with the suspicion of rectovaginal fistula, but no blue dye was observed coming from the vagina. Then, a magnetic resonance imaging was performed and a multidisciplinary surgical decision was made by the General Surgery and Gynecology physicians for the case, which was thought to be a rectovaginal fistula. After a 24-hour liquid diet, the patient was taken to surgery and given perioperative antibiotic prophylaxis. 
The patient underwent primary fistula repair and her complaints returned in the second postoperative month, and reconstruction with a Martius flap was planned.

Although the use of silver nitrate in the treatment of Bartholin gland abscess is known as a minimally invasive approach, it can lead to serious complications (13). Silver nitrate can cause chemical necrosis and damage to the surrounding tissues (13, 14). This case demonstrates that this method should be used with caution and that it is important to discuss possible complications with the patient in advance. Alternative treatment methods include low-risk methods such as marsupialization and Word catheter (15). These methods have a much lower risk of causing serious complications such as fistula.

In order to achieve successful results in rectovaginal fistula repair, a multidisciplinary approach should be taken, but more importantly, precautions should be taken for possible etiologies before the fistula develops.

Andreani S, Dang H, Grondona P, Khan A, Edwards D. Rectovaginal fistula in Crohn's disease. Diseases of the colon & rectum. 2007;50(12):2215-22.
Shieh CJ, Gennaro A. Rectovaginal fistula: a review of 11 years experience. International surgery. 1984;69(1):69-72.
Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Diseases of the Colon & Rectum. 2022;65(8):964-85.