Vogel JD, et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec;59(12):1117-1133. Full-text for Emory users.

Recommendations: Treatment of Rectovaginal Fistulas (p. 1123-1125)

1. Nonoperative management is recommended for the initial management of obstetrical rectovaginal fistula and may also be considered for other benign and minimally symptomatic fistulas. (Weak recommendation based on low-quality evidence, 2C.)
2. A draining seton may be required to facilitate resolution of acute inflammation or infection associated with rectovaginal fistulas. (Strong recommendation based on low-quality evidence, 1C.)
3. Endorectal advancement flap, with or without sphincteroplasty, is the procedure of choice for most simple rectovaginal fistulas. (Strong recommendation based on low-quality evidence, 1C.)
4. Episioproctotomy may be used to repair obstetrical or cryptoglandular rectovaginal fistulas associated with extensive anal sphincter damage. (Strong recommendation based on low-quality evidence, 1C.)
5. A gracilis muscle or bulbocavernosus muscle (Martius) flap is recommended for recurrent or otherwise complex rectovaginal fistula. (Strong recommendation based on low-quality evidence, 1C.)
6. High rectovaginal fistulas that result from complications of a colorectal anastomosis often require an abdominal approach for repair. (Strong recommendation based on low-quality evidence, 1C.)
7. Proctectomy with colon pull-through or coloanal anastomosis may be required to repair radiation-related and recurrent complex rectovaginal fistula. (Weak recommendation based on low-quality evidence, 2C.)