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An otherwise healthy 4-week-old term female of Japanese heritage presented with a 1-week history of asymptomatic progressive, generalized skin lesions. The lesion morphology, distribution, and dermatopathology result was consistent with Sweet syndrome. The patient was found to have a congenital type H rectovestibular fistula. This case highlights the rare association of rectovestibular fistula in neonatal Sweet syndrome which has only been described in neonates of Japanese heritage., (© 2024 Wiley Periodicals LLC.)

Rectovaginal fistulas (RVF) represent less than 5% of anorectal fistulas. The classification of RVF is based on the localization (low vs. high) and the etiology. The most frequent causes of RVF are birth trauma, Crohn's disease, previous surgery and pelvic irradiation. In most cases a clinical diagnostic assessment is sufficient. Additionally, endosonography is a reliable tool to detect sphincter defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for special situations (e.g., RVF related to anastomotic leakage, after pelvic irradiation or associated with complex perianal fistulizing Crohn's disease). The surgical treatment is primarily oriented to the localization and etiology. Surgical techniques range from local procedures (e.g., endorectal advancement flap repair, transvaginal or transperineal closure) up to more invasive tissue interposition (e.g., bulbocavernosus muscle fat tissue flap or transposition of the gracilis muscle). In "high" RVF transabdominal approaches such as coloanal anastomosis, pull through procedures or omental interposition are indicated. All surgical procedures show high recurrence rates. Several operations are mostly necessary and a stoma creation is often required., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: Gemäß den Richtlinien des Springer Medizin Verlags werden Autoren und Wissenschaftliche Leitung im Rahmen der Manuskripterstellung und Manuskriptfreigabe aufgefordert, eine vollständige Erklärung zu ihren finanziellen und nichtfinanziellen Interessen abzugeben. Autoren: O. Schwandner: A. Finanzielle Interessen: Takeda, Medtronic, AbbVie, Falk Foundation, med update (Honorar für Referententätigkeit, Reise- und Übernachtungskosten). – B. Nichtfinanzielle Interessen: Berufliche Tätigkeit: Leitender Arzt der Abteilung für Proktologie, Krankenhaus Barmherzige Brüder Regensburg | Mitgliedschaften in wissenschaftlichen Gesellschaften: Deutsche Gesellschaft für Chirurgie, Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Deutsche Gesellschaft für Koloproktologie, Vereinigung der Bayerischen Chirurgen, Deutsche Kontinenz Gesellschaft, American Society of Colon & Rectal Surgeons | Mitgliedschaft in Berufsverbänden: Berufsverband der Deutschen Coloproktologen | Position in wissenschaftlicher Fachgesellschaft: Mitglied des Vorstands der Deutschen Gesellschaft für Koloproktologie (Generalsekretär). Wissenschaftliche Leitung: Die vollständige Erklärung zum Interessenkonflikt der Wissenschaftlichen Leitung finden Sie am Kurs der zertifizierten Fortbildung auf www.springermedizin.de/cme . Der Verlag: erklärt, dass für die Publikation dieser CME-Fortbildung keine Sponsorengelder an den Verlag fließen. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Abstract: Pentalogy of Fallot is a rare form of congenital cyanotic heart disease with a prevalence of 3/10,000 live births characterized by an association of Tetralogy of Fallot with Atrial Septal Defect. Pentalogy of Fallot with anorectal malformation is also a rare combination. Here we describe one of the rare case reports of a full-term, 38 weeks, female baby diagnosed with pentalogy of Fallot with imperforate anus and rectovaginal fistula at a tertiary care hospital. Pentalogy of Fallot combined with an imperforate anus and rectovaginal fistula is an exceptionally rare and complex congenital condition. The co- existence of these anomalies emphasizes the need for thorough prenatal and postnatal evaluation for early detection and management.

The aim of this case report is to show the advantages of the extraperitoneal cesarean section (ECS) approach in a pregnant patient with multiple previous abdominal transperitoneal colon surgeries and Crohn's disease. A pregnant nulliparous woman with Crohn's disease was admitted for delivery. After delivery, a large rupture and lesion of the rectum was observed. Suturing of the vagina, rectum and sphincter was performed by an abdominal surgeon. Because of a very large and irregularly shaped rectum rupture, the patient underwent infraumbilical medial laparotomy and sigmoidostomy. After 18 months, the patient started to experience vaginal discharge and Y-shaped rectovaginal fistula was confirmed. Surgical reconstruction was performed. The patient's second pregnancy began one year later. At 38 weeks of pregnancy, elective extraperitoneal cesarean section was performed. A healthy newborn was delivered. Follow-up showed full and fast recovery after the ECS. In cases of pregnant women who have had multiple colon surgeries, gynecology surgeons can choose to perform an ECS to avoid transperitoneal entrance into the abdomen. ECS avoids lysis of postoperative adhesions after repetitive gastrointestinal surgeries, the formation of new adhesions by lysis of the old adhesions, and most importantly, the possibility of colon or small intestine lesions during lysis of dense or firm adhesions., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Anorectal malformations (ARM) in females are identified by abnormal location of the anal opening. Management is guided by clinical examination to find the number of perineal openings. Two openings in the perineum of a female may be seen in cases of imperforate anus without fistula, vaginal agenesis with vestibular fistula or imperforate anus with recto-vaginal fistula (RVF). We present a case series of ARM with RVF and discuss their diagnosis and management.

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and the vagina. At present, the principle method for RVF is surgery. With a variety of surgical methods, clinicians still lack a generally recognized consensus on RVF. Therefore, based on latest evidence from literature and expert experience, the Clinical Guidelines Committee of Chinese Medical Doctor Association Anorectal Branch organized domestic experts in anorectal surgery and gynecology to discuss the etiology, classification, diagnosis, treatment and special types of rectovaginal fistula of RVF, through questionnaires and expert seminars. "Chinese experts consensus on the diagnosis and treatment of rectovaginal fistula (2022 edition)" was produced in order to deepen the understanding of RVF, and to provide a standardized treatment for RVF in order to reduce the failure rate of surgery.

Purpose: The rectovaginal fistula (RVF) is a type of female ARM in which the rectum terminates in the vagina. Due to its rarity, there are limited reports on its presentation, management, and follow-up. This paper deals with the clinical presentation, management, and outcome of RVF., Methods: It was a retrospective cohort study of 10 years. The patients were evaluated for age, clinical presentation, associated anomalies, any prior surgical interventions performed elsewhere, and complications. After workup, the patients underwent three stages of surgery., Results: Fifty-six patients of RVF were managed. The median age was 13.48 months. The associated anomalies were present in 37 (66%) patients. Posterosagittal and anterosagittal anorectoplasty (PSARP and ASARP) were performed in 29 and 6 patients, respectively. Abdominoperineal pull-through (APPT) was performed in 16 patients of congenital pouch colon. The complications of the first stage included stomal stenosis (4) and stomal prolapse (3). Constipation was present in 39 patients 2 years after the third surgery., Conclusions: RVF is a distinct entity, which needs careful clinical examination. With proper planning for diagnosis and treatment, it can be managed at specialized centers. Care may be needed for the associated anomalies. The follow-up is an integral part of its management., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes., Data Sources: We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications")., Methods of Study Selection: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations., Tabulation, Integration, and Results: Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I 2  = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I 2  = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I 2  = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I 2  = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I 2  = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I 2  = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I 2  = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I 2  = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I 2  = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I 2  = 71%)., Conclusion: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the long-term results of surgical correction of H-type fistula in girls with a normal anus., Material and Methods: There were 7 patients with rectovestibular fistula and 3 patients with rectovaginal fistula with a normal anus were observed from 2014 to 2019 in the Surgical Department No. 1 of the Russian Children's Clinical Hospital. Upon admission, all patients underwent genital examination, vaginoscopy, rectal examination and probing the fistulous canal, irrigography, abdominal and retroperitoneal ultrasound. They were also examined by a gynecologist and genital smears were obtained. Surgical treatment was determined depending on the height and diameter of the fistula for each child. One patient underwent perineal fistulectomy, three patients - anterior anorectoplasty. Invaginated fistula extirpation, abdominoperineal proctoplasty and perineal fistulectomy using a pad flap between the defects were used in two cases, respectively. Patients were followed-up for the period from 6 months to 1 year after the last recurrence. Follow-up examination, irrigography and functional examination of sphincter were performed., Results: Two (20%) patients did not require redo surgery. In 6 (60%) cases, recurrences didn't occur within a year after the second surgery, in 2 (20%) cases - after 3 operations. Recurrent H-type fistula appeared after 3 of 4 perineal fistulectomy procedures, 3 of 9 anterior anorectoplasty, 2 of 2 abdominoperineal proctoplasty and 2 of 3 invaginated fistula extirpation. Hypotension of internal anal sphincter and neo-rectal ampulla, recurrent vulvovaginitis were diagnosed in 2 patients in 6 months after anterior anorectoplasty., Conclusion: We recommend anterior anorectoplasty and perineal fistulectomy using a pad flap between the defects for the treatment of H-type fistula to minimize the risk of recurrence.

Objective: To evaluate the early and long-term outcomes of rectovaginal fistula closure with vaginal rectangular flap., Material and Methods: There were 61 patients with rectovaginal fistula for the period 2012-2020. Median age of patients was 35 years [31; 48]. Postpartum fictula was observed in 27 (44.2%) cases, postoperative - 10 (16.4%) patients, inflammatory - 15 (24.6%) patients, other causes - 9 (14.8%) patients. Disease recurrence occurred in 29 (47.5%) patients., Results: Median follow-up period was 36.2 [6; 64] months. Postoperative recurrence of rectovaginal fistula occurred in 19 (31.1%) patients. Length of hospital-stay ranged from 3 to 36 days (median 14 [12; 16]). We analyzed the relationship between the risk of disease recurrence and various factors, including etiology of rectovaginal fistula, localization and diameter of the fistula, intraoperative cautery, previous surgeries and preventive colostomy., Conclusion: Vaginal rectangular flap is effective for rectovaginal fistula. Multivariate analysis confirmed two significant risk factors of postoperative recurrence: diameter of fistula over 5 mm and its localization in the rectum above the upper border of surgical anal canal (more than 7 mm from the dentate line).

Objective: To describe epidemiologic, anatomic and clinical characteristics of urogenital and rectovaginal fistula and the issue of their surgical management in Togo., Material and Methods: A retrospective study permit us to collect the operated cases during five years in the national center of obstetrical fistula. The parameters evaluated were sociodemographic aspects of patients, clinical characteristics and the issue of surgical repair., Results: The number of patients who enderwent surgery was 197, during 217 surgical interventions. The middle age of patients was 40,7 years with extrems of 18 and 70 years. The main causes of fistula were obstetrical (95%) and 3,5% were caused by surgery. Concerning anatomoclinic characteristic, vesicovaginal fistula was the most comon type representing 87,3%, where vesicouterine fistula represented 4,1%. Multiparity has been a risk factor for obstetrical fistula and ceasarien section was necessary in 70% with a high rate of fœtal mortality (88,2%). Surgical management was late in majority of cases, estimated at 10 years between occurrence of fistula and its reparation. The recovry rate was 78,1%., Conclusion: Urogenital fistula are principaly caused by obstetric conditions in Togo and multiparity is a risk factor. Treatment is often late but has a good rate of recovery. Their prevention goes through the fight against dystocia., Level of Evidence: IV., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Recto vaginal fistula can be secondary to various and multiple causes. However, intercourse is an exceptional cause. The objective of this work is to expose its clinical, therapeutic and prognostic particularities. We report the case of rectovaginal fistula in a 29-year-old patient, following consensual sex. She underwent posterior colpoperineorraphy under spinal anesthesia, with a favorable outcome. Post-coital recto vaginal fistula is a stigmatizing pathology responsible for polymorphic complications. Prompt care can improve quality of life and the obstetrical prognosis of the patient., Competing Interests: The authors declare no competing interests., (Copyright: Alphonse Nyong Ngalame et al.)

Purpose: Anti-cancer therapy put patients in an immunocompromised status. Reactivation of cytomegalovirus (CMV) in immunocompromised patient can cause a severe disease. Thus, we presented a case who had recurrent CMV colitis which complicate with rectovaginal fistula., Methods: We present a case of everolimus-associated cytomegalovirus colitis on a patient receiving everolimus and exemestane therapy for the treatment of metastasized breast cancer., Results: The patient presented septic shock and acute peritonitis at first. Emergency exploratory laparotomy was performed. However, only edematous changes were observed over the terminal ileum, sigmoid colon and rectum. Four weeks after operation, we found feces coming out from her vagina. Colonoscopy was done and revealed rectovaginal fistula. Colonic and rectal mucosa moderate inflammation with multiple ulcer was also noted. Biopsy was done and the pathology proved CMV colitis. After treatment with ganciclovir, her symptoms improved. Everolimus was stopped for 12 weeks and was added back with a decreasing dose paradigm for breast cancer treatment. However, another episode of CMV colitis occurred again after resuming the everolimus. After anti-virus treatment, she was discharged. Due to adverse effects, everolimus therapy was discontinued., Conclusion: The standard treatment of hormone receptor positive and HER-2 negative metastatic breast cancer is everolimus together with exemestane. Due to the immunosuppressive effects of everolimus, the medication may cause invasive fungal infection or other opportunistic infections. Such infections are serious and may even be fatal. In this case, we did not consider CMV infection until rectovaginal fistula formation. Thus, for solid cancer patients presented with fever of unknown origin, clinicians should consider potential complications of CMV infection.

Background/aim: The reported incidence of rectovaginal fistula is very low. Although some case reports have described surgical procedures, no systematic approach to the treatment of rectovaginal fistula according to diagnostic image and colonoscopy findings has been proposed. We present a comprehensive surgical strategy for rectovaginal fistula after colorectal anastomosis according to diagnostic image and colonoscopy findings., Patients and Methods: This retrospective study included 11 patients who developed rectovaginal fistula after colorectal anastomosis. Rectovaginal fistula was classified into 4 types according to contrast enema images and colonoscopy findings, i.e., "Alone type", "Dead space type", "Anastomotic stricture type", and "Dead space and Anastomotic stricture type". The surgical strategies were "Diversion (Stoma)", "Percutaneous drainage", "Anastomotic stricture type", "Endoscopic balloon dilation", "Curettage of foreign bodies", "Simple full-thickness closure", "Split-thickness closure", "Pedicled flaps packing", and "Reanastomosis". The surgical strategy appropriate for each rectovaginal fistula type was investigated., Results: Among "Alone type" cases, 5 (71.4%) healed with "only Diversion (Stoma)". "Alone type" cases (n=11) and all other cases (n=4) healed with "only Diversion (Stoma)" (n=5) or any other method (n=6) (p=0.022)., Conclusion: For treatment of rectovaginal fistula after colorectal anastomosis, less invasive treatment approaches should be attempted first., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

The formation of an advancement rectal flap could be technically demanding in the presence of high perianal of rectovaginal fistula, and the outcomes could be frustrated by the inadequate view, bleeding and a poor exposure through the standard transanal approach. The application of the transanal minimally invasive surgery (TAMIS) to the advancement rectal flap procedure could overcome these difficulties. In the lithotomy position, a partial fistulectomy was performed and the internal opening was closed. A full-thickness flap was mobilized initially through the classic transanal approach. Subsequently, the TAMIS port was inserted and the mobilization of the flap was carried on proximally for as long as required. The laparoscopic visualization allowed a perfect view, a proper orientation of the flap and accurate hemostasis. The TAMIS-flap procedure seems a promising technique to perform a long advancement rectal flap to treat high perianal or rectovaginal fistulae (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A208).

Purpose: This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF)., Methods: A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively., Results: Seven consecutive RVF patients underwent stapled transperineal repair. The mean operative time was 119 ± 42 minutes. The estimated blood loss during operation was 24 ± 14 mL. Concomitant levatorplasty was performed with 4 patients and sphincteroplasty with 2 patients. Over a median follow-up of 6 months (range 3-33 months), no case was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (mean preoperative vs postoperative Wexner scores 3 [range 3-4] vs 1 [range 1-2], respectively; P = .01)., Conclusions: Stapled transperineal repair of RVF appears safe and effective. The initial results are encouraging, suggesting the need for a more formal prospective assessment of this technique as part of a randomized trial for the management of low- and mid-vaginal fistulas.

Background/aim: Patients may present with gynecologic concerns after previous posterior sagittal anorectoplasty (PSARP) for repair of an anorectal malformation (ARM). Common findings include an inadequate or shortened perineal body, as well as introital stenosis, retained vaginal septum, and remnant rectovestibular fistula. An inadequate or shortened perineal body may impact fecal continence, sexual function and recommendations regarding obstetrical mode of delivery. We describe our experience with female patients referred to our center for evaluation of their previously repaired ARM, with a specific focus on perineal body anatomy and concomitant gynecologic abnormalities. We outline our collaborative evaluation process and findings as well as subsequent repair and outcomes., Material/methods: A single site retrospective chart review from May 2014 to May 2016 was performed. Female patients with a history of prior ARM repair who required subsequent reoperative surgical repair with perineoplasty were included. The decision for reoperation was made collaboratively after a multidisciplinary evaluation by colorectal surgery, urology, and gynecology which included examination under anesthesia (EUA) with cystoscopy, vaginoscopy, rectal examination, and electrical stimulation of anal sphincters. The type of original malformation, indication for reoperative perineoplasty, findings leading to additional procedures performed at time of perineoplasty, postoperative complications, and the length of follow up were recorded., Results: During the study period 28 patients were referred for evaluation after primary ARM repair elsewhere and 15 patients (60%) met inclusion criteria. Thirteen patients (86.6%) originally had a rectovestibular fistula with prior PSARP and 2 patients (13.4%) originally had a cloacal malformation with prior posterior sagittal anorectovaginourethroplasty. The mean age at the time of the subsequent perineoplasty was 4.6years (0.5-12). Patients had an inadequate perineal body requiring reoperative perineoplasty due to: anterior mislocation of the anus (n=11, 73.3%), prior perineal wound dehiscence with perineal body breakdown (n=2, 13.4%), acquired rectovaginal fistula (n=1, 6.6%), and posterior mislocated introitus with invasion of the perineal body (n=1, 6.6%). During the preoperative evaluation, additional gynecologic abnormalities were identified that required concomitant surgical intervention including: introital stenosis (n=4, 26.6%), retained vaginal septum (n=3, 20%) and remnant recto vestibular fistula (n=2, 13.3%)., Conclusions: Patients with a previously repaired ARM may present with gynecologic concerns that require subsequent surgical intervention. The most common finding was an inadequate perineal body, but other findings included introital stenosis, retained vaginal septum and remnant recto vestibular fistula. Multidisciplinary evaluation to assess and identify abnormalities and coordinate timing and surgical approach is crucial to assure optimal patient outcomes., Type of Study: Case series with no comparison group., Level of Evidence: IV., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective This study was performed to identify risk factors for postoperative rectovaginal fistula (PRF) in patients with deep infiltrating endometriosis (DIE). Methods Data were retrospectively obtained from the medical records of 104 patients with DIE, and statistical analysis was used to detect risk factors for PRF. Results Five of 104 (4.8%) patients developed PRF from 5 to 16 days postoperatively. The operative procedures included 84 (80.8%) superficial excisions, 6 (5.8%) full-thickness disc excisions, and 14 (13.5%) bowel resections. Most lesions were located in the cul-de-sac, and the mean lesion size was 2.6 cm (range, 0.5-7.0 cm). The univariate analysis showed that lesion location, larger lesion size, and surgical technique were statistically significant risk factors for PRF. Conclusion Surgical procedures should be very carefully executed in patients with DIE lesions of ≥4 cm.

Rectovaginal fistulae after sexual intercourse are rare. We report a healthy recently married 21-year-old woman who presented to the Jordan Healthcare Centre, Amman, Jordan in 2014 with a five-week history of passing flatus and stool from the vagina. Six weeks prior, she had sustained a rectovaginal injury during initial consensual sexual intercourse, leading to the development of a distal rectovaginal fistula . A successful transvaginal repair was performed nine weeks after presentation which resulted in the complete resolution of her symptoms.

Objective: To validate a symptom-based fistula screening questionnaire and estimate obstetric fistula (OF) prevalence in rural Nepal., Design: Cross-sectional and nested case-control study., Setting: Sarlahi District, Nepal., Population: Parous, reproductive age women., Methods: The questionnaire assessed symptoms of vesicovaginal and rectovaginal fistula (VVF and RVF, respectively), stress and urge urinary incontinence (SUI and UUI, respectively), fecal incontinence (FI), and included interviewer observations on the smell and presence of urine and/or stool. All women who screened positive for OF and a randomly selected group of women who screened negative for OF were included in a nested case-control study (one case, four normal controls, and four incontinent controls) and underwent confirmatory clinical examinations., Main Outcome Measures: Clinically confirmed OF, and questionnaire sensitivity (Se) and specificity (Sp)., Results: Of the 16 893 women who completed cross-sectional screening, 68 were screened-positive cases. Fifty-five (82%) screened-positive cases, 203 screened-negative normal controls, and 203 screened-incontinent controls participated in the case-control study, which confirmed one case of VVF and one case of both VVF and RVF without any false-negative cases. For VVF, the screening tool demonstrated Se 100% (95% CI 34.2-100.0%), Sp 86.9% (95% CI 83.3-89.9%), and estimated VVF prevalence as 12 per 100 000 (95% CI 3-43); for RVF, it demonstrated Se 100% (95% CI 20.7-100.0), Sp 99.8% (95% CI 98.6-100.0), and estimated RVF prevalence as 6 per 100 000 (95% CI 1-34)., Conclusions: The OF screening questionnaire demonstrated high sensitivity and specificity in this low-prevalence setting., Tweetable Abstract: Community-based obstetric fistula screening tool validation study, Nepal, n = 16 893: High Se, Sp & feasibility., (© 2016 Royal College of Obstetricians and Gynaecologists.)

Introduction: Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.

A 26 year-old female patient was admitted for the first time in the surgical, presenting an abnormal connection between the rectum and vagina given a context of an apparently clear period of time following a natural childbirth 1 year and 10 months ago. This is a rare pathological condition with a major physical, mental and sexual impact for a young female. Various surgical treatment solutions are described in the specialized literature. Yet, we have not come across any studies that analyzed the various means of surgical treatment. In what follows we will describe the technique we used in this case, with a very good immediate result and after 5 years by surgery., (Celsius.)

Background: The association of rectovestibular fistula (RVF) and vaginal agenesis (VA) presents a diagnostic and management challenge. The vaginal replacement is usually performed with rectum or sigmoid, which are the natural fecal reservoirs; thus, the fecal control could be affected. We present our experience utilizing ileum to preserve the rectum and sigmoid., Methods: We performed a retrospective study of eight patients with RVF and VA treated from May 2011 to June 2015 at two colorectal centers, at Pittsburgh and Mexico. We recorded the age at diagnosis of VA, treatment, presence of other associated malformations and outcome., Results: Eight of forty-nine girls with RVF had an associated VA (16.3%). Three patients had a timely diagnosis and five a delayed diagnosis. Six patients were submitted to a vaginal replacement with ileum and achieved fecal control. Two are waiting for surgery., Conclusions: A high index of suspicion of vaginal agenesis helps in a timely diagnosis in girls with RVF. The use of ileum allows for preservation of the fecal reservoirs, thus optimizing the chance for fecal control in patients with anorectal malformations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

BACKGROUND This study reports the pathogenesis of anal canal adenocarcinoma in a patient with longstanding Crohn's disease (CD). CASE REPORT A 50-year-old woman with a 33-year history of CD presented with perianal pain of several months' duration. She had been treated surgically for a rectovaginal fistula 26 years earlier and had been treated with infliximab (IFX) for the previous 4 years. A biopsy under anesthesia revealed an anal canal adenocarcinoma, which was removed by abdominoperineal resection. Pathological examination showed that a large part of the tumor consisted of mucinous adenocarcinoma at the same location as the rectovaginal fistula had been removed 26 years earlier. There was no evidence of recurrent rectovaginal fistula, but thick fibers surrounded the tumor, likely representing part of the previous rectovaginal fistula. Immunohistochemical analysis using antibodies against cytokeratins (CK20 and CK7) revealed that the adenocarcinoma arose from the rectal mucosa, not the anal glands. CONCLUSIONS Mucinous adenocarcinoma can arise in patients with CD, even in the absence of longstanding perianal disease, and may be associated with adenomatous transformation of the epithelial lining in a former fistula tract.

Background: Rectovaginal fistula (RVF) refers to a pathological passage between the rectum and vagina, which is a public health challenge. This study was aimed to explore the clinical value of endoluminal biplane ultrasonography in the diagnosis of rectovaginal fistula (RVF)., Methods: Thirty inpatients and outpatients with suspected RVF from January 2006 to June 2013 were included in the study, among whom 28 underwent surgical repair. All 28 patients underwent preoperative endoluminal ultrasonography, and the obtained diagnostic results were compared with the corresponding surgical results., Results: All of the internal openings located at the anal canal and rectum of the 28 patients and confirmed during surgery were revealed by preoperative endosonography, which showed a positive predictive value of 100%. Regarding the 30 internal openings located in the vagina during surgery, the positive predictive value of preoperative endosonography was 93%. The six cases of simple fistulas confirmed during surgery were revealed by endosonography; for the 22 cases of complex fistula confirmed during surgery, the positive predictive value of endosonography was 90%. Surgery confirmed 14 cases of anal fistula and 14 cases of RVF, whereas preoperative endoluminal ultrasonography suggested 16 cases of anal fistula and 12 cases of RVF, resulting in positive predictive values of 92.3 and 93%, respectively., Conclusion: The use of endoluminal biplane ultrasonography in the diagnosis of RVF can accurately determine the internal openings in the rectum or vagina and can relatively accurately identify concomitant branches and abscesses located in the rectovaginal septum. Thus, it is a good imaging tool for examining internal and external anal sphincter injuries and provides useful information for preoperative preparation and postoperative evaluation.

Background and Aims: Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience., Materials and Methods: Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected., Results: Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71%) high fistulas (including 4 rectovaginal fistulas), 5 (29%) lower fistulas (with 3 rectovaginal fistulas), and 6 (35%) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47%) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65%) patients. A clip migration was noted in 11 patients (65%) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65%) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12%) following the first insertion of the clip and in another one after a second insertion., Conclusion: Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

A lower urinary tract fistula consist in an abnormal connection between bladder, urethra and adjacent abdominal organs or skin. There are several types of urinary fistulas in paediatric age and they may be congenital or acquired. Etiology may be due to embriological defects, infectious processes, malignant tumours, pelvic irradiation as well as complications following surgical procedures, especially postsurgical repair of hypospadia or epispadia. Clinical presentation depends on the type of fistula and diagnosis is based on signs, symptoms and radiological or endoscopic examinations. We performed PubMed research using terms such as lower urinary fistulae, urology and paediatrics and we consulted medical texts. We reviewed selected articles and used the relevant ones to perform our study concentrating on classification, diagnosis and treatment of different types of fistulas. Paediatric lower urinary fistulas are an uncommon pathology, but the knowledge of their etiology and classification is important to recognise them and lead the physician to an appropriate treatment, which is surgical in most cases.

The presence of terminal ileum and complete colonic duplication associated with a rectovestibular fistula, caecal diverticulum and multiple appendixes in a child presents an extremely rare diagnostic and management conundrum. We report our surgical approach to successfully correcting this anomaly.

Background: Obstetric fistula continues to have devastating effects on the physical, social, and economic lives of thousands of women in many low-resource settings. Governments require credible estimates of the backlog of existing cases requiring care to effectively plan for the treatment of fistula cases. Our study aims to quantify the backlog of obstetric fistula cases within two states via community-based screenings and to assess the questions in the Demographic Health Survey (DHS) fistula module., Methods: The screening sites, all lower level health facilities, were selected based on their geographic coverage, prior relationships with the communities and availability of fistula surgery facilities in the state. This cross-sectional study included women who presented for fistula screenings at study facilities based on their perceived fistula-like symptoms. Research assistants administered the pre-screening questionnaire. Nurse-midwives then conducted a medical exam. Univariate and bivariate analyses are presented., Results: A total of 268 women attended the screenings. Based on the pre-screening interview, the backlog of fistula cases reported was 75 (28% of women screened). The backlog identified after the medical exam was 26 fistula cases (29.5% of women screened) in Kebbi State sites and 12 cases in Cross River State sites (6.7%). Verification assessment showed that the DHS questionnaire had 92% sensitivity, 83% specificity with 47% positive predictive value and 98% negative predictive value for identifying women afflicted by fistula among women who came for the screenings., Conclusions: This methodology, involving effective, locally appropriate messaging and community outreach followed up with medical examination by nurse-midwives at lower level facilities, is challenging, but represents a promising approach to identify the backlog of women needing surgery and to link them with surgical facilities.

Purpose: Rectovaginal fistulas constitute a serious burden for the affected patient and a major challenge for the attending surgeon. Definitive surgical treatment of the fistula depends on the size and location of the fistula, the underlying disease, and any previous therapies. In regards to complicated recurrent rectovaginal fistulas, transposition of the gracilis muscle is one of the well-established therapeutic options with a success rate of up to 70%., Material and Methods: Between 01/2004 and 06/2010, ten patients diagnosed with a recurrent rectovaginal fistula were treated in the surgical department of Klinikum Oldenburg by gracilis muscle transposition; their data were collected and analyzed. Post-operative evaluation was performed using a standardized telephone interview. All patients had a protective stoma. The primary endpoint of assessment was the long-term healing of the fistula following stoma reversal, and the comparison between those who were treated successfully versus those who were not., Results: Over a time span of 6years, ten women with a complicated rectovaginal fistula underwent fistula repair with the gracilis muscle transposition. Patient age ranged from 29 and 64years. There were five rectovaginal fistulas, four pouch-vaginal fistulas, and one anovaginal fistula. The underlying disease was rectal cancer in seven patients, Crohn's disease in one patient, previous complicated gynecologic surgery in one patient, and idiopathic anal fistula in one patient. All seven patients with rectal cancer underwent radiochemotherapy with 50.4Gy (n=6 neo-adjuvant, n=1 adjuvant). All ten patients had previously undergone repair by a different surgical approach while five presented with a second or third recurrence. Post-operative complications were noted in two patients (perineal wound defect, thigh hematoma). Follow-up of the patients ranged from 8 to 60months. Recurrent rectovaginal fistula occurred in four patients. Evaluation of the data failed to identify statistically significant criteria for treatment failure of rectovaginal fistula repair., Conclusion: Our results are similar to previous studies in this area. For the majority of the patients, the gracilis muscle transposition was a long-term effective treatment of recurrent rectovaginal fistulas, however recurrences were noted in 40% of cases. Predictive criteria for treatment failure could not be established., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: High diagnostic accuracy is reported for magnetic resonance enterography (MRE) in Crohn's disease (CD), but few studies have evaluated its role in abdominal fistulae. The primary aim of this study was to assess the reliability of MRE in the identification of internal fistulae in CD., Methods: One hundred and eighty-six patients with moderate CD (CD Activity Index : 250-400) were prospectively selected from the inflammatory bowel disease clinic of Parma University Hospital. Eligible patients had already undergone nutritional screening, pancolonoscopy, and computed tomography enterography (CTE) in the month before enrollment. MRE was performed according to the study protocol. Additional fluoroscopic contrast-enhanced studies or surgical evaluation were used for discordance between CTE and MRE results. A consensus committee resolved equivocal findings. Surgical findings and/or fluoroscopic contrast-enhanced studies together with the clinical data were considered the composite "reference standard" to which the results of MRE were compared., Results: MRE identified 22 internal fistulae in 21 patients (11%), of whom 4 (19%) also had perianal fistulae and found 7 abscesses (33%). Forty-one (22%) additional patients with perianal fistulae were identified. Thirteen patients (57%) with internal fistulae required enteral nutrition support. No statistically significant differences were found between MRE and CTE in fistula detection. There was also no significant difference between MRE and the composite diagnosis in those who underwent surgery (n = 8) and/or contrast-enhanced studies (n = 7)., Conclusions: CTE and MRE accurately detect internal fistulae in CD. MRE is preferable because it avoids radiation. Reliable identification of internal fistulae by MRE should permit earlier and improved treatment.

Contrast fistulogram (FG) and distal pressure colostogram (DPCG) are standard diagnostic methods for the assessment of anorectal malformations. Pelvic magnetic resonance imaging (MRI) earned a place among essential diagnostic methods in preoperative investigations after the Currarino syndrome and a high incidence of associated spinal dysraphism were described. The aim of our study was to evaluate the possibility of substituting FG and DPCG by a modified pelvic MRI, e.g. MRI fistulogram (MRI-FG) and MRI colostogram (MRI-DPCG). The prospective study involved 29 patients with anorectal malformations who underwent a modified pelvic MRI. The length and course of fistulas and rectum, and the presence of sacral anomalies were studied on MRI images and compared with images obtained by radiologic examinations. Modified MRI brought identical results as contrast studies in 25 patients when related to the fistula and rectum length and course. MRI was more accurate for the detection of sacral anomalies. MRI-FG was the only imaging method used in the four most recent patients. The results support the assumption that conventional contrast examinations for the assessment of anorectal malformations can be replaced by MRI, thus reducing the radiation dose., (© 2013.)

Background: Pelvic osteomyelitis is a rare but serious condition that has the potential for systemic and muscular complications if left untreated. The diagnosis is difficult due to the relative rarity of the disease, the difficulty of localizing the site of the infection, and the tendency for the presentation to mimic other disease processes., Case: A 13-year-old female who presented with complaint of severe right lower abdominal pain thought to be related to a hemorrhagic cyst but was found to have pubic osteomyelitis resulting in an abscess and vaginal fistula., Conclusion: Although rare, pelvic osteomyelitis should be included in the differential diagnosis of pelvic pain., (Published by Elsevier Inc.)

Background: The purpose of the paper is to review the incidence of associated congenital anomalies that are encountered in patients presenting anorectal malformations and compare these results with those previously published., Material and Methods: A number of 50 cases with ARM from our institution were reviewed (from 2005 to 2012) and information was collected on patient demographics, type of ARM and associated congenital anomalies, the latter being then categorized according to organ systems., Results: Out of 50 newborns, 28 were males and 22 females (1.27:1). 34 (68%) had at least one associated abnormality. The majority of patients (40%) had imperforated anus without fistula. The most frequent seen anomalies were gastrointestinal (36%), urogenital (24%) and cardiovascular (16%)., Conclusions: More than half of the children included in our series have other associated abnormalities. We found gastrointestinal anomalies to be the most common associated congenital defects in our patients. A higher incidence of this type of anomalies was encountered in newborns with persistent cloacal anomaly. The rectovestibular fistula group was most likely to present cardiac abnormalities. The incidence of genitourinary anomalies in the perineal fistula group is higher than the one described in other studies., (Celsius.)

The combination of an H-type rectovestibular fistula (RVF) and a normal anus is a rare type of anorectal malformation, resulting in abnormal communication between the normal rectum and vestibule in girls. Among the surgical methods used to treat this condition are simple fistula resection and extensive perineal dissection, but postoperative fistula recurrence is frequent. We utilized the endorectal mucosal advancement flap technique on three patients with H-type RVFs and a normal anus, all of whom had favorable outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.

Congenital rectovestibular fistulas with normal anus are a rare form of anorectal malformations, especially in the Western hemisphere. Due to its rarity, consensus on preoperative management, surgical technique and postoperative care is still in debate. We describe a specific case with its management plan and outcomes while providing an up to date literature review on current management trends.

Objective: To assess the impact of rectovaginal endometriosis on pain at intercourse and sexual functioning., Design: Case-control study., Setting: Academic department., Patient(s): Case subjects were women with rectovaginal endometriosis (n = 100), and control subjects were women with a surgical diagnosis of peritoneal and/or ovarian endometriosis (n = 100) or without endometriosis (n = 100)., Intervention(s): Questionnaires (visual analogue scale [VAS] and revised Sabbatsberg Sexual Self-Rating Scale [SRS])., Main Outcome Measure(s): Frequency and severity of deep dyspareunia and sexual functioning., Result(s): Deep dyspareunia was reported by 67/100 (67%) women in the rectovaginal endometriosis group, 52/99 (53%) in the peritoneal and/or ovarian endometriosis group, and 24/93 (26%) in the nonendometriosis group. Mean ± SD dyspareunia VAS scores were, respectively, 44 ± 34, 30 ± 32, and 13 ± 26. Women in both endometriosis groups performed significantly worse than those in the nonendometriosis group in several SRS subdomains. No significant difference in overall SRS score was detected between women in the two endometriosis groups., Conclusion(s): Women with endometriosis experienced more frequent and severe deep dyspareunia and worse sexual functioning compared with women without endometriosis, whereas differences between women with diverse endometriosis forms were marginal., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management., Methods: Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution., Results: Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain., Conclusions: This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

Objective: To establish knowledge and practice of contraception among patients presenting with a fistula attending fistula care services at 4 centers in Kenya., Methods: In a descriptive cohort study carried out between January and December 2011, patients presenting with a history of urine and/or stool leakage were screened and those with confirmed diagnosis of fistula were assessed and prepared for surgery. Informed consent was obtained from study participants before surgical intervention. After surgery, a standard questionnaire was used to collect information on sociodemographics, duration of leakage, and reproductive health practices., Results: A total of 206 patients were interviewed. Most of the patients were young (mean age 22 years). Literacy was low: only 1.7% reported tertiary-level education, and 56.7% reported primary-level education. With regard to family planning, 76.2% of patients expressed a willingness to use contraception after fistula repair., Conclusion: Among patients presenting with a fistula in Kenya, the unmet need for family planning was high. There is an urgent need for healthcare providers to integrate family planning services in fistula care programs., (Copyright © 2012 International Federation of Gynecology and Obstetrics. All rights reserved.)

Introduction: The rectovaginal fistula is a rare entity with heterogenic causality. Its genesis seems to predict the extent of operative treatment and the prognostic outcome. The aim of this study was to present different surgical techniques in the treatment of rectovaginal fistulas and their results in correspondence to the genesis., Material and Methods: Between 1 / 2000 and 1 / 2010, the data of patients with rectovaginal fistulas were collected. The retrospective analysis included biographic and anamnestic data as well as clinical parameters, general and specific complications and postoperative data., Results: In a timespan of ten years 36 patients with rectovaginal fistulas were treated. The most common causes were inflammatory diseases (n = 21) and earlier surgical measures (n = 6). Moreover tumour-associated fistulas (n = 5) and fistulas with unknown genesis (n = 4) were seen. As surgical techniques anterior resection (n = 21), transrectal flap plasty (n = 7), subtotal colectomy (n = 3), pelvine exenteration (n = 2) and rectal exstirpation (n = 1) were used. The closure of the vaginal lesion was performed by single suture (n = 25), flap plasty (n = 6), transvaginal omental plasty (n = 2) and posterior vaginal plasty (n = 1). All patients were provided with an omental plasty to perform a safe division of the concerned regions. Patients with a low fistula ( < 6 cm) were treated with transperineal omental plasty. The median follow-up was 12 months (6 - 36). Within this timespan 6 patients suffered from major complications [ARDS, anastomosis insufficiency, postoperative bleeding, recurrence of fistula (n = 3)]. Three patients died in the postoperative period (cerebellar infarct, septic complication associated with Crohn's disease, multiorgan failure in tumour recurrence)., Conclusion: The genesis of rectovaginal fistulae is an important predictor for the size of resection which can range from simple excision to exenteration. For optimal therapy the surgical intervention needs to be integrated into an interdisciplinary therapy concept., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life., Aims: To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients., Results: A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases., Conclusion: Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment., (Copyright © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.)