Management of pouch vaginal fistulae in ulcerative colitis: A 35-year experience

Abstract Background Pouch vaginal fistulae (PVF) occur following restorative proctocolectomy with an incidence of 6%. The overall rate of pouch failure is 10% but may be as high as 29% with a PVF. PVF can be relatively asymptomatic, with low volume vaginal mucus discharge alone, or can cause considerable morbidity with persistent, passive leakage of faeces and gross perianal excoriation. Management is challenging with a range of reparative techniques reported and no gold standard. Despite a lack of evidence, anti-TNF agents are increasingly used. It is unclear whether there are factors which may predict fistula closure with anti-TNF therapy. The primary aim of fistula therapy should be fistula eradication or amelioration of fistula symptoms without worsening pouch function. Methods This is a retrospective analysis of the management of PVF in ulcerative colitis in a tertiary referral centre. Demographic, clinical history and presenting symptoms of fistula including pouch function were collected. Symptomatic burden related to the fistula and the presence or absence of gastrointestinal continuity were assessed. Results Fifty patients with PVF were identified between 1984 and 2019 and complete clinical notes were available and analysed for 30 of these. The median age at diagnosis was 36 (range 19–52) years. The median follow-up from pouch creation was 12.5 years. A PVF developed in 30% within 1 year of pouch creation and in 70% after 1 year. In this cohort, 17 (56%) maintained gastrointestinal continuity, of whom 13 were asymptomatic of fistula symptoms (11 after intervention), while 4 were symptomatic but declined intervention. Of the 11 patients who were asymptomatic following treatment, 3 had perianal pouch advancement, 1 had a redo transabdominal pouch, 2 had transvaginal repair, 2 had seton drainage and 3 patients were managed with anti-TNF therapy. Anti-TNF agents were used in 5 patients, 1 of whom was already defunctioned. Three achieved quiescence of symptoms, with 1 requiring pouch excision due to ongoing symptoms. Three patients with poor pouch function prior to anti-TNF therapy noted an improvement in pouch function. Pouch excision or permanent defunctioning was performed in 13 patients (predominantly due to the burden of fistula symptoms rather than poor pouch function). Conclusion Around 50% of patients with PVF required pouch excision or permanent defunctioning. The burden of fistula symptoms drove this decision, rather than overall poor pouch function. Anti- TNF therapy improved pouch function and fistula symptoms in a small group of patients but the evidence supporting its use and indications remain limited.