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Anovaginal Fistulas: Evaluation with Endoanal MR Imaging¹

¹ From the Departments of Radiology (S.D., S.M.H., G.P.K.) and Epidemiology and Biostatistics (W.C.J.H.), Erasmus Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands. From the 2001 RSNA scientific assembly. Received September 16, 2002; revision requested November 26; final revision received July 14, 2003; accepted August 22. Address correspondence to S.M.H. (e-mail: smhussain62@hotmail.com).

View larger version (142K): [in a new window]   Figure 1a. Simple anovaginal fistula. (a) Transverse T2-weighted fast SE MR image (2,500/100) shows an anovaginal fistula (straight arrow) as a high-signal-intensity linear abnormality, with direct depiction of the internal openings with the anal canal containing the endoanal coil () and the vagina containing some air (curved arrow). (b) Sagittal T2-weighted fast SE MR image (2,443/100) confirms the findings of transverse MR imaging and shows the relationship of the anovaginal fistula (thin straight arrow) to the lower edge of the anal sphincter complex (thick straight arrows) that clinically indicates the position of the anal verge. The vagina (curved arrow), puborectal muscle (arrowhead), and endoanal coil () are also shown.

View larger version (152K): [in a new window]   Figure 1b. Simple anovaginal fistula. (a) Transverse T2-weighted fast SE MR image (2,500/100) shows an anovaginal fistula (straight arrow) as a high-signal-intensity linear abnormality, with direct depiction of the internal openings with the anal canal containing the endoanal coil () and the vagina containing some air (curved arrow). (b) Sagittal T2-weighted fast SE MR image (2,443/100) confirms the findings of transverse MR imaging and shows the relationship of the anovaginal fistula (thin straight arrow) to the lower edge of the anal sphincter complex (thick straight arrows) that clinically indicates the position of the anal verge. The vagina (curved arrow), puborectal muscle (arrowhead), and endoanal coil () are also shown.

View larger version (170K): [in a new window]   Figure 2a. Anovaginal fistula with an additional extension between the anus and the vagina. (a) Transverse T2-weighted fast SE image (2,500/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) containing low-signal-intensity air bubbles (arrowhead). The vagina (curved arrow), external anal sphincter (thick straight arrow), and endoanal coil () are also seen. (b) Midsagittal T2-weighted fast SE image (2,443/100) shows the anovaginal fistula (thin straight arrow) and a part of an additional caudal extension (arrowhead). The vagina (curved arrow), external anal sphincter (thick straight arrow), and endoanal coil () are also shown.

View larger version (157K): [in a new window]   Figure 2b. Anovaginal fistula with an additional extension between the anus and the vagina. (a) Transverse T2-weighted fast SE image (2,500/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) containing low-signal-intensity air bubbles (arrowhead). The vagina (curved arrow), external anal sphincter (thick straight arrow), and endoanal coil () are also seen. (b) Midsagittal T2-weighted fast SE image (2,443/100) shows the anovaginal fistula (thin straight arrow) and a part of an additional caudal extension (arrowhead). The vagina (curved arrow), external anal sphincter (thick straight arrow), and endoanal coil () are also shown.

View larger version (149K): [in a new window]   Figure 3a. Anovaginal fistula with an additional perianal intersphincteric fistula. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with a large internal opening in the anal canal (arrowhead). Note edema of the posterior vaginal wall (curved arrow). The external anal sphincter (thick straight arrow) and endoanal coil () are also shown. (b) Transverse T2-weighted fast SE MR image (2,500/100) obtained at the level of the puborectal muscle shows a perianal intersphincteric fistula (thin straight arrow) between the internal anal sphincter (arrowhead) and the puborectal muscle (thick straight arrow). The vagina (curved arrow) and endoanal coil () are also seen. (c) Coronal T2-weighted MR image (2,443/100) shows the intersphincteric fistula with full longitudinal extension (thin straight arrows). Note the healthy external anal sphincter (curved arrow), the puborectal muscle (thick straight arrow), and the internal anal sphincter (arrowhead) on the right side of the anal canal. Also, note that the internal sphincter on the left side of the anal canal is barely visible, which is mainly due to thinning. The endoanal coil () is also shown.

View larger version (168K): [in a new window]   Figure 3b. Anovaginal fistula with an additional perianal intersphincteric fistula. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with a large internal opening in the anal canal (arrowhead). Note edema of the posterior vaginal wall (curved arrow). The external anal sphincter (thick straight arrow) and endoanal coil () are also shown. (b) Transverse T2-weighted fast SE MR image (2,500/100) obtained at the level of the puborectal muscle shows a perianal intersphincteric fistula (thin straight arrow) between the internal anal sphincter (arrowhead) and the puborectal muscle (thick straight arrow). The vagina (curved arrow) and endoanal coil () are also seen. (c) Coronal T2-weighted MR image (2,443/100) shows the intersphincteric fistula with full longitudinal extension (thin straight arrows). Note the healthy external anal sphincter (curved arrow), the puborectal muscle (thick straight arrow), and the internal anal sphincter (arrowhead) on the right side of the anal canal. Also, note that the internal sphincter on the left side of the anal canal is barely visible, which is mainly due to thinning. The endoanal coil () is also shown.

View larger version (168K): [in a new window]   Figure 3c. Anovaginal fistula with an additional perianal intersphincteric fistula. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with a large internal opening in the anal canal (arrowhead). Note edema of the posterior vaginal wall (curved arrow). The external anal sphincter (thick straight arrow) and endoanal coil () are also shown. (b) Transverse T2-weighted fast SE MR image (2,500/100) obtained at the level of the puborectal muscle shows a perianal intersphincteric fistula (thin straight arrow) between the internal anal sphincter (arrowhead) and the puborectal muscle (thick straight arrow). The vagina (curved arrow) and endoanal coil () are also seen. (c) Coronal T2-weighted MR image (2,443/100) shows the intersphincteric fistula with full longitudinal extension (thin straight arrows). Note the healthy external anal sphincter (curved arrow), the puborectal muscle (thick straight arrow), and the internal anal sphincter (arrowhead) on the right side of the anal canal. Also, note that the internal sphincter on the left side of the anal canal is barely visible, which is mainly due to thinning. The endoanal coil () is also shown.

View larger version (180K): [in a new window]   Figure 4a. Anovaginal fistula with multiple small abscesses in the rectovaginal septum. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with small abscesses within the rectovaginal septum (arrowhead). The endoanal coil () is also shown. (b) Transverse T2-weighted MR image obtained without fat saturation (2,500/100) shows the anovaginal fistula (thin straight arrow) with multiple abscesses (arrowheads) within the rectovaginal septum. The vagina (curved arrow), puborectal muscle (thick straight arrow), and endoanal coil () are also shown. (c) Transverse T2-weighted MR image obtained with fat saturation (5,086/100) facilitates improved delineation of the anovaginal fistula (thin straight arrow) and multiple abscesses (arrowheads) as high signal intensity structures due to the suppressed signal of fatty tissue. The puborectal muscle (thick straight arrow) is not well delineated due to fat suppression. The vagina (curved arrow) and endoanal coil () are also shown.

View larger version (146K): [in a new window]   Figure 4b. Anovaginal fistula with multiple small abscesses in the rectovaginal septum. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with small abscesses within the rectovaginal septum (arrowhead). The endoanal coil () is also shown. (b) Transverse T2-weighted MR image obtained without fat saturation (2,500/100) shows the anovaginal fistula (thin straight arrow) with multiple abscesses (arrowheads) within the rectovaginal septum. The vagina (curved arrow), puborectal muscle (thick straight arrow), and endoanal coil () are also shown. (c) Transverse T2-weighted MR image obtained with fat saturation (5,086/100) facilitates improved delineation of the anovaginal fistula (thin straight arrow) and multiple abscesses (arrowheads) as high signal intensity structures due to the suppressed signal of fatty tissue. The puborectal muscle (thick straight arrow) is not well delineated due to fat suppression. The vagina (curved arrow) and endoanal coil () are also shown.

View larger version (151K): [in a new window]   Figure 4c. Anovaginal fistula with multiple small abscesses in the rectovaginal septum. (a) Sagittal T2-weighted fast SE MR image (2,454/100) shows a high-signal-intensity anovaginal fistula (thin straight arrow) with small abscesses within the rectovaginal septum (arrowhead). The endoanal coil () is also shown. (b) Transverse T2-weighted MR image obtained without fat saturation (2,500/100) shows the anovaginal fistula (thin straight arrow) with multiple abscesses (arrowheads) within the rectovaginal septum. The vagina (curved arrow), puborectal muscle (thick straight arrow), and endoanal coil () are also shown. (c) Transverse T2-weighted MR image obtained with fat saturation (5,086/100) facilitates improved delineation of the anovaginal fistula (thin straight arrow) and multiple abscesses (arrowheads) as high signal intensity structures due to the suppressed signal of fatty tissue. The puborectal muscle (thick straight arrow) is not well delineated due to fat suppression. The vagina (curved arrow) and endoanal coil () are also shown.

View larger version (156K): [in a new window]   Figure 5a. Anovaginal fistula with sphincter damage. (a) Sagittal T2-weighted fast SE MR image (2,443/100) shows high-signal-intensity anovaginal fistula (thin straight arrow) between the anal canal and the posterior wall of the vagina (curved arrow). The endoanal coil () is also shown. (b) Coronal T2-weighted fast SE MR image (2,443/100) shows thickening and scarring of the external anal sphincter (thick straight arrow) on the left side. The internal sphincter shows thinning on the left side (thin straight arrow), whereas the sphincter remains healthy on the right side (arrowhead). The puborectal muscle (curved arrow) and endoanal coil () are also shown.

View larger version (140K): [in a new window]   Figure 5b. Anovaginal fistula with sphincter damage. (a) Sagittal T2-weighted fast SE MR image (2,443/100) shows high-signal-intensity anovaginal fistula (thin straight arrow) between the anal canal and the posterior wall of the vagina (curved arrow). The endoanal coil () is also shown. (b) Coronal T2-weighted fast SE MR image (2,443/100) shows thickening and scarring of the external anal sphincter (thick straight arrow) on the left side. The internal sphincter shows thinning on the left side (thin straight arrow), whereas the sphincter remains healthy on the right side (arrowhead). The puborectal muscle (curved arrow) and endoanal coil () are also shown.