Despite various advances in surgical technique, improvements in technology and the ongoing accumulation of knowledge gained by clinical experience, rectovaginal fistulas remain complicated entities to treat. Arguably, achieving definitive success in its repair can be as troublesome to the surgeons undertaking the challenge of treatment as it is debilitating to those that suffer from its manifestations. Multiple options exist in the armamentarium to repair rectovaginal fistula. Low, small fistulas, typically a result of cryptoglandular disease or obstetrical trauma, are amenable to local repairs, often without protective diversion. In contrast, high or more complex fistulas, typically those that are sequelae of inflammatory bowel disease, malignancy, or radiation, often warrant more extensive repairs incorporating tissue interposition with the protection of temporary proximal diversion. Finally, the choice of repair depends on the presence or absence of associated sphincter injury, as many patients with obstetrical trauma will have an anterior sphincter defect. It is critical to address associated sphincter defect during repair of this subset of rectovaginal fistulas if such a defect is identified. If no sphincter defect is identified, the choice of local repair becomes a matter of surgeon preference and experience.