Rectocele Repair
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As women age the prevalence of pelvic floor dysfunction increases, including pelvic organ prolapse. A woman’s lifetime risk of having surgery for pelvic organ prolapse is 13%. [1] The United States population is getting older. Based on data from the United States Census Bureau in 2009, women older than 65 years account for 14% of the population. [2] This percentage is suspected to double in the next 25 years. [3] With this increase, there will be an increasing demand for prolapse repair, including rectocele repairs.
Up to one third or one half of women undergoing surgery for prolapse will involve the posterior vaginal wall. [4, 5] Rectoceles are one type of posterior compartment prolapse that consists of the rectum protruding into the vagina. Other conditions that impact the posterior wall include enteroceles, sigmoidoceles, intussusception and rectal prolapse. Posterior vaginal wall prolapse can manifest as an asymptomatic bulge or with bothersome symptoms such as constipation, pelvic pressure, and defecatory dysfunction including obstructed defecation. The gynecologist must keep in mind that surgical treatment should be reserved for symptomatic patients only.
Nonsurgical options for management of rectocele include expectant management, treatment of constipation, pelvic floor muscle training, and treatment with a pessary. In a study of patients with both rectoceles and obstructed defecation, 70% of patients improved. Further information on nonsurgical management can be found in the Medscape section on Rectocele: Treatment & Management.
Rectocele repair encompasses a number of surgical management options for symptomatic posterior prolapse. Determining the most appropriate candidates for surgical repair can be difficult due to a lack of correlation among symptoms and stage of prolapse. [6, 7]
Rectocele repair has few contraindications, including anticoagulation that cannot be suspended prior to the procedure or other medical problems in which the risk of surgery outweighs the benefits.
An understanding of pelvic anatomy and the defect in the anatomy of the posterior vaginal wall is paramount to successful repair of rectoceles. DeLancey originally divided the vaginal axis into three levels of support for the posterior vaginal wall. At the apex of the vagina, the cardinal-uterosacral complex suspends the vagina. The middle of the vagina is supported by the endopelvic fascia and the levator ani. Level three support, at the most caudal portion of the vagina, is represented by the perineal body and perineal membrane. [8] Identification of the breakdown in each level of support as well as addressing each level of support with repair will help in surgical planning and prevent the need for reoperation.
The rectovaginal septum has an important role in maintaining posterior vaginal wall integrity. This fascia runs downward and integrates distally into the perineal body. This tissue forms the anterior surface of the rectovaginal space and is thinnest along the midline. The rectovaginal septum is made of dense fibromuscular elastic tissue. [8] The distension and tearing of these fibers during childbirth may cause posterior wall prolapse. Separation of the rectovaginal septum transversely causes the uppermost type of rectocele. A lesion in the upper third of the vagina is usually part of a full-length rectocele and may result from a transverse separation of the rectovaginal septum from the descending cardinal-uterosacral fibers.
Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014 Jun. 123 (6):1201-6. [Medline].
Age and Sex in the United States: (2007, March 26). Retrieved April 6, 2011, from U.S. Census Bureau. Available at http://www.census.gov/population/www/socdemo/age/age_sex_2009.html. Accessed: 2009.
U.S. Census Bureau (2000). Retrieved March 6, 2011, from U.S. interim projections by age, sex, race, and Hispanic origin. Available at http://www.census.gov/ipc/www/usinterimproj. Accessed: 2011.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997 Apr. 89 (4):501-6. [Medline].
Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Mar. 19 (3):421-8. [Medline].
Burrows LJ, Meyn LA, Walters MD, Weber AM. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol. 2004 Nov. 104 (5 Pt 1):982-8. [Medline].
Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery. 2014 Apr. 155 (4):659-67. [Medline].
Herschorn S. Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Rev Urol. 2004. 6 Suppl 5:S2-S10. [Medline].
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1. 70 (3):195-283. [Medline].
Practice Bulletin No. 176: Pelvic Organ Prolapse. Obstet Gynecol. 2017 Apr. 129 (4):e56-e72. [Medline].
Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol. 2006 Dec. 195(6):1762-71. [Medline].
Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30. CD004014. [Medline].
Kahn MA, Stanton,SL, Kumar D, Fox SD. Posterior colporrhaphy is superior to the transanal repair for treatment of posterior vaginal wall prolapse. Neurourology and Urodynamics. 1999. 18:70.
Nieminen K, Hiltunen KM, Laitinen J, Oksala J, Heinonen PK. Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study. Dis Colon Rectum. 2004 Oct. 47(10):1636-42. [Medline].
Zhang ZG, Yang G, Pan D, et al. Efficacy of endoscopic stapled transanal rectal resection for the treatment of rectocele. Eur Rev Med Pharmacol Sci. 2014 Dec. 18(24):3921-6. [Medline].
Miklos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol. 1998 Dec. 179 (6 Pt 1):1418-22; discussion 1822-3. [Medline].
Cundiff, G. W., & Fenner, D. Evaluation and treatemtn of women with rectocele: focus on associated defecatory and sexual dysfunction. Journal of Obstetrics and Gynecology. 2004. 104:1403-21.
Maher CF, Qatawneh AM, Baessler K, Schluter PJ. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Obstet Gynecol. 2004 Oct. 104(4):685-9. [Medline].
Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, Sand PK. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol. 2005 Feb. 105(2):314-8. [Medline].
Stephanie G Clark, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine
Disclosure: Nothing to disclose.
Ashley W Carroll, MD Assistant Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine; Associate Program Director, Department of Obstetrics and Gynecology Residency Program, Medical Director, Women’s Surgical Unit, Virginia Commonwealth University Medical Center
Ashley W Carroll, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urogynecologic Society, International Urogynaecology Association, Richmond Academy of Medicine, Ware-Dunn Society
Disclosure: Nothing to disclose.
Kris Strohbehn, MD Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center
Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: I am on the Board for the Society of Gynecologic Surgeons (SGS). SGS is a non-profit organization whose mission is: “is to promote excellence in gynecologic surgery through acquisition of knowledge and improvement of skills…”.
Tanaz R Ferzandi, MD, MA Assistant Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Director, Division of Urogynecology and Pelvic Reconstructive Surgery, Tufts Medical Center
Tanaz R Ferzandi, MD, MA is a member of the following medical societies: American College of Obstetricians and Gynecologists, Massachusetts Medical Society, AAGL, American Urogynecologic Society
Disclosure: Nothing to disclose.
Barbara Samm Frank, MD Brookline Village ObGyn, Brigham Health
Disclosure: Nothing to disclose.
Rectocele Repair
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