Surgical Treatment of Rectocele: Gynecologic Approaches

Abstract

Unlike surgery to treat urinary stress or fecal incontinence, for which a patient usually undergoes careful preoperative evaluation, the gynecologic preoperative evaluation of a symptomatic posterior vaginal bulge typically includes only a history and physical examination. Gynecologists have not adopted the performance of defecography or other evaluation techniques for the evaluation of this anatomic defect. Although 80% of colorectal surgeons use defecography, only 6% of gynecologists use it. In addition, differentiation between enterocele and rectocele components of posterior vaginal wall prolapse is typically performed on a clinical and intraoperative basis, rather than radiographically. It is unclear at this time whether surgical therapy outcomes are negatively impacted by the lack of preoperative evaluation beyond a history and physical exam. Most gynecologists consider repair of the rectocele to be commonly necessary during routine pelvic reconstructive procedures, and it is associated with low morbidity for their patients. Herniation of the rectum or posterior vaginal wall into the vaginal canal, resulting in a vaginal bulge, is commonly termed a rectocele. Women may complain of perineal and vaginal pressure, obstructive defecation, constipation, and the need to splint or digitally reduce the vagina in order to effectuate a bowel movement. These anatomic defects arise from a superior, inferior, or lateral tear or central stretching of the rectovaginal fascia. If the weakness is present below the levator musculature, it is termed a rectocoele. If the weakness occurs above the levator muscles, it is more likely an enterocele. Very commonly, both anatomic defects coexist. Although anatomic cure rates with surgery are high, there are conflicting reports with regard to functional outcome, postoperative defecatory symptoms, and sexual dysfunction including dyspareunia. Marked differences exist between the management approaches followed by urogynecologists and colorectal surgeons. Rectocele repair, or posterior colporrhaphy, represents one of the most commonly performed gynecologic pelvic reconstructive procedures. In a recent survey, 100% of gynecologists surveyed managed rectoceles, whereas 68% of colorectal surgeons manage them. There are a large number of gynecologic indications for rectocele repair (Table 19.1). The restoration of normal anatomy to the posterior vaginal wall is referred to as an enterocele repair if it involves the upper posterior vaginal wall, and as a posterior repair or colporrhaphy if the lower wall is involved. Although sometimes used interchangeably with the term rectocele 19 Surgical Treatment of Rectocele: Gynecologic Approaches