MEDICAL THERAPY :
Patients with rectoceles may present with an asymptomatic bulge found during the pelvic examination or with a myriad of symptoms. For patients without symptoms, expectant management is recommended.
Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele. Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. One responsibility of the physician is to inform women of their treatment options and the potential benefits and risks of each option. Medical treatment options for women with symptoms primarily consist of management with pessaries.
Prophylactic measures
Prophylactic measures for preventing rectocele include diagnosis and treatment of chronic respiratory and metabolic disorders, correction of constipation and intra-abdominal disorders that may cause chronic increases in intra-abdominal pressure, and administration of estrogen to menopausal women who have no contraindication to its use.
Counsel patients about the preventive effects of weight control, proper nutrition, smoking cessation, and avoidance of strenuous occupational and recreational stresses that could damage the pelvic support system. Teach and encourage women to perform pelvic muscle exercises as a method of strengthening their pelvic diaphragm and as prophylaxis against the development of rectocele.
Failure to recognize and treat significant support defects at the time of concomitant gynecologic surgery can lead to progression of rectocele. Similarly, opening up the genital hiatus by performing a retropubic urethropexy (eg, Burch procedure) can predispose a patient to enterocele and rectocele. Disabilities that may occur include inability to defecate without manual replacement of the uterus, bladder, or rectum; sexual dysfunction; and vaginal ulceration.
For mild degrees of relaxation, especially in younger women immediately following childbirth, levator muscle exercises, sometimes called Kegel exercises, are helpful in restoring the tone of the muscles of the pelvic floor. Instruct patients how to appropriately contract the puborectalis muscles. Patients should repeat this exercise approximately 75 times during the day. Like most forms of physical therapy, this is usually more effective in premenopausal women than in older women, in whom generalized skeletal muscle atrophy has occurred. With minor degrees of pelvic relaxation, estrogenic hormones may help improve the condition of the vaginal mucous membrane and relieve minor symptomatology.
In addition to strengthening pelvic muscles and considering the administration of estrogen to menopausal women, nonsurgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. Numerous vaginal pessaries are available that are designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet. On occasion, the vagina and its outlet may be so dilated that it does not hold a pessary. If no other reasonable therapeutic option is available for such a patient, a perineorrhaphy can be performed with the patient under local anesthesia, thus constricting the vaginal outlet to enable it to retain a pessary.
Pessaries can cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized, making exogenous estrogen essential in the hypoestrogenic patient. Remove, clean, and reinsert vaginal pessaries periodically; failure to do so can result in serious consequences, including fistula formation.
Patients can be treated successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations due to pessary use, or genuine stress incontinence that the patient deems unacceptable.
Surgical therapy: A variety of surgical techniques have been described, including posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal approaches.
Historically, the primary surgical therapy for rectocele has been posterior colporrhaphy. The principal objective of the posterior repair is to repair perineal tears that occurred during vaginal delivery. The perineal closure is designed to narrow the caliber of the vaginal introitus, develop a perineal shelf, and partially close the genital hiatus. The original description described reduction of the rectocele, suturing of the levator ani muscles anterior to the rectum, repair of the perineal body, and correction of existing enterocele or prevention of potential enterocele. Approximating the levator muscles in the midline increases the length of the levator plate, shortens the longitudinal and transverse diameters of the genital hiatus, and improves the competence of the pelvic valve. This, however, is a nonanatomical approach to pelvic floor dysfunction and rectocele repair.
Preoperative details: Surgical repair of rectocele is indicated for a symptomatic patient with a rectocele caused by a rectovaginal fascial defect. The criteria necessary to perform a repair are in contrast to the outdated dictum that posterior colporrhaphy should always accompany anterior colporrhaphy.
Rectoceles can be diagnosed based on physical examination and imaging study findings. A prudent plan is to consider performing preoperative radiologic evaluations of unusual rectoceles or those associated with rectal prolapse. Detachment of the posterior vaginal wall does not necessarily confirm the presence of a rectocele. Consider posterior colporrhaphy or other surgical management as a distinct and separate procedure when pelvic organ prolapse is repaired.
Intraoperative details:
Posterior colporrhaphy
Depending on the need for reconstruction of the perineum, the skin can be incised in a V-shaped fashion over the perineum or transversely along the external margin of the posterior fourchette. The vaginal wall of the posterior fourchette is sharply dissected from the underlying tissues of the perineal body. The rectovaginal space is entered and widely dissected to the vaginal apex, beyond the top of the rectocele (see Images 5-6). At this point, looking for an enterocele and repairing it as necessary is extremely important. The pararectal fascia is plicated over the rectum with interrupted, delayed, absorbable or permanent sutures from the vaginal apex to the introitus (see Image 7).
As each suture is placed, the diameter of the vagina is assessed to ensure no transverse constriction is occurring that might result in dyspareunia. Linear, lateral, relaxing incisions relieve any constrictions that occur. If necessary, redundancy of the posterior vaginal wall flaps is trimmed and care is taken to preserve the vaginal caliber. The cut edges of the upper posterior vaginal wall are approximated in the midline. If a defective perineal body is present, its connective tissue is plicated in the midline. Plicating the muscle itself is not necessary; rather, plicate the capsule of the muscle. Plicating the capsule of the muscle most commonly involves the pubis rectalis muscle. The remaining cut edges of the posterior vaginal wall and perineum are approximated (see Images 8-9).
Perineorrhaphy
If a deficient perineal body is present after vaginal repair, consider performing a perineorrhaphy. The perineal deficit might be due to attenuation, laceration, or hypermobility of the perineal body. Whether levator ani plication adds to the success of the operation remains controversial. If any muscles are approximated in the midline, do not strangulate or destroy them. Take care to not constrict the posterior fourchette because this may result in dyspareunia.
Defect-directed or site-specific repair
A more anatomical approach has recently been described. Some authors advocate repairing the discrete fascial defects responsible for rectoceles. Discrete tears or breaks have been described in the rectovaginal septum, most commonly transverse separation of the rectovaginal septum from the perineal body. The defect-directed repair, or site-specific fascial repair, aims to provide an anatomical repair to close these fascial tears or defects.
Begin with a midline epithelial incision and separate the epithelium from the rectovaginal fascia. The edges of the fascial defects or tears are identified; then, the defect is repaired with interrupted, delayed, absorbable sutures. Unlike the traditional posterior colporrhaphy, the sutures are placed from cephalad to caudad. The best plan is probably to repair the muscles of the perineal body, if separated, and then reconstruct the perineal body. The vaginal epithelium is then reapproximated; however, it is not intentionally narrowed, as with a posterior colporrhaphy.
All studies using the site-specific defect repair report very low rates of dyspareunia with good functional and anatomical outcomes, but the long-term cure rates are unknown.
Transanal repair
In the colorectal literature, the transanal repair has been advocated via the rectal side of the rectocele. This repair has several variations, but the purpose of the procedure is to remove or plicate the redundant rectal mucosa, thus decreasing the size of the rectal vault, and to plicate or repair the anterior rectal wall musculature.
Generally, the procedure is performed with the patient in the prone jackknife position. A U- or T-shaped incision is made transanally just above the dentate line. A mucosal flap is developed, separated from the rectovaginal septum, and excised. Then, the rectovaginal septum is plicated from the rectal side with absorbable sutures. The plication includes the anterior rectal musculature. The rectal mucosa and submucosa are closed in a separate layer.
Advantages of this procedure include the excision of redundant rectal mucosa and the ability to deal with coincident anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse. Disadvantages include an inability to reconstruct the perineal body unless a second incision is made, an inability to correct an anal sphincter defect if present, and difficulty accessing a high rectocele. Complications of transanal repair include infection and rectovaginal fistula.
One major concern after transanal rectocele repair is postoperative anal incontinence. This significant problem has been described in up to 38% of patients after transanal repair. Fecal incontinence may occur because of an occult sphincter laceration that causes symptoms with aging, or it may develop as a result of the anal dilation and stretching during the rectocele repair.
One area that deserves attention is the recurrent rate of prolapses. Two separate randomized trials have shown that the transanal approach has a significantly higher failure rate when compared with the transvaginal approach (Maher, 2006).
Posterior fascial displacement
To prevent or reduce the risk of rectocele recurrence, a variety of graft materials and meshes have been used. These materials have been used in the traditional method of posterior colporrhaphy and in the defect-directed repair.
Some surgeons have used graft material after a defect-directed repair. Placing a dermal allograft over the repair and securing it to the rectovaginal fascia cephalad, to the arcus tendineus fascia rectovaginalis laterally, and to the perineal body distally creates a second layer of support. Although the graft may strengthen the repair, remember that graft materials may shrink. Importantly, this can create a repair that is too tight and can decrease the flexibility of the posterior wall and cause restriction of the rectum, such that it cannot expand during accommodation or during coitus. This loss of flexibility in the posterior wall can lead to fecal urgency and dyspareunia.
If the use of graft material is considered, the surgeon must choose the ideal material. It should have a very low rejection rate, be relatively inexpensive, decrease recurrence rates, and cause no harm with respect to bowel and sexual function. Currently, no good data support the use of one type of graft material over another. Many different materials have been used without clinical trials or long-term data to support their use.
Abdominal approach
This approach is most commonly used when correction of an accompanying enterocele or vault prolapse is indicated. Patients with rectocele often present with apical prolapse or defecatory problems, including chronic constipation or fecal incontinence. One advantage to using an abdominal approach, such as a sacral colpopexy for the repair of an apical support defect, is that the surgery can be completed with a single surgical approach.
If the defect in the rectovaginal fascia is in the superior portion of the posterior vaginal wall, it can be repaired through the cul-de-sac during the sacral colpopexy. Some surgeons advocate extending the posterior graft of the sacral colpopexy down the posterior wall to correct these defects.
Another modification of sacral colpopexy is the sacral colpoperineopexy. This procedure is used to treat perineal descent with posterior and apical pelvic organ prolapse. The aim of this procedure is to replace the normal support of the vagina and the continuous endopelvic fascia that runs from the sacrum to the perineal body. This procedure may be performed totally abdominally or as a combined abdominal and vaginal procedure.
From the abdominal approach, the peritoneum overlying the apex and posterior wall of the vagina is incised to open the rectovaginal space. Sutures are placed over the length of the posterior wall, from the apex to the perineal body. The perineal body is elevated by the surgeon's nondominant hand. Stitches are placed abdominally into, or as close to, the perineal body as possible. The permanent graft is placed abdominally between the posterior vaginal wall and the rectum. The sacrocolpopexy is completed with attachment of the anterior wall graft and posterior wall graft to the previously placed sacral sutures.
In the combined abdominal/vaginal approach, the sacral colpoperineopexy is performed as described above, except the perineal body sutures are placed transvaginally.
Postoperative details: Postoperative care usually consists of control of minor pain either with oral narcotics or with nonsteroidal anti-inflammatory drugs. For vaginal procedures, most patients are able return home the same day. Of course, abdominal procedures mandate stronger analgesia such as patient-controlled analgesia, and the patient stays in the hospital for 2-3 days.