Rectocel Cundiff and Fenenr

CLINICAL EXPERT SERIES
Evaluation and Treatment of Women With Rectocele: Focus on Associated Defecatory and Sexual Dysfunction
Geoffrey W. Cundiff, MD, and Dee Fenner, MD
Pelvic organ prolapse is a common and growing condition for which women seek help and frequently undergo surgical management. Prolapse of the posterior vaginal wall, alone or in combination with other compartment defects, can be a challenge for the pelvic surgeon. A clear understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship or lack of relationship between anatomy and function is required. Vaginal support defects occur with and without symptoms, and many of the symptoms attributed to pelvic organ prolapse can result from other causes. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difcult defecation, and fecal incontinence are some of the symptoms that have been correlated with rectoceles. Whether the prolapse is the cause of these symptoms or is a result of straining and stretching of support tissues in women with defecation disorders is still unknown. We will present the current literature on these relationships and what evaluations are useful when caring for a woman with a rectocele and defecation disorders. Either pessaries or surgery can be used for treating rectoceles. Several surgical techniques have been described, including transvaginal, transanal, abdominal, and the use of graft materials to treat both anatomical defects and functional symptoms. The success, rationale, and complications of each approach, including anatomic cure, impact on defecation, and sexual function, are presented. (Obstet Gynecol 2004;104:140321. 2004 by The American College of Obstetricians and Gynecologists.)
Pelvic organ prolapse is the indication for more than 300,000 surgeries in the United States annually, at a price tag of more than $1 billion.1 Moreover, the number of women seeking care for disorders of the pelvic oor are predicted to increase by 45% in the near future, suggesting that the evaluation and treatment of these disorders will dominate a large portion of gynecologic care in the coming years.2
From Johns Hopkins Medicine, Baltimore, Maryland; and University of Michigan, Ann Arbor, Michigan.
Recent studies provide insights into the epidemiology of pelvic organ prolapse, but signicant gaps remain. Among studies of ambulatory women, the prevalence of pelvic organ prolapse varies widely from 30% to 93%.3 6 Some of the variation reects methodological differences, but there are other factors that affect the reported prevalence too. One is the heterogeneous nature of pelvic support defects. Pelvic organ prolapse includes support defects of the vaginal apex, anterior wall, and posterior wall, although most patients have support defects at multiple locations. Among ambulatory women, most pelvic organ prolapse is mild, remaining inside the vagina, with pelvic organ prolapse beyond the vaginal introitus being found in fewer than 5% of cases.4 Lastly, reporting anatomical defects alone fails to account for the fact that pelvic support defects can be quite symptomatic in some women, yet minimally symptomatic in others. Although there is a paucity of data to describe asymptomatic pelvic organ prolapse, there is better data to dene the prevalence of symptomatic pelvic organ prolapse. Olsen et al7 dened symptoms in terms of careseeking by investigating women seeking surgery for pelvic organ prolapse or urinary incontinence. In an integrated health care program serving 149,544 women, there was an 11.1% lifetime risk for surgery for pelvic organ prolapse or urinary incontinence. Importantly, the reoperation rate in this cohort was 29.9%, suggesting that our surgical interventions are not always optimal. Another suggestion of less than optimal effectiveness for surgical intervention is the number of techniques advocated for treatment. Surgical procedures for posterior pelvic organ prolapse are a good example. There are multiple techniques from multiple surgical approaches presently in use, each with its own advocates, yet there are no direct comparisons to dene if one repair is superior overall or even more appropriate for specic populations of patients. The literature on the treatment of posterior pelvic organ prolapse is predominantly comprised of retrospective case series, frequently with small sample sizes. Outcome measures are inconsistent, which
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complicates information synthesis. In this article we will present the available data, noting shortcomings, to help the pelvic surgeon treating posterior pelvic organ prolapse. The pelvic surgeon who provides optimal care for pelvic organ prolapse must recognize the heterogenous nature of pelvic organ prolapse, accounting not only for support defects in different compartments, but also directing treatment to relieving symptoms attributable to specic support defects. The symptoms commonly attributed to posterior pelvic organ prolapse include herniation symptoms, defecatory dysfunction, and sexual dysfunction. Predicting which patients will have relief depends on a thorough understanding of the anatomy of the support of the posterior wall as well as the differential diagnosis of defecatory dysfunction and sexual dysfunction. POSTERIOR VAGINAL WALL ANATOMY The anatomy of the posterior vaginal wall cannot be clearly conceptualized separately from the anatomical supports of the rest of the vagina. Moreover, it is essential to understand that vaginal support arises from interactions between the pelvic musculature and connective tissue. The muscular support results from the pelvic diaphragm, a group of paired muscles including the levator ani and coccygeus (ischiococcygeus) muscles. The levator ani are subdivided, from medial to lateral, into the puborectalis, pubococcygeus, and ileococcygeus muscles. These muscles originate from the pubic rami on either side of the midline at the level of the arcus tendineus levator ani. The muscle bers pass laterally to the vagina and rectum creating a U-shaped sling surrounding the genital hiatus medially, but fanning out to create the pelvic oor posteriorly and laterally. These muscles are comprised of a unique type of striated muscles that contain a majority of type I (slow twitch) muscle bers, maintaining a constant resting tone over time. Each muscle group also contains a smaller proportion of type II (fast twitch) bers, permitting them to respond quickly during sudden increases in intra-abdominal pressures.8 Contraction of the pelvic diaphragm provides a horizontal levator plate on which the pelvic viscera lie, as well as closes the genital hiatus. The constant resting tone of the puborectalis and pubococcygeus not only closes the genital hiatus but also pulls the distal vagina and anorectal junction toward the pubic symphysis, creating a near 90 angle between the anal and rectal canals, referred to as the anorectal angle. A connective tissue layer known as the endopelvic fascia invests the vaginal walls and apex. The term fascia
Fig. 1. Oblique sagittal view of anatomy of the lateral attachments of the vaginal connective tissue. Illustration: Lianne Krueger Sullivan.
Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.
is ambiguous because this bromuscular tissue layer includes broblasts, smooth muscle cells, and elastin in addition to type III collagen, all loosely arrayed to create an elastic bromuscular layer.9 At the vaginal apex, this bromuscular layer coalesces to create the cardinal and uterosacral ligaments. The fan-shaped cardinal ligament creates a sheath that envelops the uterine artery and vein, fusing with the paracervical ring medially. The uterosacral portion inserts into the posterior and lateral aspect of the paracervical ring and then curves laterally along the pelvic sidewall to attach to the presacral fascia overlying the second, third, and fourth sacral vertebrae.10 Together the cardinal and uterosacral ligaments pull the vagina horizontally toward the sacrum, suspending it over the muscular levator plate. The endopelvic fascia of the posterior vaginal wall is also known as Denonvilliers fascia or the rectovaginal septum. It arises from fusion of the 2 walls of the embryological peritoneal cul-de-sac.11 This creates a bromuscular sheet that spans the posterior vaginal wall and coalesces with surrounding structures to provide a barrier to prolapse. Superiorly, it attaches to the cervix and the cardinal uterosacral support of the vaginal apex. Laterally, the rectovaginal fascia attaches to the pelvic sidewall (Fig. 1).12 In the upper vagina, the lateral attachment coalesces with the lateral support of the anterior vaginal wall to create the fascia endopelvina.13 This web of connective tissue coalesces with the fascia of the obturator internus muscle to create the arcus tendineus fascia pelvis or white line. The lower half of the rectovaginal fascia fuses with the aponeurosis of the levator ani muscle along a line referred to as the arcus tendineus fascia rectovaginalis.12 It converges with the arcus tendineus fascia pelvis at a point approximately midway
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Rectocele and Defecatory Dysfunction
OBSTETRICS & GYNECOLOGY
Fig. 2. Oblique view of the anatomy of the perineal body and its attachments to the rectovaginal fascia. Illustration: Lianne Krueger Sullivan.
between the pubic symphysis and the ischial spine to form a y conguration on the sidewall of the pelvis (Fig. 1). The point of convergence of the 2 lines is at the point along the tube of the vagina where the pelvic oor becomes wider than the vagina. Superior to this point, the fascia endopelvina bridges the gap between the vaginal tube and the pelvic sidewall. At its most inferior portion, the rectovaginal septum fuses with the perineal body. The perineal body is a pyramidal structure located between the vaginal introitus and anus with the base of the pyramid on the perineum (Fig. 2). Much like the hub of a wheel, it is a conuence of the perineal membrane (comprised of the bulbocavernosus muscles, supercial transverse perineal muscles, and investing fascia), a portion of the levator ani muscles, the external anal sphincter, and the rectovaginal fascia. Through its attachment to the cardinal and uterosacral ligaments, the rectovaginal septum stabilizes the perineal body, which is essentially suspended from the sacrum. The perineal body is further stabilized through the lateral attachments of the perineal membrane to the ischiopubic rami.14 Between the lateral and superior support, there is limited downward mobility of the perineal body, which normally lies within 2 cm of an imaginary line between the ischial tuberosities.15 DeLanceys14 analysis of the posterior vaginal wall provides the best evidence of the interrelationships between muscular and connective tissue support of the vagina. Through its attachments to the lateral rectovaginal fascia and the perineal body, the resting tone of the pelvic diaphragm augments the support of the posterior vaginal wall and perineal body. Moreover, under normal conditions the anterior displacement provided by the resting tone of the puborectalis muscles brings the
posterior vaginal wall into direct contact with the anterior vaginal wall. With this arrangement, pressure applied to the anterior and posterior vaginal walls is balanced, and the force is carried to the levator ani muscles and perineal body. Denervation of the pelvic diaphragm results in opening of the genital hiatus and separation of the anterior and posterior vaginal walls. In this circumstance, pressures applied to the anterior and posterior vaginal walls must be borne by the connective tissue alone. Because of its lateral attachments to the levator ani muscles (Fig. 1), the loss of muscular tone also produces laxity in the rectovaginal fascia. The connective tissue response to constant pressure is attenuation or tearing, and both have been described in the rectovaginal fascia. Based on cadaveric dissections, Richardson16 hypothesized that most rectoceles were due to discrete tears in the rectovaginal fascia. This opinion was corroborated by a study based on surgical ndings that showed that these tears occur at lateral, superior, and inferior attachments, as well as within the rectovaginal fascia itself (Fig. 3).17 In this series, left lateral detachments, inferior detachments, and superior detachments were the most common, with each comprising approximately a third of tears, although combinations were also common. Importantly, detachments of the rectovaginal fascia from the perineal body can compromise the support of the perineum, resulting in perineal descent. Excessive perineal descent was rst described in the colorectal literature by Parks et al in 1966.18 Since that time, multiple studies have associated perineal descent with a variety of defecatory disorders, including constipation, solitary rectal ulcer syndrome, rectal pain, and fecal incontinence.19 22 Neurophysiologic studies have demonstrated that one mechanism for fecal incontinence is pudendal neuropathy.23 This is not surprising because excessive perineal descent has been associated with 20% elongation of the pudendal nerve.24 Although recent studies have demonstrated an association of perineal descent with posterior wall prolapse, perineal descent is commonly overlooked in the gynecologic descriptions of repairs. This has led to what Richardson25 refers to as a perineal rectocele, which occurs following a rectocele repair that fails to re-establish the normal support of the perineum. In these patients the posterior wall support may appear normal, but the rectum continues to bulge into the perineal body. Perineal rectoceles commonly present with complaints of defecatory dysfunction, including a sense of incomplete emptying, tenesmus, and the need to splint or use digital manipulation for defecation.
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associated with coitus, as well as duration of abstinence, was also strongly associated with worsening pelvic organ prolapse. Defecatory dysfunction, including incomplete evacuation and digital manipulation, was associated with worsening posterior pelvic organ prolapse. Weber et al27 also described defecatory dysfunction in association with posterior pelvic organ prolapse. The majority of the sample in this study had stage I or greater posterior pelvic organ prolapse. Although most (92%) reported normal stool frequency, 74% reported straining and 24% strained usually or always. Similarly, 31% required splinting of the posterior vaginal wall or digitation of the rectum during bowel movement, and 16% reported fecal incontinence. Not surprisingly, on a 10-point bother scale, the impact of bowel function was greater than 5 points in 50% and 8 or more points in 28%. Although these symptoms occur with posterior pelvic organ prolapse, they also result from other forms of defecatory dysfunction, requiring the pelvic surgeon treating posterior pelvic organ prolapse to understand the differential diagnosis of defecatory dysfunction. Defecatory Dysfunction Voluntary storage and defecation of the rectal contents is a complex neuromuscular mechanism that involves coordinated physiologic processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation, and the continence mechanism. Colonic motility is complex, with regional heterogeneity. The colon is responsible for absorption of water and associated electrolytes, as well as peristaltic movement of stool. The rectosigmoid is uniquely adapted for reabsorption, as stool transit is signicantly delayed in this region to permit complete reabsorption of fecal water and electrolytes before elimination. As stool enters the rectal vault, there is a transient decrease in internal anal sphincter tone and an increase in external sphincter tone, known as the rectoanal inhibitory reex. This allows for sampling, in which the sensory-rich anal canal determines whether the rectal contents are solid, liquid, or gas. This is followed by accommodation, whereby relaxation of the rectum permits it to accept the increased rectal volume. As rectal volume increases, an urge to defecate is experienced. If this urge is voluntarily suppressed, the rectum relaxes to continue the accommodation of stool. If it is not suppressed, defecation of solid stool is initiated by a Valsalva maneuver, which raises intra-abdominal and intrarectal pressure. Voluntary inhibition of the external anal sphincter and puborectalis enables the rectum to empty. This is assisted by coordinated peristaltic activity of the rectosigmoid. When evacuation is completed the external anal sphincter and puborectalis contract
Fig. 3. Surgical view showing the defect-directed rectocele repair. The upper inset (cross section) delineates surgical layers, while the lower inset demonstrates the potential locations for tears in the rectovaginal fascia. Illustration: Lianne Krueger Sullivan.
DIAGNOSTIC APPROACH There are several key principals that inform the clinical evaluation of rectocele. Firstly, vaginal support defects occur with and without symptoms. Secondly, many of the symptoms attributed to pelvic organ prolapse can result from other causes. Consequently, the clinical evaluation focuses on eliciting the patients complaints, dening the location and severity of support defects, and establishing a relationship between the symptoms and the support defects through elimination of other causes of pelvic oor symptomatology. Recent studies have sought to dene symptoms associated with pelvic organ prolapse. Ellerkman et al26 investigated symptoms commonly attributed to pelvic organ prolapse, categorizing symptoms according to both prolapse severity and associated anatomic compartment. Pelvic pressure and discomfort, along with visualization of prolapse, were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Impairment of sexual relations, including dyspareunia and urinary incontinence
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Table 1. Differential Diagnosis of Defecatory Dysfunction by Category of Disease Disease category Metabolic Endocrine Subcategory Hypercalcemia Hypokalemia Diabetes mellitus Panhypopituitarism Pheochromocytoma Glucagonoma Porphyria Central Peripheral Congenital Pharmacologic Analgesics Anticholinergics Neurally active compounds Cation-containing agents Systemic disorders Spinal cord trauma, multiple sclerosis, Parkinsons disease, Shy-Drager syndrome Chagas disease, paraneoplastic neuropathy Hirschsprungs disease, colonic agangliosis, hypergangliosis, sphincter achalasia, intestinal pseudoobstruction Naproxen, ibuprofen Antispasmodics, antidepressants, antipsychotics, antiparkinsonian drugs Opiates, antihypertensives, ganglionic blockers, vinca alkaloids, calcium-channel blockers, diuretics Iron supplements, aluminum antacids, barium sulfate Systemic sclerosis Amyloidosis Myotonic muscular dystrophy Irritable bowel syndrome Cognitive disorders Limited mobility Nutrition Psychological causes Diagnosis
Neurologic
Functional
(termed the closing reex), and the continence mechanism is initiated again. Although patients frequently complain of constipation, the term has limited clinical utility because of its broad meaning. When patients complain of the symptom constipation, they can refer to infrequency of defecation, hard stool, or incomplete evacuation. The term defecatory dysfunction is a preferable diagnostic term. Defecatory dysfunction refers to any difculty with defecation, but does not include fecal incontinence. The complexity of the normal physiology translates to a lengthy differential diagnosis, and defecatory dysfunction is frequently multifactorial (Table 1). Systemic disorders such as diabetes mellitus, thyroid disorders, and neuromuscular diseases are common causes. Some of the most commonly used medications also result in defecatory dysfunction, including aluminum antacids, -blockers, calcium channel blockers, anticholinergics, antidepressants, and opiates. Defecatory dysfunction can also result from mechanical obstruction due to malignancy, inammatory bowel disease, or Hirschsprungs disease. Lifestyle issues such as inadequate ber intake, insufcient uid intake, and lack of mobility can result in defecatory dysfunction by themselves, or they may exacerbate other causes. Bowel function can also be af-
fected by psychiatric disorders, including depression, dementia, and anorexia. Initial evaluation and treatment should be directed at these most common causes. In the absence of one of these causes, a diagnosis of idiopathic constipation is made. Idiopathic is a misnomer in this context, because the pathophysiology of idiopathic constipation is clear (Table 2). There are 2 categories: motility disorders and outlet obstruction. The motility disorders include disorders with and without dilation. Outlet obstruction includes support defects of the posterior vaginal wall, perineum, and rectum, as well as anismus, or failure of the puborectalis to relax during defecation. In treating
Table 2. Idiopathic Causes of Defecatory Dysfunction Type of dysfunction Motility disorders Outlet obstruction Details With dilation Without dilation Anismus Pelvic organ support defects Causes Megacolon, megarectum Colonic inertia, global motility disorder Rectocele, enteroceles, perineal descent, rectal prolapse
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idiopathic constipation, the distinction between disorders of motility and outlet obstruction is an important one, because women with disorders of motility are best treated with dietary or pharmacologic modalities, or in extreme cases, with colectomy. Those with outlet obstruction are not. Similarly, pelvic support defects can be cured surgically, whereas anismus responds best to biofeedback. Distinguishing between these subcategories of idiopathic constipation, therefore, has important conceptual as well as therapeutic implications. Difculties arise in the patient who has ndings indicating more than one of these etiologies. Because support defects can arise from chronic straining, it can be difcult to determine the primary basis for constipation in women who have support defects in combination with disorders of motility or anismus. There is evidence that patients with anismus combined with support defects do not have a higher failure rate for surgical correction of support defects when compared with women with isolated support defects.28 The literature does not address whether women with slow transit constipation combined with support defects should have surgery that addresses both of these entities. We recommend optimizing nonsurgical treatment for either anismus or slow transit constipation before pursuing surgical repair of support defects. Sexual Dysfunction Although academic efforts to describe, dene, and treat female sexual dysfunction are in their infancy, it is clear that the prevalence of this disorder is signicant. The National Health and Social Life Survey, a populationbased survey of U.S. adults, aged 18 59 years, reported sexual dysfunction in 43% of women.29 Like defecatory dysfunction, the differential diagnosis is complex. However, prolapse in general (not specically posterior pelvic organ prolapse) has been strongly associated with sexual complaints in studies of women seeking treatment of pelvic oor disorders.30 Common sexual complaints include dyspareunia, decreased sexual desire, and anorgasmia.31 It is also common for patients to report abstention from coitus because of concern by the patient or her partner that coitus will worsen the pelvic organ prolapse. It is unclear whether these sexual complaints are due to the physical or emotional impact of the pelvic oor disorder or to other factors, such as the effects of menopause, prior surgeries, or the presence of other comorbid conditions.28 Age has also been identied as an important confounder.28,32 Nevertheless, there are theoretical bases for sexual dysfunction due to posterior wall pelvic organ prolapse. Immunohistochemical studies have shown increased density of free intraepithelial nerve endings in the distal vagina and vaginal introitus, which have been hypothesized to be important to sexual re-
sponse.33 The function of these nerve endings may be affected by loss of support of the perineum and distal vagina. Conversely, they may be negatively affected by surgical dissection. Vasculogenic female sexual dysfunction because of diminished pelvic blood ow can also present with vaginal wall dryness and dyspareunia and should be considered in the differential diagnosis.34 Psychogenic female dysfunction can occur with or without organic disease and may reect problems of self-esteem, body image, or partner relationship. The complexity of the interplay of physical and psychological factors in female sexual dysfunction makes it difcult to predict outcomes following repair. Pelvic Examination The goals of the pelvic examination are to objectively dene the degree of prolapse and determine the integrity of the connective tissue and muscular support of the pelvic organs. The pelvic examination is performed in the dorsal lithotomy position, although it is important that the patient conrms maximal protrusion, and this may require further examination on a commode or in the standing position. Valsalva with hard straining facilitates maximal protrusion, and a hand mirror can be used for patient conrmation. It is important to objectively document the extent of prolapse, both before and after interventions. In dening the extent of prolapse, the degree of descent is measured with respect to the hymenal ring. There are a number of ordinal staging systems to describe the degree of descent, although the Pelvic Organ Prolapse Quantitation examination is the most widely accepted. A full description of this system is beyond the scope of this article, but it is easily learned and is reproducible. It has been adopted by the American Urogynecologic Society and the International Continence Society.35 Generally, it includes 6 topographical points on the vaginal walls and 2 on the perineum, as well as the vaginal length. Vaginal support should be evaluated independently at all sites, including the vaginal apex, the anterior wall, and the posterior wall. The posterior wall is assessed while supporting the vaginal apex and anterior wall with a Sims speculum or with a disarticulated posterior blade of a Graves speculum. This permits the examiner to focus on the specic location of the rent in the rectovaginal fascia. Careful attention to the rugations in the vaginal epithelium can provide clues to the location of the rectovaginal fascia tears because the rugation pattern is frequently lost overlying the defect.36 This technique is especially useful for enteroceles caused by tears in the superior rectovaginal fascia, which have a smooth thin epithelium over the enteroceles sac or peritoneum. Careful inspection in some patients with enteroceles will
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reveal peristaltic movements beneath the vaginal epithelium. A rectovaginal examination also provides information regarding the integrity of the rectovaginal fascia as well as the perineal body. Normally, the perineum should be located at the level of the ischial tuberosities or within 2 cm of this landmark (Fig. 2). A perineum below this level, either at rest or with straining, represents perineal descent. Subjective ndings of perineal descent include widening of the genital hiatus and perineal body and attening of the intergluteal sulcus. Women with perineal descent also tend to have less severe pelvic organ prolapse based on the Pelvic Organ Prolapse Quantitation staging system, because it measures descent from the hymenal ring, which is not a xed point in perineal descent. One of the unique aspects of the Pelvic Organ Prolapse Quantitation system is the assessment of the perineum, including measurement the length of the genital hiatus and perineal body with and without straining. An increase in these values with straining suggests perineal descent. The degree of perineal descent can also be objectively measured with a thin ruler placed in the posterior introitus at the level of the ischial tuberosities. Descent is measured as the distance the perineal body moves when the patient strains, although pelvic oor uoroscopy is the gold standard for measuring perineal descent. We usually reserve uoroscopy for patients with symptoms of severe defecatory dysfunction and evidence of perineal descent on pelvic examination. The bimanual examination investigates the location, size, and tenderness of the bladder, uterus, cervix, and adnexa. The pelvic diaphragm should be assessed for integrity of the muscle body and insertion, as well as the strength, duration of a contraction, and the anterior lift of the contraction. Several standardized systems have been described to assess muscle strength objectively, but none are universally accepted.37 The integrity of the pelvic diaphragm muscles can be evaluated by observation and palpation of these structures during voluntary contraction. The rm muscular sling of the puborectalis should be readily palpable posteriorly because it creates a 90 angle between the anal and rectal canals. Voluntary contraction of this muscle pulls the examining nger anteriorly toward of the muscles insertion on the pubic rami. Neuropathy affecting the puborectalis can likewise be recognized if the anorectal angle is obtuse and if there is a palpable weakness with voluntary contraction. As previously mentioned, a rectovaginal examination provides useful information regarding the integrity of the rectovaginal septum and can demonstrate laxity in the support of the perineal body. The rectovaginal examination also helps in the diagnosis of a high enteroceles, which can be felt lling the rectovaginal septum between
Fig. 4. Surgical view showing the posterior colporrhaphy. (The diamond-shaped skin from the perineorrhaphy is discarded.) The cross section inset delineates surgical layers. Illustration: Lianne Krueger Sullivan.
the vaginal and rectal ngers during patient straining. The presence of fecal material in the anal canal may suggest fecal impaction or neuromuscular weakness of the anal continence mechanism. Ancillary Tests A number of ancillary tests are commonly used to augment the physical examination of pelvic organ prolapse. These include physiological tests of bladder and rectal function and imaging tests to clarify anatomical derangements. Urodynamics are commonly used for patients who have urinary incontinence in addition to pelvic organ prolapse, although the benet of urodynamics for women without urinary incontinence is controversial. In a study to assess the benet of urodynamics in women with posterior pelvic organ prolapse, Myers et al38 noted that severe posterior pelvic organ prolapse impacted urodynamic parameters and masked urinary stress incontinence. They recommended urodynamics with reduction of the posterior vaginal wall in these patients. Similarly, anorectal physiologic testing is useful for women with suspected anismus or concurrent fecal incontinence.
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Table 3. Posterior Colporrhaphy

Mean follow-up (mo) Levator plication Anatomic cure (%) Constipation (%) 75 54 100 88 22 33 21 4 64 31 Vaginal bulge (%) Vaginal digitation (%) 20 36 50 0 8 8 4 11 5 (23) Fecal incontinence (%) De novo dyspareunia in sexually active patients (n % )
Study Arnold et al Preoperative Postoperative Mellgren et al51* Preoperative Postoperative Kahn & Stanton52 Preoperative Postoperative Weber et al53* Preoperative Postoperative Sand et al54* Preoperative Postoperative
50
n 29 24 25 25 231 171 53 53 70 67
Yes
80
12
Yes
96
2 (8)
42 12
Yes
76
33
27 (16)
No 12 No 90
14 (26)
* Prospective. One of 53 patients did have plication.
Patients presenting with defecatory dysfunction should undergo a standard gastrointestinal evaluation, including a barium enema or colonoscopy, to eliminate colorectal malignancy from the differential diagnosis. Anoscopy may reveal anorectal pathology such as prolapsing hemorrhoids, and proctosigmoidoscopy helps to exclude intrarectal prolapse or a solitary rectal ulcer. Referral to an anorectal physiology laboratory may be necessary to differentiate between patients with colonic motility disorders and those with predominant pelvic outlet symptoms. Standard evaluation in these laboratories includes colonic transit studies, pelvic oor uoroscopy, anorectal manometry, and electromyography.
Table 4. Defect-Directed Repair Mean follow-up (mo) 12 82 6 82 12 90 3 100 18 92 Anatomic cure (%)
Useful radiologic studies include the colonic transit study, pelvic oor uoroscopy, and dynamic magnetic resonance imaging. Colonic transit studies involve the use of ingested radio-opaque markers, followed by serial abdominal radiographs over a 5-day period. The patient ingests a capsule with 24 radio-opaque markers, followed by serial abdominal radiographs every other day until all the markers are gone. Specic regimens vary, but 80% of markers should be passed by day 5, and less than this suggests a motility disorder. Collection of the markers in the sigmoid is suggestive of outlet obstruction but is not diagnostic. The colonic motility test is primarily indicated for patients with a suspected motility disor-
Study Cundiff et al Preoperative Postoperative Porter et al56 Preoperative Postoperative Kenton et al57 Preoperative Postoperative Glavind & Madsen58 Preoperative Postoperative Singh et al59* Preoperative Postoperative
* Prospective.
55
n 69 61 125 72 66 46 67 67 42 33
Constipation (%) 46 13 60 50 41 57
Difcult evacuation (%) 32 15 61 44 53 46 40 4 57 27
Vaginal bulge (%) 100 18 38 14 86 9
Vaginal digitation (%) 39 25 24 21 30 15
78 7
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der based on abnormal stool frequency (greater than every 3 days). Pelvic oor uoroscopy is useful for women with pelvic organ prolapse and severe defecatory dysfunction. It is especially useful for women with complaints of incomplete evacuation because it helps to differentiate causes of outlet obstruction: anismus and support defects. In this study, the small bowel is opacied with oral contrast, the vagina and bladder with liquid contrast, and the rectum with contrast paste. A series of sagittal still lms and, in some laboratories, cinevideography, are made with uoroscopy while the patient sits and defecates on a radiolucent commode. The patient is lmed at rest, during defecation, and while squeezing the anal sphincters. Measurements are taken of the size of the rectal ampulla, length of the anal canal, size of the anorectal angle, motion of the puborectalis, and degree of pelvic oor descent. This not only provides radiologic evidence of herniation of the surrounding organs into the vagina but also provides dynamic assessment of pelvic oor function during defecation. Rectoceles, dened as an extension of the anterior rectal wall, are commonly found on proctograms, and small bulges of the anterior rectal wall detected on evacuation proctography might be normal ndings because they are frequently asymptomatic. The consensus is that they should be considered abnormal if there is barium trapping, that is to say that the rectocele does not completely empty on evacuation.39 Although pelvic oor uoroscopy is the gold standard for measuring perineal descent and is more accurate than physical examination for dening which organ is herniating into the vagina,40 it is usually reserved for patients with marked defecatory dysfunction.41 Dynamic magnetic resonance imaging
provides a similar evaluation but also provides multiplanar information about the soft tissues of the pelvic oor.42 It is most appropriate for patients with complex pelvic organ prolapse or symptoms that are not explained by the physical examination.42 Because anismus can mimic the defecatory symptoms of posterior pelvic organ prolapse, as well as cause posterior pelvic organ prolapse as a result of outlet obstruction, it is an important component of the differential diagnosis. Anismus can be suspected in the patient with tender, hypercontracted puborectalis muscles on bimanual examination, especially if she cannot relax these muscles on command. Pelvic oor uoroscopy also provides evidence of anismus, including lack of straightening of the anorectal angle and failure to evacuate two thirds of contrast after 30 seconds of straining. However, the balloon expulsion test and surface electromyogram are anorectal physiological tests that are superior methods for diagnosing anismus.33 In planning the therapeutic evaluation of a patient with posterior pelvic organ prolapse, the most important consideration is the presenting symptoms. Isolated herniation symptoms are easily attributable to the posterior pelvic organ prolapse and do not usually warrant further testing. Patients with defecatory dysfunction have a more extensive differential diagnosis that may benet from further evaluation. Suspicions of a motility disorder warrant a colonic transit study. Anorectal physiologic testing is important to evaluate fecal incontinence and suspected anismus. Imaging studies are useful for patients with perineal descent, poorly dened outlet obstruction, or physical examination ndings that do not correlate with symptoms. THERAPEUTIC APPROACHES Rectoceles may present as an asymptomatic bulge found at the time of pelvic examination or with a myriad of symptoms. For patients without symptoms, expectant management of the prolapse is recommended. Treatment options for women with symptomatic rectoceles include nonsurgical management with pessaries and a variety of surgical techniques, including posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal approaches. Pessaries Pessaries have been used for centuries for the treatment of pelvic organ prolapse, yet despite their utility and minimal risk, there is a paucity of data on their use, tting, and management. Adams et al43 attempted a Cochrane Database review in 2004 and could not nd a single randomized trial to evaluate effectiveness of pes-
Fecal incontinence (%) 13 8 24 21 30
Dyspareunia (%) 29 19 67 46 28 8 12 3
De novo dyspareunia in sexually active patients (n % )
1 (2) 3 (4) 3 (7) 2 (3) 0
9 5
31 15
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Fig. 5. Surgical view showing the transanal rectocele repair. The cross section inset delineates surgical layers. Illustration: Lianne Krueger Sullivan.
saries for pelvic organ prolapse. Therefore, the type and size of pessary that is best for posterior compartment prolapse, and specically rectoceles, is not known. There are 2 basic types of pessaries: supportive and space occupying. The ring pessary, with or without oor, is a common supportive pessary, whereas the Gelhorn and cube pessaries are common space-occupying pessaries.44 Clemons et al45 evaluated 100 consecutive women with pelvic organ prolapse and found that 73 women could successfully retain a pessary for at least 1 week. A short vaginal length ( 6 cm) and a wide vaginal introitus (4 nger breadths accommodated) were associated with unsuccessful trial (P .02 and P .04, respectively). Ring pessaries were used more with stage II and III prolapse, whereas Gelhorn pessaries were used with stage IV prolapse. Descent of the leading edge of the prolapse and whether the leading compartment was anterior wall, apical, or posterior wall had no impact on successful pessary trial. Thus, women with rectoceles were just as likely to be able to wear a pessary as those with predominantly cystoceles or uterine prolapse. There is no data relating patients symptoms, specically constipation or need to splint to defecate, and the ability to retain a pessary. Heit et al46 found that women over the age of 70 years with less severe prolapse are more likely to choose a pessary over surgery. But some women of all ages and stages of prolapse may choose to try a pessary, so nonsurgical management should be made an option for all women. Large, randomized trials are needed to determine the type and size of pessary best
Table 5. Transanal Repair Mean follow-up (mo) Anatomic cure (%) Constipation (%) Difcult evacuation (%) 58 2 82 15 72 16 63 33 83 32 92 27 38 3 40 28 Vaginal bulge (%) 27 26 26 4 23 0 38 Vaginal digitation (%)
Study Sullivan et al Preoperative Postoperative Sehapayak64 Preoperative Postoperative Janssen & van Dijke65* Preoperative Postoperative van Dam et al66* Preoperative Postoperative Ayabaca et all67* Preoperative Postoperative
61
n 137 117 355 204 64 64 89 89 49 34
18
96 98
12 52 48
70 72 90
RV, rectovaginal. * Prospective. Combined transanal and transvaginal repair.
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suited for the treatment of rectoceles and whether bowel function or other symptoms relate to success. Posterior Colporrhaphy The traditional posterior colporrhaphy was an operation devised in the early 19th century to deal mainly with perineal tears incurred during vaginal delivery. The perineal closure was designed to narrow the caliber of the vaginal introitus, develop a perineal shelf, and partially close the genital hiatus.47 The original description included plication of the pubococcygeus muscles along with plication of the posterior vaginal wall (colporrhaphy) and reconstruction of the perineal body (perineorrhaphy) as a single procedure known as posterior colpoperineorrhaphy. Posterior colpoperineorrhaphy has been used for all forms of genital and related rectal prolapse without any real understanding of the uterine and vaginal supports and defecation process, leading to a fundamentally nonanatomical approach.48 A posterior colporrhaphy begins with a midline incision extended to the apex of the vagina for a high or large rectocele or to the cephalad border of a smaller or distal rectocele. The rectovaginal fascia is mobilized from the vaginal epithelium and plicated in the midline with interrupted or continuous absorbable suture (Fig. 4). Alternatively, a wedge incision with excision of vaginal epithelium and rectovaginal fascia can be performed in block to simply narrow the vagina. Plication of the levator ani muscles may be performed. Excess vaginal epithelium is trimmed, and the vaginal epithelium is closed with a running, absorbable suture. A perineorrha-
Fecal incontinence (%) 39 3
Dyspareunia (%)
Complications 1 RV stula
0 20 19 Infections, 1 RV stula None 28 44 None
40 9 10 16 71 27
1 infection, 1 pyogenic granuloma, 4 dehiscence, 1 anal ssure
phy is frequently performed in conjunction with this procedure by reconstructing the perineal body. The intrinsic muscles of the perineal body, including the supercial perineal muscles and the bulbocavernosus muscles, may be separated or damaged from childbirth. They are brought to the midline using ne absorbable suture to reconstruct the perineum. Despite the fact that transvaginal colporrhaphies have been the preferred surgical procedure for rectocele repair among gynecologic surgeons for over 100 years, there is a paucity of data reporting long-term anatomical success. Even more concerning is that, despite the fact the Francis and Jeffcoate49 reported in 1961 the high incidence of dyspareunia following colporrhaphy with levator plication, even less information is known about sexual function following this procedure. The operation was not evaluated for its effect or impact on bowel function until 1987.50 Table 3 summarizes the literature on posterior colporrhaphy with and without levator plication. Most of the studies report a greater than 75% improvement in anatomical outcome or bulge and the need to splint the perineum to defecate. However, the studies suggest that there is at least a 15% incidence of new dyspareunia after posterior colporrhaphy, with or without levator plication. Patients with symptoms of slow-transit constipation have little improvement in defecation dysfunction. In the largest retrospective review, Kahn and Stanton52 reported on 171 women with a mean follow-up of 42.5 months. Twenty-four percent had recurrent rectoceles on vaginal examination. Except for the symptom of lump or pressure, all other symptoms, including incomplete bowel emptying, fecal incontinence, and sexual dysfunction, increased after colpoperineorrhaphy. There was also a strong association between fecal incontinence and a history of more than one posterior colporrhaphy (P .001). Mellgren et al51 published the rst prospective study on posterior colporrhaphy with levator plication. At 12-month follow-up, 5 of 25 (20%) had a recurrent rectocele on defecography, whereas only 1 was diagnosed by pelvic examination (4%). Twenty-four women complained of constipation before surgery, and while improvement was seen in most (88%), resolution of constipation was noted in only half the patients. Weber and colleagues53 at the Cleveland Clinic prospectively followed 81 women with pelvic organ prolapse and urinary incontinence before and after surgery for sexual function and vaginal anatomy. Dyspareunia occurred in 14 (25%) women after posterior colporrhaphy (P .01) and in 8 (38%) of 21 women who had Burch colposuspension and posterior colporrhaphy performed together (P .01). When comparing the women with and without dyspareunia, the postoperative introital caliber was
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the same. While this prospective study is well done, one should not make broad conclusions from a small series of patients. Dyspareunia is not only dependent on the caliber of the vagina but can result from scarring or levator spasm. However, surgeons should be cautious when decreasing the vaginal caliber with transvaginal colporrhaphy. Of the 53 patients who had posterior colporrhaphy, 9 (17%) complained of introital tightness compared with none of the 27 women who did not have posterior colporrhaphy (P .03). In summary, the traditional transvaginal colpoperineorrhaphy provides good anatomical support with moderate relief of functional symptoms and a high rate of de novo dyspareunia. Defect-Directed Repair More recently, repair of the discrete fascial defects responsible for rectoceles has been advocated. Richardson16 described discrete tears or breaks in the rectovaginal septum found and studied during cadaveric dissections and at the time of rectocele repair. With meticulous technique and keen observation, he noted a variety of defects in the rectovaginal septum, with the most common being the transverse separation of rectovaginal septum from the perineal body. The defect-directed repair, or site-specic fascial repair as it is also referred to, aims for an anatomical repair to close these fascial tears of defects. The surgical approach begins with a midline epithelial incision and separation of the epithelium from the rectovaginal fascia. With the nondominant index nger in the rectum, the edges of the fascial defects or tears are located. The defect is then repaired with interrupted delayed absorbable sutures (Fig. 3). Often the stitches are placed from cephalad to caudad, in contrast to the traditional side-to-side plication. Richardson16 also strongly advocated that, if separated, the intrinsic muscles of the perineal body should be repaired and the perineal body reconstructed. The vaginal epithelium is then reapproximated but not intentionally narrowed as with the posterior colporrhaphy. Table 4 gives the anatomical and functional outcomes of the defect-directed rectocele repairs reported in the literature. Singh et al59 is the only prospective study and reports on patients undergoing a rectocele repair alone. The other retrospective series include patients with rectocele repairs performed along with concomitant repair of other pelvic oor defects. None of the series reported plication of levator muscles in the midline. Singh et al noted that 9 of the 42 patients in her series required perineorrhaphy because of an attenuated perineal body. Cundiff et al55 excluded patients who had a perineorrhaphy or sacrocolpopexy but still noted reduction in the size of the genital hiatus. The decrease was believed to be secondary to reattachment and stabilization of the peri-
neal body to the rectovaginal septum. Two thirds of the patients noted an improvement in bowel function and dyspareunia in this series. Both Porter et al56 and Kenton et al57 reported similar anatomical successes at 82% and 90%, respectively. But Kenton et al reported only half of her patients had improvements in constipation and manual evacuation. All patients in this series had a rectocele documented preoperatively by defecography, but no postoperative assessment by defecography was performed. Improvement in sexual dysfunction ranges from 38% to 92%, with variability again indicating a broad range of denitions for sexual dysfunction and dyspareunia used in the studies. All studies report very low rates of de novo dyspareunia with good functional and anatomical outcomes, but the long-term durability is unknown. Transanal Repair Marks,60 a colorectal surgeon in the late 1960s, was one of the rst to note the persistent difculty with rectal evacuation following traditional colpoperineorrhaphy. He also noted that many women diagnosed with rectoceles had a thinning of the anterior rectal wall, including the circular and longitudinal muscles, and an enlarged rectal ampulla. Based on these observations, he advocated repair of the rectal side of the rectocele. Although there are several variations and modications of the transanal repair, the aim 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. The basic technique is frequently preformed in the prone jackknife position. A U-shaped or T incision is made transanally just above the dentate line. A mucosal ap is raised, separated from the rectovaginal septum, and excised. 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 (Fig. 5).61 Block62 reported a similar technique but did not open the rectal wall, simply plicating the excess mucosa without excision. This technique is less popular because some patients complain of persistent tenesmus and urge to defecate if the mucosa is not removed. In addition, necrosis of the plicated rectal mucosa has led to postoperative infection. The advantages of the transanal repair include the ability to deal with coincident anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse, and the excision of redundant rectal mucosa.48 Disadvantages include the inability to reconstruct the perineal body unless a second incision is made, inability to correct an anal sphincter defect if present, and difculty accessing a
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high rectocele.63 Other complications include infection (6%) and rectovaginal stula (3%), which, while serious, appear to be rare.64 Because transanal repairs were developed and are primarily performed by colorectal surgeons, the major outcomes of this procedure are bowel related and include both defecatory disorders and fecal incontinence. In most series, the indications for surgery are constipation or obstructed defecation, and the surgery is performed for only low or distal rectoceles. Vaginal bulge or protrusion is noted but not critical for surgical management. Retrospective series report improvement of these symptoms in 3298% of patients. Successful resolution of defecatory disorders and the need to splint do not correlate with the size of rectocele or inability to completely evacuate on defecography. Arnold et al50 retrospectively reported on 64 nonrandomized patients, 35 of whom underwent transanal repair and 29 of whom underwent transvaginal repair. The indication for surgery was defecatory dysfunction by symptoms only. Forty-six of the 64 were contacted after a minimum of 2 years. Before surgery 75% of the patients complained of constipation and 20% complained of the need for vaginal digitalization. In the long term, there was no difference in constipation, anal incontinence, sexual dysfunction, or patient satisfaction between groups. Postoperatively, 23% of the transvaginal group and 21% of the transanal group complained of sexual dysfunction. There was no difference in postoperative complications between the groups. Signicantly more patients in the transvaginal group, 32% versus 4% in the transanal group, complained of postoperative pain. Because of the small number of patients reported in this series, the study lacks power to detect statistically signicant differences between transvaginal and transanal repairs. Table 5 reports on the larger retrospective series and the few prospective series of transanal rectoceles repairs. A prospective study by Janssen and van Dijke65 in 1994 reported on 64 women with either symptomatic rectoceles and/or anterior rectal wall prolapse on defecography as inclusion criteria. Seventy-two percent had obstructed defecation on defecography, and 40% also complained of fecal incontinence. Postoperatively, half had no complaints and showed improved rectal sensation, defecation at lower stool volumes, and improvement in both constipation and incontinence. A major concern after transanal rectocele repair is de novo anal incontinence. Arnold et al50 reported that 38% of patients developed fecal incontinence after transanal repair. Fecal incontinence may occur because of an occult sphincter laceration that becomes symptomatic with aging or may develop as a result of the anal dilation and stretching during the rectocele repair.65
It is impossible, with the current literature, to reliably compare the transanal rectocele repair with any of the vaginal approaches. Transanal repairs are generally performed for defecation disorders, and transvaginal repairs are generally performed for prolapse of the posterior vaginal wall. A prospective, randomized trial with adequate power to evaluate the impact on bowel and sexual function along with anatomical cure is warranted. Combined Transvaginal/Transanal Repair van Dam and colleagues66 have reported on 89 women having a combined transvaginal and transanal rectocele repair who were followed for a mean of 52 months. Seventy-one percent of the women had successful outcome by defecography, physical examination, and defecation symptoms. Seven patients developed fecal incontinence and 41% developed dyspareunia. A second analysis of these patients found that no parameters such as vaginal splinting, barium entrapment, or rectocele size affected outcome. Poor functional outcome was signicantly correlated with preoperative loss of anal sensation
Fig. 6. Surgical view showing the posterior fascial replacement. The graft is connected superiorly but has not yet been attached laterally or inferiorly, permitting visualization of the defect-directed rectocele repair beneath the graft. The cross section inset delineates surgical layers. Illustration: Lianne Krueger Sullivan.
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Table 6. Repairs With Graft Materials Mean follow-up (mo) Anatomic cure (%) Constipation (%) Difcult evacuation (%) Vaginal bulge (%)
Study Transvaginal Oster & Astrup69 Preoperative Postoperative Sand et al54* Preoperative Postoperative Goh & Dwyer70* Preoperative Postoperative Kohli & Miklos68 Preoperative Postoperative Transperineal Watson et al71* Preoperative Postoperative Mercer-Jones et al72 Preoperative Postoperative Abdominal Cundiff et al73 Preoperative Postoperative Sullivan et al74 Preoperative Postoperative
RV, rectovaginal. * Prospective.
Graft material
15 15 73 65 43 43 43 30 9 9 22 22 19 19 236 205
Autologous Dermis Polyglactin Mesh Polypropylene Mesh Cadaveric Dermis Polypropylene Mesh 14 Polypropylene 8 Polyvinyl chloride Polyester Mesh Polypropylene Mesh
30 100 12 92 12 12 93 29 89 12 95 50 14 58 16 100 33
47 0
80 0
100 0
100 12 95 32
100 0 86 23
3 60
100 100
32 9
57 0
on anal manometry and absence of a daily urge to defecate or infrequent bowel movement (specically, for women who reported less than one bowel movement per week). Moreover, while uncommon, the risk of rectovaginal stula must be recognized with this combination of repairs. Posterior Fascial Replacement In an attempt to reduce the risk of rectocele recurrence, a variety of graft materials and meshes has been used in attempts to strengthen the repairs. Graft materials have been used with both the traditional method of colporrhaphy and the defect-directed repair. Kohli and Miklos68 recently described the use of a dermal allograft to augment the defect-directed repair. After a defect-directed repair as described above, a second layer of support is created with a rectangular dermal allograft placed over the repair and secured to the rectovaginal fascia cephalad, laterally to the arcus tendineus fascia rectovaginalis, and distally to the perineal body. (Fig. 6) When placing a graft, it is important to remember that graft materials may shrink after placement. A repair that is too tight can lead to loss of exibility of the posterior wall and restric-
tion of the rectum, such that it cannot expand during accommodation or during coitus. This stiffness in the posterior wall can lead to fecal urgency and dyspareunia. The use of a graft, either allograft or xenograft, is a common technique employed in repairing other facial defects or hernias. The purpose of the graft is either to replace the fascia as a permanent barrier to herniation or to act as an absorbable collagen scaffold for broblast inltration and scar formation. Both types of grafts have been used in rectocele repairs. The use of grafts in reconstructive gynecologic surgery has gained popularity in recent years and many new products are available. The ideal material for a posterior fascial replacement should have a very low rejection rate, be relatively inexpensive, decrease recurrence rates, and cause no harm with respect to bowel and sexual function. An autologous graft is an alternative to commercially available grafts but needs to be easy to harvest with little added morbidity. It remains to be determined which, if any, of the current grafts available today is best suited for rectocele repair in terms of safety and efcacy. Many materials have been used without proper trials and are
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Vaginal digitations (%)
De Novo dyspareunia in sexually active patients (n % )
Number of complications
100 12
1 infection 3 (20) None 1 R/V stula 3 Erosions None
100 12 64 23
None 1 (14) None 1 (5) None
4 (3)
11 Erosions
recommended by manufacturers rather than by data showing long-term improvement of patients symptoms or decreased recurrence rates. When using any graft material, whether synthetic, allograft, or autograft, the surgeon should be as familiar as possible with the product and discuss current knowledge of risks and benets with the patient before using it. Prospective, randomized trials performed with institutional review board approval are urgently needed before any recommendations using graft materials can be made. Oster and Astrup69 in 1981 rst reported the use of a 10 5 cm dermal autograft for the repair of large rectoceles with a thin lax walls in 15 patients. Patients were followed for 1 4 years, with a mean of 2.6 years. No patients had a recurrence of the rectocele, but 1 patient had a postoperative vaginal infection, 5 had constipation, and 3 complained of dyspareunia. Over the last 20 years, there have been few additional case series, but with the increased used of graft materials for hernia repairs, many pelvic surgeons are using graft materials regardless of the evidence. Table 6 lists the rectocele repairs that use graft materials placed either vaginally or abdominally.
Watson et al71 reported on 9 women selected because of the need to vaginally splint at the time of defecation. He placed a Marlex mesh transperineally and plicated the levators in the midline. With a median follow-up of 29 months, 8 of the 9 women were able to successfully evacuate without manual vaginal splinting. One patient had a wound infection that was treated with antibiotics without graft removal, and one patient developed dyspareunia. Sand et al54 reported the largest prospective study to date using absorbable vaginal mesh. Preoperatively, 143 women had rectoceles diagnosed by physical examination, and of these, 91 had rectocele to the midvagina, 31 to the hymenal ring, and 22 beyond the introitus. Patients were randomly selected on the day of surgery by computer-generated, random-number table to receive or not receive polyglactin 910 mesh during anterior colporrhaphy and posterior colporrhaphy. Mesh was placed by incorporating a strip within the imbricating fold of the endopelvic fascia as it was plicated in the midline during a traditional colporrhaphy. The authors found no difference in recurrence rates when comparing 70 women with a traditional colpoperineorrhaphy with 73 women having a traditional repair with the placement of a polyglactin mesh, 10% versus 8% respectively. Bowel or sexual function was not described. As seen in the Goh and Dwyer70 series, mesh erosion and rectovaginal stula are uncommon but serious complications. Rectal erosion may require a diverting colostomy to remove and repair the erosion site, with signicant and perhaps life-long morbidity for the patient. Erosion of vaginal mesh causes signicant morbidity, including vaginal discharge and bleeding in the patient and dyspareunia for the patient and her partner. The use of nonsynthetic grafts to augment the defectdirected repair aims to achieve its functional and anatomical success with improved longevity, but without graftassociated complications. Kohli and Miklos68 performed 43 defect-directed repairs with the placement of dermal grafts over a 1-year period. Thirty women were followed for an average of 12.9 months. Inclusion criteria was based on intraoperative assessment of weak tissue or increased risks for failure, such as prior repair, obesity, chronic constipation, or advanced prolapse that was not dened. There were no major intraoperative complications. Postoperatively, no patients had a graft infection, erosion, or stula formation. No patients reported dyspareunia, and 2 of 30, or 7% of patients, had an anatomical failure with the posterior wall at 0.5 cm above the hymen or greater. Additional cost was not reported. Nonsynthetic grafts appear to be safer and have fewer erosions than synthetics, but prospective, randomized trials are needed to evaluate their effect on defecation
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and sexual function as well as improved long-term reduction in recurrences. Abdominal Approach The abdominal approach to the correction of a rectocele is most often employed when correction of an accompanying enterocele or vault prolapse is indicated. Advanced pelvic organ prolapse results from a combination of support defects and neuromuscular dysfunction of the pelvic oor. Patients often present with apical prolapse, a rectocele, and defecatory problems, including chronic constipation or fecal incontinence. When an abdominal approach, such as a sacral colpopexy, is planned for the repair of the apical support defect, there is an advantage to completing the surgery 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 via a laparotomy. Some surgeons have advocated extending the posterior graft of the sacral colpopexy down the posterior wall to correct such high defects.75,76 The sacral colpoperineopexy is another modication of the sacral colpopexy developed to treat perineal descent with concurrent posterior and apical pelvic organ prolapse.73 The aim of this surgery is to reconstruct and replace the normal suspensory ligaments of the vagina and the continuous fascial sheet that runs from the sacrum to the perineal body. The sacral colpoperineopexy can be performed totally abdominally or as a combined abdominal and vaginal procedure. First, from the abdominal approach, the peritoneum overlying the apex and posterior wall of the vagina is incised to open the rectovaginal space. Stitches are placed the length of the posterior wall from the apex to the perineal body. The perineal body is palpated and elevated with the surgeons 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 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 above, except that the perineal body stitches are placed transvaginally. The posterior vaginal wall is opened and fully dissected as described for the defect-directed repair. The vaginal dissection is then opened superiorly to connect with the abdominal dissection, permitting a graft to be pulled from the abdominal eld into the vaginal eld. Here, it is anchored to the perineal body and bilaterally to the arcus tendineus fascia rectovaginalis. An alternative method is to place the perineal body stitches transvaginally and
then open the posterior wall and pass only the sutures abdominally and attach them to caudad edge of the graft. This technique decreases exposure of the graft material to the vagina and may decrease vaginal erosion rates. Both Cundiff et al73 and Sullivan et al74 have reported on the sacral colpoperineopexy but for different indications. Sullivan et al74 reported on 205 women who had a sacral colpoperineopexy using Marlex for apical prolapse, rectocele, and enterocele. His technique included placing a trapezoidal piece of Marlex mesh posteriorly from the sacrum to the perineum. He used a needle carrier from above to pass the perineal body stitches from the cul-de-sac to the perineum. In addition, he added 2 straps of mesh on each side around the vagina laterally, and these were then sutured to Coopers ligament. With 10-year follow-up, he reported a 25% failure rate with a 5% mesh erosion rate. Cundiff et al73 reported on early results in 19 women who underwent the sacral colpoperineopexy for apical prolapse and perineal descent. The anatomical results for apical and posterior prolapse, as well as perineal descent, were excellent. Defecatory dysfunction resolved in 66% of patients. Four years after Cundiffs initial report from the Duke experience, Visco et al77 reported follow-up of 150 sacral colpopexies and 88 abdominal sacral colpoperineopexies via a laparotomy and with no vaginal incision. Among the 88 colpoperineopexies, 30 also had a vaginal incision. Of these 30 colpoperineopexies with vaginal incision, 5 had the mesh placed via the vaginal incision and 25 had sutures placed vaginally, which were passed into the abdominal cavity and then attached to the permanent mesh. All used Merselene mesh. The erosion rate for a traditional sacrocolpopexy and the abdominal sacral colpoperineopexy when the vagina was not opened were not statistically different at 3.2% versus 4.5%. The erosion rates were higher when the vagina was opened: 16% for vaginally placed sutures and 40% for vaginally placed mesh. Cundiff and coauthors73 reported a subsequent series of 11 patients with apical and posterior pelvic organ prolapse combined with perineal descent and rectal prolapse who were treated with sacral colpoperineopexy and suture rectopexy. In this series all grafts were placed vaginally, but using a dermal allograft. The anatomical cure rate was 82%. Symptom improvement included prolapse 75%, constipation 70%, incomplete defecation 60%, and assisted defecation in 70%. There were no graft erosions in this series. CONCLUSION The demographics of our aging population predict that gynecologists will see increasing numbers of women with rectoceles. Rectoceles can produce a variety of
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symptoms, including herniation, defecatory dysfunction, and sexual dysfunction. To provide optimal care for these patients, the gynecologist should conrm that pelvic organ prolapse symptoms are due to a rectocele by eliminating other causes of the differential diagnosis. Asymptomatic rectoceles are best managed expectantly. There is minimal data to dene optimal pessary use, but the virtual absence of associated morbidity with properly managed pessaries, coupled with the absence of alternative nonsurgical treatment options, recommends it for patients who want to avoid surgery. There are a variety of surgical options for patients who want to pursue surgical correction with signicantly different functional outcomes. The traditional posterior colporrhaphy, with or without levator plication, in prospective studies has been found to have good anatomical results, but high rates of de novo dyspareunia. When choosing this surgical approach, the current and potential coital activity of the patient must be considered. There are no direct comparisons of the different surgical techniques to date, but the available data suggest that better functional results, both in terms of defecatory function and sexual function, are found with the defect-directed repair. The posterior fascial replacement theoretically should have the functional results of the defect-directed repair with enhanced durability, although this is unproven presently. The sacral colpoperineopexy may provide better relief of defecatory symptoms associated with perineal descent, although the use of a synthetic graft with this procedure has high graft-related morbidity. Regardless of the type of vaginal repair, resolution of the bulge correlates well with correcting the need to splint or support the perineum to defecate. Other symptoms that have been attributed to rectoceles, including impaired sexual relations, loss of the sensation to defecate, and fecal incontinence, appear less amenable to surgical correction. Both the surgeon and patient should be aware that restoring structure with a surgical repair may not restore defecatory or sexual function.58,67,72
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10. Buller JL, Thompson JR, Cundiff GW, Krueger Sullivan L, Schon Ybarra MA, Bent AE. Uterosacral ligament: description of anatomic relationships to optimize surgical safety. Obstet Gynecol 2001;97:8739. 11. van Ophoven A, Roth S. The anatomy and embryological origins of the fascia of Denonvilliers: a medico-historical debate. J Urol 1997;157:39. 12. Lefer KS, Thompson JR, Cundiff GW, Buller JL, Burrows LJ, Schon Ybarra MA. Attachment of the rectovagi nal septum to the pelvic sidewall. Am J Obstet Gynecol 2001;185:413. 13. Uhlenhuth E, Day EC, Smith RD, Middleton EB. The visceral endopelvic fascia and the hypogastric sheath. Surg Gynecol Obstet 1948;86:9 28. 14. DeLancey JOL. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 1999;180:81523. 15. Skomorowska E, Hegedus V, Christiansen J. Evaluation of perineal descent by defaecography. Int J Colorectal Dis 1988;3:191 4. 16. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976 83. 17. Burrows LJ, Sewell C, Lefer KS, Cundiff GW. The accuracy of clinical evaluation of posterior vaginal wall defects. Int Urogynecol J 2003;14:160 3. 18. Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med 1966;59:477 82. 19. Henry MM, Parks AG, Swash M. The pelvic oor musculature in the descending perineum syndrome. Br J Surg 1982;69:470 2. 20. Bartolo DC, Read NW, Jarrett JA, Read MG, Donnelly TC, Johnson AG. Differences in anal sphincter function and clinical presentation in patients with pelvic oor descent. Gastroenterology 1983;85:68 75.
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38. Myers DL, Lasala CA, Hogan JW, Rosenblatt PL. The effect of posterior wall support defects on urodynamic indices in stress urinary incontinence. Obstet Gynecol 1998;91:710 4. 39. Cundiff GW, Nygaard I, Bland D, Versi E. Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders. Am J Obstet Gynecol 2000;182:S110. 40. Kelvin FM, Maglinte DD. Dynamic evaluation of female pelvic organ prolapse by extended proctography. Radiol Clin North Am 2003;41:395 407. 41. Kaufman HS, Buller JL, Thompson JR, Pannu HK, DeMeester SL, Genadry RR, et al. Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic oor disorders. Dis Colon Rectum 2001;44:1575 83. 42. Pannu HK, Genadry R, Gearhart S, Kaufman HS, Cundiff GW, Fishman EK. Focal levator ani eventrations: detection and characterization by magnetic resonance in patients with pelvic oor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:89 93. 43. Adams E, Thomson A, Maher C, Hagen S. Mechanical devices for pelvic organ prolapse in women (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Oxford: Update Software. 44. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use by members of the American Urogynecologic Society. Obstet Gynecol 2000; 95:9315. 45. Clemons JL, Aquitar VC, Tillinghast TA, Jackson ND, Myers DL. Risk factors associated with an unsuccessful pessary tting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004;190:34550. 46. Heit M, Rosenquist C, Culligan P, Graham C, Murphy M, Shott S. Predicting treatment choice for patients with pelvic organ prolapse. Obstet Gynecol 2003;101:1279 84. 47. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol 1959;77:490 502. 48. Zbar AP, Leinemann A, Fritsch H, Beer-Gabel M, Pescatori M. Rectocele: pathogenesis and surgical management. Int J Colorectal Dis 2003;18:369 84. 49. Francis WJA, Jeffcoate TNA. Dyspareunia following vaginal operations. J Opt Soc Am 1961;68:110. 50. Arnold MW, Stewart WR, Aguilar PS. Rectocele repair: four years experience. Dis Colon Rectum 1990;33:684 7. 51. Mellgren A, Anzen B, Nilsson BY, Johansson C, Dolk A, Gillgren P, et al. Results of rectocele repair: a prospective study. Dis Colon Rectum 1995;38:713. 52. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol 1997; 104:82 6. 53. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000;182:1610 5.
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69. Oster S, Astrup A. A new vaginal operation for recurrent and large rectocele using dermis transplant. Acta Obstet Gynecol Scand 1981;60:4935. 70. Goh JTW, Dwyer PL. Effectiveness and safety of polypropylene mesh in vaginal prolapse surgery. Int Urogynecol J 2001;12:S90. 71. Watson SJ, Loder PB, Halligan S, Bartram CI, Kamm MA, Phillips RKS. Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. J Am Coll Surg 1996;183: 257261. 72. Mercer-Jones MA, Sprowson A, Varma JS. Outcome after transperineal mesh repair of rectocele: a case series. Dis Colon Rectum 2004;47:864 8. 73. Cundiff GW, Harris RL, Coates K, Low VHS, Bump RC, Addison WA. Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associates with vaginal vault prolapse. Am J Obstet Gynecol 1997;177:134555. 74. Sullivan ES, Longaker CJ, Lee PY. Total pelvic mesh repair: a ten-year experience. Dis Colon Rectum 2001;44: 857 63. 75. Addison WA, Cundiff GW, Bump RC, Harris RL. Sacral colpopexy is the preferred treatment for vaginal vault prolapse. J Gynecol Tech 1996;2:69 74. 76. Lyons TL, Winer WK. Laparoscopic rectocele repair using polyglactin mesh. J Am Assoc Gynecol Laparosc 1997;4:381 4. 77. Visco AG, Weidner AC, Barber MD, Myers ER, Cundiff GW, Bump RC, et al. Vaginal mesh erosion after abdominal sacral colpopexy. Am J Obstet Gynecol 2001;184: 297302.
Address reprint requests to: Geoffrey Cundiff, MD, Johns Hopkins Medicine, Department of Obstetrics and Gynecology, 4940 Eastern Avenue, Room 125 A1C, Baltimore, MD 21224; e-mail: gcundiff@jhmi.edu.
Received May 24, 2004. Received in revised form September 13, 2004. Accepted September 16, 2004.
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CLINICAL EXPERT SERIES

Cundiff and Fenner

Rectocele and Defecatory Dysfunction

OBSTETRICS & GYNECOLOGY

VOL. 104, NO. 6, DECEMBER 2004

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Rectocele and Defecatory Dysfunction

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OBSTETRICS & GYNECOLOGY

VOL. 104, NO. 6, DECEMBER 2004

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Rectocele and Defecatory Dysfunction

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OBSTETRICS & GYNECOLOGY

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Table 3. Posterior Colporrhaphy

* Prospective. One of 53 patients did have plication.

Difcult evacuation (%) 32 15 61 44 53 46 40 4 57 27

Vaginal bulge (%) 100 18 38 14 86 9

Vaginal digitation (%) 39 25 24 21 30 15

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Rectocele and Defecatory Dysfunction

OBSTETRICS & GYNECOLOGY

Fecal incontinence (%) 13 8 24 21 30

De novo dyspareunia in sexually active patients (n % )

1 (2) 3 (4) 3 (7) 2 (3) 0

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n 137 117 355 204 64 64 89 89 49 34

RV, rectovaginal. * Prospective. Combined transanal and transvaginal repair.

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OBSTETRICS & GYNECOLOGY

Fecal incontinence (%) 39 3

0 20 19 Infections, 1 RV stula None 28 44 None

1 infection, 1 pyogenic granuloma, 4 dehiscence, 1 anal ssure

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OBSTETRICS & GYNECOLOGY

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OBSTETRICS & GYNECOLOGY

Vaginal digitations (%)

De Novo dyspareunia in sexually active patients (n % )

1 infection 3 (20) None 1 R/V stula 3 Erosions None

None 1 (14) None 1 (5) None

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OBSTETRICS & GYNECOLOGY