The goal of rectocele repair, or posterior colporrhaphy, is treatment of the patient’s symptoms. Uterovaginal or vaginal vault prolapse can manifest as an asymptomatic bulge or as bothersome symptoms such as constipation and defecatory dysfunction. The gynecologist must keep in mind that surgical treatment should be reserved for symptomatic patients only.
The patient must be evaluated as a whole, including evaluation of age, body-mass index (BMI), parity, previous pelvic surgery, and preoperative prolapse quantification. The risk of shortening the vagina and the patient’s goal for future sexual activity, specifically vaginal intercourse, must also be considered in deciding treatment options. It is important to examine the vaginal tissue for atrophy.
The authors tend to treat most patients with vaginal estrogen cream to help tissue health before surgery. The surgeon must also consider not only the strength of the tissue in the posterior compartment but also the specific defect(s) during the examination and whether they play a role in the patient’s symptoms.
The United States population is getting older. Based on data from the United States Census Bureau in 2009, women older than 65 years account for 14% of the population.  . This percentage is suspected to double in the next 25 years.  Therefore, with the prevalence of pelvic organ prolapse increasing with age, there will be an increase demand for this procedure.
Nonsurgical treatment with a pessary is an option in some women who find the use of the device acceptable. In patients who use this device, the authors recommend visits to the provider every 3 months to clean the device and to check on the health and integrity of the vaginal epithelium. For long-term pessary users, we advise use of vaginal estrogen (cream, tablets, ring), although no evidence suggests that the use of vaginal estrogen (eg, Premarin) can help to treat prolapse.  However, many clinicians choose to prescribe estrogen for the health of the tissue for future surgical procedures, for use with pessary, or for help with dyspareunia.
A pessary may not be the ideal choice in a woman who is sexually active, as the device must be removed for intercourse. Pessaries are great as a first-line nonsurgical treatment or as an option in patients who opt against undergoing surgery. The indication for surgery after pessary use includes the desire for definitive treatment and recurrent ulcerations/erosions.
Rectocele repair is indicated for symptomatic uterovaginal or vaginal vault prolapse.
Rectocele repair has few contraindications, including anticoagulation that cannot be suspended prior to the procedure or other medical problems in which the risk of surgery outweigh the benefits.
One complication of rectocele repair during the operation includes fecal contamination. To prevent this, an adhesive drape can be placed on the perineum above the anus. Some surgeons use a purse-string suture prior to the case to close the anus, but this prevents concomitant rectal examination and may cause ballooning of the distal rectum. In addition, bowel preparation prior to transvaginal approach is not recommended, as it may increase the risk of contamination of the field. It is suggested the surgeon evacuate the rectal vault as needed prior to beginning the operation.
An important consideration to discuss with the patient is the potential for postoperative dyspareunia. This may occur in patients who undergo levator plication,  The authors of this article do not recommend the procedure. The authors also suggest not trimming the vaginal epithelium excessively, as tissue scarring and contracture occurs along the incision during the healing process, which can increase the risk of dyspareunia. 
A randomized control trial in 2006 comparing 3 different surgical techniques for rectocele repair concluded that each method resulted in significant improvement in symptoms, quality of life, and sexual function. 
Two randomized trials have compared the vaginal and transanal approaches and concluded that the transvaginal approach yielded a lower reoperation rate and led to better anatomic results based on pelvic organ prolapse (POP-Q) examination during the follow-up period. [7, 8]
An understanding of the vaginal axis is crucial in successful vaginal surgery. The vaginal axis includes, proximally to distally, the cardinal-uterosacral complex, the rectovaginal septum (fascia of Denonvilliers), the perineal body, and the levator plate. The cardinal-uterosacral complex suspends the proximal vagina posteriorly and superiorly to the pelvic walls and sacrum. The next important structure is the rectovaginal septum, which has an important role in maintaining posterior pelvic integrity.
Separation of the rectovaginal septum transversely causes the uppermost type of rectocele. This fascia runs downward and integrates distally into the perineal body. The rectovaginal septum has dense elastin, which is important during childbirth. The distension and tearing of these fibers during delivery may cause posterior wall prolapse. The rectovaginal septum is the most important part of the posterior pelvic integrity, and its fibers are the densest of the entire pelvic floor. A lesion in the upper third of the vagina is usually part of a full-length rectocele and may result from a transverse separation of the rectovaginal septum from the descending cardinal-uterosacral fibers.
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