eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence

Relaxed Vaginal Outlet: Treatment

Author: R Duane Cespedes, MD, Residency Program Director, Director of Female Urology and Urodynamics, Department of Urology, Wilford Hall Medical Center; Clinical Associate Professor, Department of Surgery, Division of Urology, University of Texas Health Science Center at San Antonio
Coauthor(s): Javier L Arenas, MD, Resident Physician, Department of Urology, San Antonio Uniformed Services Health Education Consortium Residency Program, Wilford Hall Medical Center
Contributor Information and Disclosures

Updated: Dec 22, 2008

Treatment

Medical Therapy

Conservative management for many patients with relaxed outlet and rectocele may include pelvic floor muscle training (PMFT) (Kegel exercises). These exercises can be taught during the pelvic examination by applying pressure to the posterior introitus and instructing the patient to tighten these muscles while keeping the buttocks, thighs, and abdomen relaxed. Instructing patients to practice by stopping and starting their urine stream can also ensure proper technique, but may sometimes lead to dysfunctional voiding if done excessively. A typical PFMT regimen includes 10 consecutive contractions lasting 10-20 seconds each at least 3 times daily. Results may not be evident for 6-12 weeks, but progressive improvement may occur over 6 months. If patients have difficulty with PFMT, the use of vaginal cones, biofeedback, and/or electrical stimulation may assist in learning and performing the exercises.

Biofeedback provides the patient with some type of confirmation when she correctly contracts the pelvic floor muscles. The vaginal cone, a type of biofeedback, is a weight placed inside the vagina that requires pelvic floor contraction to retain the cone while upright. The patient should aim to use the cone at least 15 minutes, 3 times daily. As patients increase the strength of their pelvic floor muscles, the weight of the cone may be increased.             

Pessaries are another conservative option that do not compromise a patient’s future options for surgical therapy. The practitioner may choose from many shapes and sizes of pessaries depending upon the desired effect. When placing a pessary, the size of the pessary should be estimated based on the pelvic examination and changed until a proper fit is achieved. A trial with the pessary should be done by allowing the patient to leave the office and return in a couple of hours. The patient should be able to spontaneously void with the pessary in place. Most patients will be able to insert and remove their own pessary. The pessary offers patients a noninvasive therapy that may be accompanied by behavioral modifications.

Surgical Therapy

Surgical therapy, including rectocele and perineal body repair, are the mainstays of treatment. The choice of surgical treatment of a relaxed outlet or rectocele is based on the severity of symptoms and the presence of concomitant pathology. Repair is not always required unless the defect is large and/or symptomatic. It would be difficult to justify postoperative dyspareunia to address a small asymptomatic rectocele or perineal body. Conversely, some investigators believe that not performing these repairs at the time of an incontinence procedure or hysterectomy may cause undue pressure on other areas of the pelvic floor, possibly necessitating additional surgery at a later date.^16,17  

When treatment is indicated, management choices are both nonsurgical and surgical; however, surgery is the mainstay of treatment.²² With respect to surgical management, reconstructive repairs (eg, posterior colporrhaphy, perineorrhaphy) and obliterative repairs (eg, colpocleisis) have been performed depending on the age, level of sexual activity, and associated prolapse in other areas.^23,8

For the management of relaxed outlet and rectocele, surgery is the mainstay of treatment.¹¹ A successful surgical outcome is best facilitated by awareness of the various surgical approaches and techniques as well as adequate preoperative planning. Over the years, various surgical treatments for rectocele have been proposed and performed. The surgical approach for repair includes the following approaches: transabdominal, transvaginal, transperineal, combined transabdominal and transperineal, transanal, and laparoscopic.^{24,25,26,27,23,28,29,30}

Multiple retrospective studies have shown transvaginal repair to be the superior approach in terms of recurrent prolapse and postoperative morbidity. Transvaginal repair provides better surgical exposure and the opportunity to perform additional pelvic and incontinence procedures.^23,11,30 The traditional rectocele repair using sutures to reapproximate the separated fascia remains the most common and effective approach, especially in primary repairs.

A relatively recent addition to the treatment of a relaxed outlet is the use of graft materials as a reinforcing material in pelvic prolapse surgery. Several authors have reported the use of various graft materials (synthetic and biologic) for interposition midline fascial repair of rectocele as well as re-enforcing primary rectocele repair. Materials that have been used include cadaveric fascia lata, small intestinal submucosa (SIS), dermis, xenograft (porcine dermis), polyglycolic acid, and Prolene mesh. Long-term results using reinforcing materials in rectocele repair have had mixed outcomes. A 3-year follow-up on porcine xenograft outcomes reported a 41% rectocele recurrence rate, with 50% persistence in rectal emptying difficulties.³¹  Multiple studies have been published studying polypropylene mesh, with promising short-term follow-up results of 84-100% cure rates after 6-12 months follow-up.^32,33

Even more recently, percutaneous polypropylene mesh kit procedures have been introduced, but no long-term studies have yet been reported. The trocars are often placed in proximity to the rectum and therefore rectal injuries may be increased. Furthermore, laparoscopic repair with placement of synthetic mesh has also been described in a small study of cohorts, with promising short-term success rates of 80-100%.²⁷ Overall, limited scientific evidence exists to support the use of reinforcing materials in the routine primary repair, and long-term follow-up data is still needed. Long-term issues such as tissue hardening, dyspareunia, and late mesh extrusions or infections are not yet defined. However, the use of reinforcing material in patients with weak tissue and after multiple recurrent rectocele repairs seems justified.

Several authors have reported their experience with site-specific rectocele repair. Site-specific repair, in which only the focal area of weakness is repaired, has recently been shown to have a lower cure rate than the traditional posterior repair. In most cases, the posterior fascial defect is continuous from the most proximal extent of the defect all the way down to the perineal body. In a large retrospective review, Abramov et al demonstrated that site-specific rectocele repair was associated with a significantly higher anatomic recurrence rate with similar rates of dyspareunia and bowel symptoms compared with the standard repair.³⁴  

Furthermore, Paraiso et al compared site-specific repair, posterior colporrhaphy, and porcine mesh interposition. Their study demonstrated failure rates of 46%, 22%, and 14% for porcine mesh, site-specific repair, and posterior colporrhaphy respectively.³⁵

Preoperative Details

Premarin cream in the preoperative setting helps to strengthen the vaginal mucosa and improve healing time for any anticipated surgical intervention. Typically, 1-2 grams applied twice a week, beginning 4-6 weeks preoperatively is a common maneuver. Furthermore, the patient is administered enemas the night before the procedure to cleanse the rectum, and preoperative intravenous antibiotics are also given. Generally, if other procedures are to be performed, the rectocele and perineal body repair are performed last because these repairs obscure proximal vaginal exposure.

Intraoperative Details

Some investigators place Betadine-soaked rectal packing to assist in the identification of the rectum and to avoid injury; however, the authors prefer to manually push the rectum down and away (46). The ultimate size of the vaginal orifice is determined by placing Allis clamps on the inner aspect of the posterior labia and bringing the clamps together. Two fingers should be admitted easily. The skin between the Allis clamps is incised, followed by a triangular skin incision (with the apex pointing toward the anus) on the perineal body. The overlying skin is removed and a midline vaginal incision is made in the rectovaginal space, extending at least 1 cm proximal to the beginning of the rectocele.^22,29,30

The underlying rectum is dissected off the posterior vaginal wall until the medial margins of the pubococcygeus muscle are observed. Starting near the vaginal apex, the pararectal fascia is closed over the rectal wall using absorbable or nonabsorbable 2-0 or 0 sutures in an interrupted fashion, all the way to the perineal body (see Media files 1-6).

An evaluation after the first few sutures are placed should allow 2 fingers to be admitted easily. If an inadequate vaginal caliber is created, dyspareunia or an inability to engage in sexual intercourse may occur.¹⁶ The sutures are placed sequentially all the way to the perineal body. The perineal body is repaired by placing multiple 0 absorbable sutures deeply into the bulbocavernosus and superficial transverse perineal muscles. The perineal body is then fixated to the distal end of the rectocele repair using a purse string type suture placement. This is an important consideration as the 2 structures will otherwise function as separate entities and the perineum can descend, making defecation difficult.^36,28

If the patient has weak tissue or if additional strength is desired, a reinforcing material can be placed over the completed rectocele repair. The authors typically use preperforated porcine dermis and anchor it with 1-0 Vicryl sutures in at least 6 places using a Capio needle driver.

Recheck that at least 2 fingers can be easily admitted into the vaginal opening. The vaginal mucosa is closed with absorbable suture in a running locking fashion, and the perineal skin is closed subcuticularly. A vaginal pack is placed.

Postoperative Details

Patients should maintain a diet that keeps their stools soft, avoid any straining or heavy lifting, and refrain from sexual intercourse for approximately 4-6 weeks to allow complete tissue healing.

Complications

Significant complications are uncommon with one study reporting a 12.5% incidence of transient urinary retention but no rectal injuries, fecal incontinence, or hemorrhage. Postoperative dyspareunia rates are quite variable between series, and, in some cases, a rectocele repair can improve preoperative dyspareunia.⁹ Haase and Skivsted reported a 9% de novo dyspareunia rate; however, 24% of all patients had an improvement in their sexual satisfaction.¹⁷ Zimmern reported an 11% dyspareunia rate, yet 73% of patients stated their sexual function was improved.^29,30

Complications associated with the use of reinforcing materials are low. Blood loss during these procedures has been reported at 2 g or less of hemoglobin, with a 2-3% infection rate. Multiple studies have reported postoperative dyspareunia to be negligible.

With regard to mesh extrusion or erosion, these occurrences are also infrequent. A study by Porter using polypropylene mesh reported a 13% vaginal extrusion rate; however, all responded to local debridement only.³⁷ Other studies have reported even lower extrusion rates, and no reports of viscus erosion have been identified.³⁸  The use of allograft dermis has resulted in an 8% extrusion rate but none required operative treatment. The exact incidence of rectal injury is unknown and likely underreported; most rectal injuries can be easily repaired and no long-term sequelae have been reported. A rectovaginal fistula is a dreaded and fortunately rare complication.³⁹

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