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Rectocele

  • Author: Howard A Shaw, MD, MBA; Chief Editor: Kris Strohbehn, MD  more...
 
Updated: Mar 01, 2016
 

Background

Pelvic organ prolapse (POP) is a common condition that is increasing in incidence. Many cases of prolapse of the posterior vaginal wall occur along with other pelvic support defects. Pelvic surgeons who treat rectocele must have an excellent understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship between anatomy and function. These pelvic support defects may or may not cause symptoms. Pelvic pressure, vaginal protrusion, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been described in patients with rectoceles. Whether prolapse is the cause or result of these symptoms is uncertain.[1]

This article focuses on (1) current knowledge regarding the relationship of rectocele anatomy and function and (2) useful evaluations and treatments for women with rectoceles and defecation disorders.

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History of the Procedure

The surgical treatment of rectocele since the early 19th century has been the posterior colporrhaphy. This procedure was originally designed to repair perineal tears and included plication of the pubococcygeus muscles and the posterior vaginal wall (effectively creating a perineal shelf and partially closing the genital hiatus) with reconstruction of the perineal body.[2]

Richardson has advocated the site-specific repair of discrete breaks or tears in the rectovaginal septum.[3] This approach aims for a more anatomic repair. Other considerations for treatment include the approach (transvaginal vs transanal) and the introduction of different types of grafts or "kits" to attempt improvement of the longevity of the procedure.

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Problem

Rectocele is defined as herniation or bulging of the posterior vaginal wall, with the anterior wall of the rectum in direct apposition to the vaginal epithelium.

Sites of occurrence. Sites of occurrence.
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Epidemiology

Frequency

POP is very common, and it is the indication for more than 200,000 surgeries in the United States annually.[4] The number of women seeking care for pelvic organ prolapse is predicted to increase by 45% over the next few years.[5, 6]

Ambulatory women have a reported prevalence rate of pelvic organ prolapse of 30-93%. One of the difficulties in reviewing studies of pelvic organ prolapse is that these studies include all support defects (eg, defects of the vaginal apex, anterior wall, posterior wall), although most women have support defects at multiple locations. It is difficult to determine the prevalence of POP in ambulatory women, since most POP is mild, with prolapse beyond the vaginal introitus occurring in less than 5% of cases.[7]

Data on symptomatic women with prolapse are somewhat more robust. In a review of 149,544 women, Olsen et al found an 11.1% lifetime risk of surgery for pelvic organ prolapse or urinary incontinence. Approximately 40% of these women had posterior support defects.[8]

Thus, POP and rectocele are relatively common, although the supporting data are limited. The incidence of POP and rectocele increases with age, parity, and BMI. However, even nulliparous women may present with a clinically significant rectocele, albeit relatively uncommon.

 

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Etiology

Rectocele and other forms of POP are the result of women attaining an erect bipedal posture. Etiologically, most cases are the result of vaginal childbirth[9] and chronic increases in intra-abdominal pressure (such as chronic constipation). In some patients, rectocele is thought to develop as a result of congenital or inherited weaknesses within the pelvic support system.

A number of iatrogenic factors may contribute to POP, including failure to adequately correct all pelvic support defects during pelvic reconstructive surgery. In some patients, the failure to reattach the endopelvic fascia to the perineal body at the time of vaginal delivery leads to a site-specific defect in the endopelvic fascia. Additionally, procedures that alter the direction of pelvic forces can cause areas to prolapse that previously had been adequately supported. Examples include (1) ventral suspensions of the urethra, uterus, or vagina that increase exposure of the cul-de-sac to increases in intra-abdominal pressure; (2) posterior fixation of the vaginal apex; (3) failure to detect and correct an occult enterocele; and (4) excessive shortening of the vagina.

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Pathophysiology

Rectocele is a defect of the rectovaginal septum, not the rectum. The pelvic surgeon must know the anatomy of the pelvic floor and the other supports of the vagina in order to diagnose and treat this disorder.

The muscular support of the pelvis is from the pelvic diaphragm. The pelvic diaphragm is made up of a group of paired muscles that include the levator ani and coccygeus muscles. The levator ani are composed of the puborectalis, pubococcygeus, and ileococcygeus muscles. These muscles have their origin at the pubic rami on either side of the midline at the level of the arcus tendineus levator ani. The muscle fibers of the levator ani pass lateral to the vagina and rectum, creating a sling surrounding the genital hiatus. They also create the pelvic floor posteriorly and laterally. When a woman contracts the levator ani, the pelvic diaphragm provides a horizontal shelf where the pelvic viscera lie and the genital hiatus closes.

The thin membranous connective tissue in the rectovaginal septum (and surrounding the entire vaginal tube) is called the Denonvilliers aponeurosis (fascia) or endopelvic fascia and is fused to the underside of the posterior vaginal wall. This rectovaginal fascia extends downward from the posterior aspect of the cervix and cardinal-uterosacral ligaments to its attachment on the upper margin of the perineal body; then, it laterally extends to the fascia over the levator ani muscles. The cardinal and uterosacral ligaments pull the vagina horizontally toward the sacrum, suspending it over the muscular levator plate.

The perineal body is located between the vaginal introitus and anus. It is the attachment for the perineal membrane (bulbocavernosus muscles, superficial transverse perineal muscles, and investing fascia), a portion of the levator ani, the external anal sphincter, and the rectovaginal (endopelvic) 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. Between the lateral and superior support, the downward mobility of the perineal body is limited. However, if this attachment is separated, as can occur during childbirth, the perineal body can become more mobile, leading to rectocele and perineal descent.[10]

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Presentation

Patients with rectocele often present with feelings of pelvic pressure, a sensation of "bearing-down," or a perception that something is "falling out." Symptoms are often accentuated by standing and lifting and relieved by lying down. Symptoms directly related to the prolapse include the sensation of a mass or bulge in the vagina, pelvic pressure and pain, low back pain, and difficulty with intravaginal intercourse. Symptoms directly related to rectocele include defecatory dysfunction, inability to completely evacuate the distal rectum without straining, constipation, and dyspareunia.[11] However, constipation is considered a colonic motility disorder not treated by posterior surgery.[12]

 

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Indications

Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. Indications for surgery include the desire for definitive surgical correction of the mass or bulge in the vagina, pelvic pressure and pain, low back pain, difficulty with intravaginal intercourse, recurrent vaginal ulcerations due to pessary use, or fecal incontinence that the patient deems unacceptable.

Using strict indications for surgical repair of symptomatic rectoceles appears to improve surgical outcomes, including quality of life and a reduction in recurrence rates.[13] Hall et al used dynamic magnetic resonance imaging defecography (MRID) to evaluate 143 patients with obstructive defecation syndrome over an 8-year period (2006-2013). Seventeen patients met the following criteria and underwent surgical repair:

  • Defecation required manual assistance
  • MRID revealed an anterior defect larger than 2 cm, incomplete evacuation, and no perineal descent.

At a median follow-up of 23 months, the investigators reported an improvement in quality of life scores from 57.3 to 76.5 (P = .041) and a recurrence rate of 5.8%.[13]

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Relevant Anatomy

Histologically, the apex of the posterior vaginal wall consists of squamous epithelium, a superficial and deep muscularis layer and an adventitial layer. The fibromuscular layer is commonly called the rectovaginal fascia. Kleeman et al have described the histology of the rectovaginal septum. The apical portion is mostly adipose tissue while the midportion consists of an adventitial layer containing fat, fibrous tissue, blood vessels, nerves, and elastic fibers. The distal portion at the level of the perineal body contains dense connective tissue.[14]

Anatomically, the pelvic organs are maintained within the bony pelvis by levator ani muscles that are posteriorly fused (pelvic floor). The levator ani muscles are attached to the bony pelvis anteriorly and posteriorly; laterally, they are attached to the arcus tendineus musculi levatoris ani, which overlie the obturator internus muscles of the pelvic sidewalls. The anterior separation between the levator ani is called the levator hiatus. Inferiorly, the urogenital diaphragm covers the levator hiatus. The urethra, vagina, and rectum pass through the levator hiatus and urogenital diaphragm as they exit the pelvis. The posterior joining of the levator ani in the midline by the anococcygeal ligament forms the levator plate. DeLancey has described the 3 levels of pelvic support.[15]

The vagina and supportive structures. Paracolpium The vagina and supportive structures. Paracolpium extends along the lateral wall of the vagina.
Level I is suspension and level II is attachment. Level I is suspension and level II is attachment. The paracolpium suspends the vagina from the lateral pelvic walls in level I. These fibers extend vertically and posteriorly toward the sacrum. The vagina in level II is attached to the arcus tendineus fascia of the pelvis and superior fascia of the levator ani.
Level II and III detail. In level III, the vagina Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.

The perineal body is a central point for the attachment of the perineal musculature. The perineal body lies beneath and supports the pelvic diaphragm. The distal posterior wall of the vagina is fused to the ventral surface of the perineal body. The perineal body is also important to the support of the rectum. The pelvic organs, their interrelationships, and their support systems must be thought of conceptually and functionally in 3 dimensions (see above images).

Although the contents of the abdominal cavity bear down on the pelvic organs, they remain suspended in their relation to each other and to the underlying levator sling and perineal body. Each organ is capable of independent function because it is separated from other organs by connective-tissue spaces within the endopelvic connective-tissue support system. The normal tonic contraction of the levator ani muscles supports the pelvic organs from below and contributes to urinary and fecal continence. Relaxation of the levator ani muscles allows descent of the pelvic organs and aids urination and defecation.

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Contraindications

Current anticoagulation and a medical risk profile that exceeds the benefits gained from surgical treatment of rectocele are contraindications for this somewhat elective procedure.

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Contributor Information and Disclosures
Author

Howard A Shaw, MD, MBA Clinical Professor of Obstetrics and Gynecology, Yale University School of Medicine; Medical Director, Department of Women's and Children's Services, Yale-New Haven Hospital, Saint Raphael Campus

Howard A Shaw, MD, MBA is a member of the following medical societies: American Medical Association, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Connecticut State Medical Society, American Urogynecologic Society, American Society for Colposcopy and Cervical Pathology, American College of Healthcare Executives, International Urogynaecology Association, American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, American Association for Physician Leadership, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Kris Strohbehn, MD Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Jordan G Pritzker, MD, MBA, FACOG Adjunct Professor of Obstetrics/Gynecology, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center; Medical Director, Aetna, Inc; Private Practice in Gynecology

Disclosure: Nothing to disclose.

References
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Sites of occurrence.
The vagina and supportive structures. Paracolpium extends along the lateral wall of the vagina.
Level I is suspension and level II is attachment. The paracolpium suspends the vagina from the lateral pelvic walls in level I. These fibers extend vertically and posteriorly toward the sacrum. The vagina in level II is attached to the arcus tendineus fascia of the pelvis and superior fascia of the levator ani.
Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.
An Allis clamp tracts upward in the midline of the distal posterior vaginal wall at the site of the bulge. Traction is applied laterally and outward to create a flat triangle. The vaginal wall is then dissected off the anterior wall of the rectum.
In A, penetration with the fifth finger establishes direct access to the levator ani, bilaterally. In B, Allis clamps are placed on both sides. Traction on these clamps elevates the posterior wall of the vagina and places the junction of the rectal and vaginal walls under tension. An incision with a scalpel at this site separates the rectum from the posterior vaginal wall.
In A and B, rectocele is imbricated. Several layers may be required. Dense connective tissue must be identified and plicated. In C, levator ani are brought into the field from their lateral position and sutured in the midline, anterior to the rectum. Some authors omit this step secondary to postoperative pain.
In A, a second suture is placed into the levator ani to reduce the dimension of the genital hiatus. The more anterior these sutures, the smaller the genital hiatus. In B, redundant vaginal wall is trimmed.
In A, the perineal body is repaired. In B, the perineum is rebuilt. In C and D, the posterior vaginal wall is closed.
 
 
 
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