Background

As women age, the prevalence of pelvic floor dysfunction increases, including pelvic organ prolapse. A woman’s lifetime risk of having surgery for pelvic organ prolapse is 13%.^[1] 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.^[2] This percentage is suspected to double in the next 25 years.^[3]With this increase, there will be an increasing demand for prolapse repair, including rectocele repairs.

Up to one third to one half of women undergoing surgery for prolapse will have procedures that involve the posterior vaginal wall.^{[4, 5]}Rectoceles are one type of posterior compartment prolapse that consists of the rectum protruding into the vagina. Other conditions that impact the posterior wall include enteroceles, sigmoidoceles, intussusception, and rectal prolapse. Posterior vaginal wall prolapse can manifest as an asymptomatic bulge or with bothersome symptoms such as constipation, pelvic pressure, and defecatory dysfunction, including obstructed defecation. The gynecologist must keep in mind that surgical treatment should be reserved for symptomatic patients only.

Nonsurgical options for management of rectocele include expectant management, treatment of constipation, pelvic floor muscle training, and treatment with a pessary. In a study of patients with both rectoceles and obstructed defecation, 70% of patients improved. Further information on nonsurgical management can be found in the Medscape section on Rectocele: Treatment & Management.

Indications

Rectocele repair encompasses a number of surgical management options for symptomatic posterior prolapse. Determining the most appropriate candidates for surgical repair can be difficult due to a lack of correlation among symptoms and stage of prolapse.^{[6, 7]}

Contraindications

Rectocele repair has few contraindications, including anticoagulation that cannot be suspended before the procedure or other medical problems in which the risk of surgery outweighs the benefits.

Anatomy

An understanding of pelvic anatomy and the defect in the anatomy of the posterior vaginal wall is paramount to successful repair of rectoceles. DeLancey originally divided the vaginal axis into three levels of support for the posterior vaginal wall. At the apex of the vagina, the cardinal-uterosacral complex suspends the vagina. The middle of the vagina is supported by the endopelvic fascia and the levator ani. Level three support, at the most caudal portion of the vagina, is represented by the perineal body and perineal membrane.^[8] Identification of the breakdown in each level of support as well as addressing each level of support with repair will help in surgical planning and prevent the need for reoperation.

The rectovaginal septum has an important role in maintaining posterior vaginal wall integrity. This fascia runs downward and integrates distally into the perineal body. This tissue forms the anterior surface of the rectovaginal space and is thinnest along the midline. The rectovaginal septum is made of dense fibromuscular elastic tissue.^[8] The distension and tearing of these fibers during childbirth may cause posterior wall prolapse. Separation of the rectovaginal septum transversely causes the uppermost type of rectocele. 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.

Periprocedure

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