Rectocele Repair

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.

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.

Informed consent is an integral part of the planning process. The authors believe that it is important to discuss all the risks and benefits that pertain to surgery, including, but not limited to, the risks of bowel injury, dyspareunia, need for reoperation, and defecatory dysfunction. Patients should be adequately prepared for surgery and have all questions answered prior to surgery.

If the use of mesh is considered, it is imperative to disclose the recent FDA advisory statements. The surgeon should review the current guidelines put forth by the American Urogynecologic Society pertaining to this matter.

Materials that show diagrams of the anatomy are also very helpful. Pamphlets provided by the American College of Obstetrics and Gynecology for Pelvic Organ Prolapse have general information regarding procedures, frequently asked questions, and helpful drawings.

The patient should undergo a thorough history and in-office physical examination. Assessment should include evaluation of age, body-mass index (BMI), parity, previous pelvic surgery, and preoperative prolapse quantification. Prolapse can be evaluated using the pelvic organ prolapse-quantification system or the Baden-Walker system. Validated quality of life questionnaires such as the Colorectal-Anal Impact questionnaire can aid in addressing bowel symptoms.

An assessment of the anal sphincter should be performed prior to operative planning, as any defect in the sphincter may need additional testing.

If there is any discrepancy between symptoms of the patient and the findings on examination, the surgeon should pursue further work up of the symptom prior to proceeding with surgery.

The risk of shortening the vagina and the patient’s goal for future sexual activity must also be considered in deciding on treatment options. 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.

It is important to examine the vaginal tissue for atrophy, with consideration to treat patients with vaginal estrogen cream to help improve tissue health prior to surgery. 

Basic equipment for rectocele repair includes a complete vaginal surgery tray and suction.

In some cases, a self-retaining vaginal retractor (eg, Lone Star [Lone Star Medical Products, Stafford, TX], Magrina-Bookwalter vaginal retractor [Codman, Piscataway, NJ]) can be helpful. These retractors can help immensely with exposure without the need for multiple assistants or having to suture the labia to the medial thighs.

Antibiotic Prophylaxis: Due to the vaginal incision for repair, this procedure is a clean-contaminated procedure and therefore prophylactic antibiotics are recommended. Cefazolin 2gm IV or 3gm for those weighing greater than 120kg is a standard option.[9, 10]  

Anesthesia: Anesthesia is up to the discretion of the surgeon and patient. General, regional, or sedation anesthesia may be used. Many surgeons choose general anesthesia, regardless of the length of the procedure, to ensure adequate relaxation of the legs and pelvic floor.

Positioning: The patient should be in the dorsal lithotomy position to maximize exposure. The use of adjustable stirrups may help optimize exposure during the surgery. The Trendelenburg position may be helpful for exposure; however, prolapse may be masked with Trendelenburg positioning. Colorectal surgeons tend to prefer prone or jack-knife position for an endoanal approach.

Prior to beginning the procedure, a thorough examination of the patient under anesthesia should be completed. The surgeon should perform a thorough vaginal and rectal exam.  It is important to re-evaluate the defect and to determine the extent of surgery when the patient is at maximum relaxation.

Patients are usually discharged the day of the procedure or the following day if the repair is completed vaginally. Based on the patient and need for hemostasis, a vaginal pack and Foley catheter may be left overnight or removed later in the day.

Pain is usually manageable with oral medications starting on the day of surgery. Low dose narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay for postoperative pain control.

Patients should be instructed on a good bowel regimen in order to prevent straining and excessive Valsalva post-procedure. Stool softeners and a dietary instruction sheet should be provided prior to discharge, if not done at the preoperative office visit.

Pelvic rest for at least 6 weeks following the procedure is also recommended.

Perioperative complications include temporary urinary retention, pain, and constipation. More serious complications of the procedure include hemorrhage, infection (both at the operative site or urinary tract), injury to the rectum (with rare risk of rectovaginal fistula), and injury to nearby vessels. The authors are also cautious about performing an aggressive repair in a woman who plans to be sexually active, as rectocele repair can result in a foreshortened vagina and/or dyspareunia.

Postoperatively, it is important the patient reduce certain risk factors that may have caused or contributed to the rectocele in the first place. These include cessation of smoking, treatment of chronic pulmonary disease to decrease coughing (which increases intraabdominal pressure), avoidance of constant straining with bowel movements, and avoidance of occupational vocations that include heavy lifting.

Rectocele repair can be accomplished via many surgical techniques. One randomized controlled trial that compared three different surgical techniques concluded that each method resulted in significant improvement in symptoms, quality of life, and sexual function.[11]  The two transvaginal approaches include posterior colporrhaphy and site-specific posterior vaginal repair. These repairs will be explained in the following sections. Both options for transvaginal repair can be conducted with or without a perineorrhaphy for additional Level III support. Graft or mesh augmentation can be used with either technique, although no studies have shown improved outcomes; complications associated with mesh are discussed in a later section. The abdominal and laparoscopic approaches for apical defects associated with posterior compartment defects are not discussed in this review.

Colorectal surgeons often approach rectocele repairs via a transanal approach. Transanal repair has been shown to be less effective than transvaginal repairs. A Cochrane Database systematic review comparing transvaginal repair to transanal repair of rectoceles concluded that transvaginal repair results in lower recurrence rate of symptoms.[12]  Two randomized trials have compared 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.[13, 14]   A prospective study demonstrated that endoscopic stapled transanal rectal resection (STARR) is an effective treatment for rectocele causing obstructed defecation syndrome; the study’s findings were significant improvement between the preoperative and postoperative Longo obstructed defecation syndrome scores and significant reduction or disappearance of the rectocele on defecography.[15]

The following sections will go into more detail regarding each of the transvaginal approaches to rectocele repair.

To begin either transvaginal technique it is first important to assess the degree of the rectocele and genital hiatus and plan the incision accordingly. Often a perineorrhaphy will be performed in addition to a rectocele repair and the incision will likely incorporate portions of the perineal body in this case. It is important to determine the desired genital hiatus closure and to not extend the incision beyond this point for risk of constricting the vaginal introitus which can result in dyspareunia.   

An Allis clamp is placed on the vaginal epithelium at the most proximal and distal aspect the rectocele. If planning a perineorrhaphy, two additional Allis clamps are placed mucocutaneous junction of the widened introitus at the desired level of closure. The purpose of the Allis clamps are to assist with delineation of the borders for the incision as well as serve as countertraction for dissection purposes. The authors recommend injection of lidocaine with a dilute vasoconstrictor below the vaginal epithelium to aid with hydrodissection and hemostasis.

Using sharp or electrocautery dissection, an incision should be made between the two clamps. If perineorrhaphy is to be incorporated, an inverted isosceles triangle of skin should be denuded from the perineum. If the perineum is short, defined as less than 2 cm, the triangular incision may not be possible. The goal of this incision is to prevent redundant skin that will bunch after the repair is complete.

With the posterior vaginal wall on tension, the vaginal epithelium is dissected off the underlying tissue with sharp dissection. The authors prefer to place the nondominant index finger in the rectum to gauge the thickness of the tissue being dissected. In most cases, the dissection should continue only to the point slightly above the defect and should always be carried out to the sidewalls.

Once the vaginal epithelium has been fully mobilized off the underlying rectocele, the rectovaginal septum is then plicated in the midline using interrupted 2-0 absorbable sutures (see image in media section). Care should be taken to ensure that the rectum was not incidentally incorporated in the sutures and the vagina was not overly constricted. At this point the rectocele should be fully reduced and a perineorrhaphy can be performed, which is discussed below.

Excision of the excess tissue and then closure of the vaginal epithelium completes the procedure. Care should be taken not to overly trim the vaginal epithelium prior to closure to prevent scarring and contracture of the tissue. Reattachment of the rectovaginal connective tissue to the perineal body is recommended in all repairs when separation is observed.

The site-specific defect repair is based on the assumption that there are specific defects in the rectovaginal septum that allow for the serosal layer of an enterocele or rectum to abut the vaginal epithelium directly.[16]  Each defect in the vaginal fascia is individually isolated and repaired.

The vaginal epithelium is incised in a similar manner as described in the posterior colporrhaphy section. This procedure is best performed with the surgeon placing one finger in the rectum as guidance in repairing palpable defects. Interrupted delayed absorbable suture is used to plicate the tissue over the surgeon’s rectal finger. With multiple sutures, bulking of this tissue will be felt, eventually resulting in scar formation and creation of a stronger fascial plane (see image in media section).

Perineorrhaphy should be performed with any posterior repair where there is separation of the perineal muscles. This is done by dissecting the free ends of the bulbocavernosus and transverse perineal muscles. Each muscle group should be plicated in the midline and reattached to the rectovaginal septum with a 2-0 absorbable suture. Careful attention should be taken during this step to allow for three finger-breadths genital hiatus at the finish of the repair for adequate sexual function.

Several randomized studies have shown no benefit in adding graft or mesh augmentation to posterior colporrhaphy. A systematic review found no difference in anatomic and quality-of-life outcomes when using a biologic graft or synthetic mesh for transvaginal posterior compartment repairs.[17]  Routine use of synthetic mesh or biologic grafts should be avoided in transvaginal rectocele repairs for the primary repair of posterior vaginal wall prolapse.[11]  If it is used, prior to closure of the vaginal epithelium, the graft is placed over the fibromuscularis plication in the traditional posterior colporrhaphy or over the corrected defects after the site-specific repair. The graft can be attached to the apical support sutures if the patient is undergoing an apical repair at the time of posterior repair. The graft material should also be attached bilaterally to the endopelvic attachment on the levator ani muscles. The surgeon should rule out tension on the graft, as this will cause further contracture during the healing process. Finally, the distal portion of the graft is attached to the perineal body.

In 2011, the Food and Drug Administration (FDA) issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which may require multiple surgeries to repair and can be debilitating in some women. Mesh contraction, which causes vaginal shortening, tightening, and pain, was also reported.

The FDA’s update states, "Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse, or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion." See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse

In 2016, the FDA reclassified surgical mesh for transvaginal repair of pelvic organ prolapse from a moderate-risk device (class II) to a high-risk one (class III) and gave manufacturers 30 months to prove that their products are safe and effective.[18]

On April 16, 2019, the FDA mandated that all manufacturers of surgical mesh intended for transvaginal repair of anterior compartment prolapse (cystocele) stop selling and distributing their products.[19] The FDA has determined that the vaginal mesh kit manufacturers have not demonstrated reasonable assurance of safety and effectiveness for these devices, which is the premarket standard that now applies to them since the FDA reclassified them into class III (high risk) in 2016. Please note that the FDA restrictions for transvaginal mesh for pelvic organ prolapse do not affect the abdominally or laparoscopically placed mesh for pelvic organ prolapse (sacrocolpopexy mesh), nor the mesh sling used to treat stress urinary incontinence.

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.[17] It is generally not recommended as part of a posterior vaginal prolapse repair for patients who wish to remain sexually active. Special attention should be made to avoid 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.[20]

There is no conclusive evidence that one transvaginal approach is better than the other for surgical outcomes. One study concludes that site-specific rectocele repair is associated with higher anatomic recurrence rates than a standard posterior colporrhaphy and similar rates of dyspareunia and bowel symptoms.[21]   A prospective, randomized controlled trial concluded that posterior colporrhaphy and site-specific rectocele repair result in similar anatomic and functional outcomes and that the addition of porcine-derived graft did not improve outcomes.[11]  Bowel, sexual function, and quality of life significantly improved in all three groups.[11]