Rectocele Treatment & Management

Patients with rectoceles may present with an asymptomatic bulge found during the pelvic examination or with a myriad of symptoms. For patients without symptoms, expectant management is recommended. Currently, no evidence supports the use of estrogen to prevent or treat prolapse. ^[11]

Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele. 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. One responsibility of the physician is to inform women of their treatment options and the potential benefits and risks of each option. Medical treatment options for women with symptoms primarily consist of fiber supplementation to manage stool consistency, splinting or management with pessaries. Physical therapy and biofeedback can also improve patient ability to defecate.

Prophylactic measures

Prophylactic measures for preventing rectocele include diagnosis and treatment of chronic respiratory and metabolic disorders, correction of constipation, and intra-abdominal disorders that may cause chronic increases in intra-abdominal pressure.

Counsel patients about the preventive effects of weight control, proper nutrition, smoking cessation, and avoidance of strenuous occupational and recreational stresses that could damage the pelvic support system. Teach and encourage women to perform pelvic muscle exercises as a method of strengthening their pelvic diaphragm and as prophylaxis against the development of rectocele.  

Failure to recognize and treat significant support defects at the time of concomitant gynecologic surgery can lead to progression of rectocele. Similarly, opening up the genital hiatus by performing a retropubic urethropexy (eg, Burch procedure) can predispose a patient to enterocele and rectocele. Disabilities that may occur include inability to defecate without manual replacement of the uterus, bladder, or rectum; sexual dysfunction; and vaginal ulceration.

For mild degrees of relaxation, especially in younger women immediately following childbirth, levator muscle exercises, sometimes called Kegel exercises, are helpful in restoring the tone of the muscles of the pelvic floor. Instruct patients how to appropriately contract the puborectalis muscles. Patients should repeat this exercise approximately 75 times during the day. Like most forms of physical therapy, this is usually more effective in premenopausal women than in older women in whom generalized skeletal muscle atrophy has occurred. Learning appropriate relaxation of the puborectalis muscles with biofeedback may also help with evacuation. ^[18]

Pessaries

In addition to strengthening pelvic muscles, nonsurgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. Numerous vaginal pessaries are available that are designed to support specific types of pelvic organ prolapse. ^[19] Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet. On occasion, the vagina and its outlet may be so dilated that it does not hold a pessary. If no other reasonable therapeutic option is available for such a patient, a perineorrhaphy can be performed with the patient under local anesthesia, thus constricting the vaginal outlet to enable it to retain a pessary.

Pessaries can cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized, making exogenous estrogen essential in the hypoestrogenic patient. Remove, clean, and reinsert vaginal pessaries periodically; failure to do so can result in serious consequences, including fistula formation.

Patients can be treated successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations due to pessary use, or genuine stress incontinence that the patient deems unacceptable. ^[11]

Despite advances in understanding of pelvic floor anatomy, physiology, and disorders along with the advances in surgical techniques (including laparoscopy), no consensus exists regarding the optimal method of repair. ^[20] A variety of surgical techniques have been described, including posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal approaches.

In a comparison between transvaginal and transanal approach for rectocele repair, Leanza et al noted that although both approaches are effective for posterior compartment defects and improvement in quality of life, there are variations in outcome. ^[21] Gynecologists generally use the vaginal approach with successful anatomic results and minimal postprocedure pain, but sexual dysfunction is a concern. The transanal approach yields better rectal function and tends to be performed by general surgeon or proctologists. ^[21]  Transvaginal repairs have had lower rates of recurrent prolapse. ^{[22, 23, 24, 25, 19]}

Historically, the primary surgical therapy for rectocele has been posterior colporrhaphy. The principal objective of the posterior repair is to repair perineal tears that occurred during vaginal delivery. The perineal closure is designed to narrow the caliber of the vaginal introitus, develop a perineal shelf, and partially close the genital hiatus. The original description described reduction of the rectocele, suturing of the levator ani muscles anterior to the rectum, repair of the perineal body, and correction of existing enterocele or prevention of potential enterocele. ^[2] Approximating the levator muscles in the midline increases the length of the levator plate, shortens the longitudinal and transverse diameters of the genital hiatus, and improves the competence of the pelvic valve. This, however, is a nonanatomical approach to pelvic floor dysfunction and rectocele repair and likely increases risks of dyspareunia.

Surgical repair of rectocele is indicated for a symptomatic patient with a rectocele caused by a rectovaginal fascial defect. The criteria necessary to perform a repair are in contrast to the outdated dictum that posterior colporrhaphy should always accompany anterior colporrhaphy.

Rectoceles can be diagnosed based on physical examination and imaging study findings. A prudent plan is to consider performing preoperative radiologic evaluations of unusual rectoceles or those associated with rectal prolapse. Detachment of the posterior vaginal wall does not necessarily confirm the presence of a rectocele. Consider posterior colporrhaphy or other surgical management as a distinct and separate procedure when pelvic organ prolapse is repaired. 

Many surgeons use some type of barrier/drape to decrease the risk of fecal contamination. In one randomized controlled trial of women undergoing transvaginal pelvic organ prolapse repair, an anal purse string suture placed after sterile preparation significantly reduced gross fecal contamination.

Posterior colporrhaphy

Depending on the need for reconstruction of the perineum, the skin can be incised in a V-shaped fashion over the perineum or transversely along the external margin of the posterior fourchette. The vaginal wall of the posterior fourchette is sharply dissected from the underlying tissues of the perineal body. The rectovaginal space is entered and widely dissected to the vaginal apex, beyond the top of the rectocele.

At this point, looking for an enterocele and repairing it as necessary is extremely important. The pararectal fascia is plicated over the rectum with interrupted, delayed, absorbable or permanent sutures from the vaginal apex to the introitus.

As each suture is placed, the diameter of the vagina is assessed to ensure no transverse constriction is occurring that might result in dyspareunia. Linear, lateral, relaxing incisions relieve any constrictions that occur. If necessary, redundancy of the posterior vaginal wall flaps is trimmed and care is taken to preserve the vaginal caliber. The cut edges of the upper posterior vaginal wall are approximated in the midline. Plicating the muscle itself is not necessary; rather, plicate the capsule of the muscle. Plicating the capsule of the muscle most commonly involves the puborectalis muscle (this may risk dyspareunia). If a defective perineal body is present, its connective tissue is plicated in the midline. The remaining cut edges of the posterior vaginal wall and perineum are approximated. ^[26]

Perineorrhaphy

If a deficient perineal body is present after vaginal repair, consider performing a perineorrhaphy. The perineal deficit might be due to attenuation, laceration, or hypermobility of the perineal body. Whether levator ani plication adds to the success of the operation remains controversial due to concerns about dyspareunia. If any muscles are approximated in the midline, do not strangulate or destroy them. Take care to not constrict the posterior fourchette because this may result in dyspareunia.

Defect-directed or site-specific repair

Discrete tears or breaks have been described in the rectovaginal septum, most commonly transverse separation of the rectovaginal septum from the perineal body that are thought to be responsible for rectocele. Richardson described the defect-directed repair, or site-specific fascial repair, the aim of which is to provide an anatomical repair to close these fascial tears or defects. ^[3]

Begin with a midline epithelial incision and separate the epithelium from the rectovaginal fascia. The edges of the fascial defects or tears are identified; then, the defect is repaired with interrupted, delayed, absorbable sutures. Unlike the traditional posterior colporrhaphy, the sutures are placed from cephalad to caudad. The best plan is probably to repair the muscles of the perineal body, if separated, and then reconstruct the perineal body. The vaginal epithelium is then reapproximated; however, it is not intentionally narrowed, as with a posterior colporrhaphy. ^[3]

Most studies using the site-specific defect repair report very low rates of dyspareunia with good functional and anatomical outcomes. ^[27] However, some authors have noted that obstructed defecation is not corrected as successfully as the midline posterior colporrhaphy. ^[22]

Transanal repair

In the colorectal literature, the transanal repair has been advocated via the rectal side of the rectocele. This repair has several variations, but the purpose of the procedure is to remove or plicate the redundant rectal mucosa, thus decreasing the size of the rectal vault, and to plicate or repair the anterior rectal wall musculature.

Generally, the procedure is performed with the patient in the prone jackknife position. A U- or T-shaped incision is made transanally just above the dentate line. A mucosal flap is developed, separated from the rectovaginal septum, and excised. Then, the rectovaginal septum is plicated from the rectal side with absorbable sutures. The plication includes the anterior rectal musculature. The rectal mucosa and submucosa are closed in a separate layer. ^[26]

Advantages of this procedure include the excision of redundant rectal mucosa and the ability to deal with coincident anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse. Disadvantages include an inability to reconstruct the perineal body unless a second incision is made, an inability to correct an anal sphincter defect if present, and difficulty accessing a high rectocele. Complications of transanal repair include infection and rectovaginal fistula.

One major concern after transanal rectocele repair is postoperative anal incontinence. This significant problem has been described in up to 38% of patients after transanal repair. ^[28] Fecal incontinence may occur because of an occult sphincter laceration that causes symptoms with aging, or it may develop as a result of the anal dilation and stretching during the rectocele repair.

One area that deserves attention is the recurrent rate of prolapse. Two separate randomized trials have shown that the transanal approach has a significantly higher failure rate when compared with the transvaginal approach. ^{[22, 24, 25]}

A newer method of transrectal rectocele repair has been described. ^[29]  The Stapled Transanal Rectal Resection or STARR procedure. An anal dilator (CAD 33) is introduced into the anal canal and the posterior rectal wall is protected by a retractor placed in the lower hole on the dilator.  The dilator is then pushed along the anal canal. A PSA 33 anoscope is introduced into the dilator, and three half purse-strings permanent sutures placed which includes the prolapsed rectal wall with mucosa, submucosa and rectal muscle wall inserted above the hemorrhoidal apex .1–2 cm apart, including the top of rectocele or prolapse A 33 mm circular stapler is opened, and the head placed above the posterior vaginal valve and withdrawn. The anterior stapled line is reinforced using 3-0 absorbable sutures. The procedure is repeated in the posterior rectal wall, with the retractor inserted into the upper hole of the dilator.

A study by Zhang et al indicated that endoscopic stapled transanal rectal resection (STARR) is an effective treatment for rectocele. Sixty-one patients with severe rectocele underwent the procedure. The patients in the study had significant reduction or disappearance of the rectocele on defecography. ^[30]

Grafts

To prevent or reduce the risk of rectocele recurrence, a variety of graft materials and meshes have been used. These materials have been used in combination with the traditional methods of posterior colporrhaphy and in the defect-directed repair. ^[31]

In the case of a defect-directed repair, one may place a dermal allograft over the repair and secure it to the rectovaginal fascia cephalad, to the arcus tendineus fascia rectovaginalis laterally, and to the perineal body distally, which creates a second layer of support. Although the graft may strengthen the repair, graft materials may shrink. This can create a repair that is too tight and can decrease the flexibility of the posterior wall and cause restriction of the rectum, such that it cannot expand during accommodation or during coitus. This loss of flexibility in the posterior wall can lead to fecal urgency and dyspareunia.

If the use of graft material is considered the surgeon must choose the material with a very low rejection rate, be relatively inexpensive, decrease recurrence rates, and cause no harm with respect to bowel and sexual function. Currently, no good data support the use of one type of graft material over another. Many different materials have been used without clinical trials or long-term data to support their use.

In a randomized clinical trial comparing posterior colporrhaphy, site-specific defect repair, and grafts, Paraiso et al found an 86% success rate for posterior colporrhaphy and 78% success rates for site-specific defect repair. The addition of graft material did not improve outcomes. ^[32]

Mesh kits

On July 13, 2011, the 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 can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.

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.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. 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. ^[33]

The FDA reclassified all urogynecologic mesh instrumentation from class I (low risk) to class II (moderate risk). ^{[19, 34]}  In 2016, the FDA reclassified surgical mesh for transvaginal repair of POP 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. ^[35]

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. ^[36] 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 POP do not affect the abdominally or laparoscopically placed mesh for POP (sacrocolpopexy mesh), nor the mesh sling used to treat stress urinary incontinence.

With the overwhelming success of monofilament polypropylene mesh midurethral slings for the treatment of urinary stress incontinence has come great interest in the use of these materials in other prolapse surgery. These vaginal mesh kits for posterior vaginal prolapse that have been developed place synthetic material in the rectovaginal space. The mesh or graft is suspended through the iliococcygeous fascia or sacrospinous ligaments. These procedures have gained wide use without appropriate long-term safety or outcomes data.

After the posterior vaginal wall is opened to a few centimeters from the apex, the surgeon makes stab incisions 3 cm lateral and 3 cm posterior from anus bilaterally. After palpating the ischial spine with 1 finger vaginally, a needle is passed on the same side through the perianal stab incision into the ischiorectal fossa. The finger in the vagina follows the needle tip to help protect the rectum. The needle is passed along the lateral pelvic sidewall toward the ischial spine and penetrates the levator muscle 1 cm distal to the ischial spine.

This is repeated on the contralateral side. The mesh is then connected to the needle and reversed back through the perianal skin incisions and the mesh is sutured to the apex of the vagina. The rest of the repair is performed in the traditional fashion and the mesh ends are cut and stab incisions closed.

Complications consist of mesh exposure into the vagina or rectum, mesh contraction, granuloma, rectovaginal fistula, vascular injury, dyspareunia, and chronic pelvic pain.

In one study, the authors reported on 106 patients who had undergone an anterior, posterior, or total Prolift procedure. In this case series with 3 months of follow-up, they identified a 4.7% mesh erosion rate and 17% mesh shrinkage. The mesh erosions were treated with topical estrogen. Those who failed required surgical excision of the exposed mesh. ^[37]

Another group using the Apogee device retrospectively analyzed the outcomes of 120 women observed for 1 year. ^[38] The authors noted an 11% mesh erosion rate with a total of 4 women (3%) requiring excision of the mesh.

Current preliminary data is retrospective in nature and provides no comparative data to show differences between anatomic or functional cure rates using these devices compared with traditional procedures. Even in these preliminary studies, serious complications have been reported.

In January of 2017, The American Congress of Obstetricians and Gynecologists concluded “synthetic mesh or biologic grafts should not be placed routinely through posterior vaginal wall incisions to correct POP for primary repair of posterior vaginal wall prolapse.” ^[19]

Abdominal approach

This approach is most commonly used when correction of an accompanying enterocele or vault prolapse is indicated. Patients with rectocele often present with apical prolapse or defecatory problems, including chronic constipation or fecal incontinence. If the defect in the rectovaginal fascia is in the superior portion of the posterior vaginal wall, it can be repaired through the cul-de-sac during the sacral colpopexy.

Another modification of sacral colpopexy is the sacral colpoperineopexy. This procedure is used to treat perineal descent with posterior and apical pelvic organ prolapse. The aim of this procedure is to replace the normal support of the vagina and the continuous endopelvic fascia that runs from the sacrum to the perineal body. This procedure may be performed totally abdominally or as a combined abdominal and vaginal procedure.

From the abdominal approach, the peritoneum overlying the apex and posterior wall of the vagina is incised to open the rectovaginal space. Sutures are placed over the length of the posterior wall, from the apex to the perineal body. The perineal body is elevated by the surgeon's nondominant hand. Stitches are placed abdominally into, or as close to, the perineal body as possible. The permanent graft is placed abdominally between the posterior vaginal wall and the rectum. The sacrocolpopexy is completed with attachment of the anterior wall graft and posterior wall graft to the previously placed sacral sutures.

In the combined abdominal/vaginal approach, the sacral colpoperineopexy is performed as described above, except the perineal body sutures are placed transvaginally.

Levator ani plication

Although levator ani plication has been championed in the past, this procedure should rarely, if ever, be used during posterior colporrhaphy secondary to the significant increased risk of dyspareunia in sexually active women. ^[12]

Postoperative care usually consists of control of minor pain either with oral narcotics or with nonsteroidal anti-inflammatory drugs. For vaginal procedures, most patients are able to return home the same day. Of course, abdominal procedures mandate stronger analgesia such as patient-controlled analgesia, and the patient stays in the hospital for 2-3 days.

Immediate complications include adverse anesthesia reactions; hemorrhage; infection of the operative site or lower urinary tract; and injury of contiguous organs, blood vessels, or nerves. Infectious complications are rare (3-6%). Patients in whom graft material has been used have a graft erosion rate of up to 10%. Long-term complications include recurrent pelvic organ prolapse and dyspareunia in 20-30% of women. ^[26]

Failure and/or recurrence rates are highly variable. ^[27] Important factors in prognosis are teaching patients to decrease intra-abdominal pressure through adequate control of respiratory illnesses and to decrease straining. Identifying and treating all pelvic floor defects at the time of the original surgery and Pelvic Organ Prolapse-Quantified system (POP-Q) stage are the greatest predictors of long-term success.

Individualize management of rectocele and pelvic organ prolapse. Patients who are candidates for surgical correction should undergo a careful preoperative assessment that includes treatment of contributing medical problems, identification of all support defects, and evaluation of pelvic floor function. Surgeons who perform reconstructive procedures for rectocele and pelvic organ prolapse should be familiar with multiple surgical procedures because intraoperative modification of the preoperative plan may be required. Thorough knowledge of the anatomy and physiology of these disorders allows selection of a surgical approach that is usually successful in relieving symptoms and restoring and preserving anatomic relationships, visceral function, and coital function long term.