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The lower gastrointestinal tract, common conditions, and recommended treatments
Published in Simon R. Knowles, Laurie Keefer, Antonina A. Mikocka-Walus, Psychogastroenterology for Adults, 2019
A rectocele is an outpouching of the rectum (last part of the large bowel) caused by a central weakness in the tissue between the rectum and vagina (Figure 3.4). The resultant herniation forms a pouch-like space which can ‘trap’ faecal material, resulting in obstructed defaecation. Rectoceles are incredibly common (found in up to 90% of healthy female patients on proctography studies (radiology study which assesses rectal emptying during attempted evacuation) [2]. However, the majority are small (<2cm) and without functional impact so few result in symptoms. In symptomatic patients who have large functional rectoceles (>4cm) surgery may be beneficial; however, there is increasing evidence that conservative therapy such as bowel retraining should be first line [3] as approximately 60% of patients with rectoceles have an underlying or concurrent functional defaecation condition (see later) [4].
Fecal Incontinence, Physical Examination
Published in Han C. Kuijpers, Colorectal Physiology: Fecal Incontinence, 2019
Rectocele is common after childbirth and can be diagnosed by requesting the patient to strain, which forces the rectocele to protrude into the vagina. An anterior rectocele can be demonstrated best simply by inserting the index finger into the rectum and then pushing the anterior rectal wall forward and then downward into the vagina. Posterior rectocele is recognized by hooking the finger backward into the space between the anus and the coccyx.
Rectal Prolapse and Associated Pelvic Organ Prolapse Syndromes
Published in Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams, Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
André D’Hoore, Oliver M. Jones
A rectocele is a bulge that occurs in the front wall of the rectum and pushes into the vagina. It occurs due to injury, weakness or laxity of the rectovaginal septum. Rectocele is covered in more detail in the Gynaecology for the Colorectal Surgeon section (Chapter 1).
Investigation of pelvic floor disorders
Published in Climacteric, 2019
Pelvic floor ultrasound can also be used to evaluate descent of the vaginal walls, the uterus, the small bowel, and the rectum. For women with anterior vaginal prolapse, ultrasound may distinguish between a true cystocele from other conditions such as urethral diverticulum, Gartner duct cyst, and anterior enterocele24. For those women with cystocele, ultrasound may distinguish between those who have cystourethrocele (Green type II cystocele) and those with an intact retrovesical angle (Green type III cystocele)37. The first is associated with good urine flow rates and USI, while the latter is associated with voiding dysfunction and a low likelihood of SUI38. Ultrasound can be particularly useful for women with posterior vaginal wall prolapse. In these cases, ultrasound may distinguish a true ‘rectocele’ due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum. Rectal intussusception, a condition that is found in approximately 4% of patients in a urogyneoclogy clinic, is strongly associated with symptoms of obstructed defecation39. The preoperative diagnosis of this condition is important for planning the optimal surgical technique. Finally, on translabial ultrasound, a descent of the bladder of 10 mm and of the rectum or uterus >15 mm below the symphysis pubis at maximum Valsalva manoeuvre are strongly associated with POP symptoms and are proposed as cut-off values for the ultrasonic diagnosis of significant prolapse40,41.
Surgical management of pelvic organ prolapse
Published in Climacteric, 2019
C. F. Maher, K. K. Baessler, M. D. Barber, C. Cheong, E. C. J. Consten, K. G. Cooper, X. Deffieux, V. Dietz, R. E. Gutman, J. J. van Iersel, C. W. Nager, V. W. Sung, R. de Tayrac
Transvaginal options for the repair of posterior vaginal wall defects include midline fascial suture plication (posterior colporrhaphy [PC]), or augmentation of the repair with biological graft or synthetic mesh. DeLorme’s procedure is a transanal procedure for rectal prolapse but has been evaluated for management of rectocele, while the ventral rectopexy is an abdominal intervention recommended for rectal prolapse that some have suggested may also be suitable for rectocele. The findings of the 2017 ICI review include the following:PC has superior anatomical success to transanal repair with similar functional outcomes (GoR B).No evidence demonstrates benefit for synthetic or biological graft at vaginal repair (GoR C).No data demonstrate ventral rectopexy ± vaginal graft is effective for rectocele (GoR D).These recommendations are reflected in the treatment pathway with green guidance arrows supporting native tissue PC as the treatment of choice for posterior compartment prolapse.
Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation
Published in Journal of Investigative Surgery, 2018
C. A. Leo, P. Campennì, J. D. Hodgkinson, P. Rossitti, F. Digito, G. De Carli, L. D'Ambrosi, P. Carducci, L. Seriau, G. Terrosu
Between October 2006 and September 2013, 170 patients with a diagnosis of ODS underwent IDP. Male to female ratio was 18:152 (10.59%:89.41%). Median age was 60.41 yearsTABLE 2 (SD: ±13.27). A predominant preoperative reported symptom in 165 patients (97%) was feeling of incomplete evacuation. Sixty-three patients (37%) reported incomplete evacuation. Thirty-eight patients (22%) reported digitating via rectum or vagina to aid defecation. Eighty-five patients (50%) had tenesmus. Sixty-seven patients (38%) had a diagnosis of rectocele with mucosal prolapse. Fifty-nine (33%) had mucosal prolapse and rectal intussusception. Rectocele with mucosal prolapse and intussusception was found in 44 patients (24.8%). Of the 170 patients, 23.5% had perineal descent >4 cm. Twenty-six patients (15%) had a previous colorectal surgical procedure (including left/right hemicolectomy, hemorrhoidectomy, and hemorrhoid banding). Seventy patients (41%) had anorectal manometry studies within the normal range values. Fifty-one (30%) patients were found to have a low resting pressure, with normal other manometry pressures. Forty-nine patients (29%) had a significant alteration in rectal volumes tolerated. Results of this cohort are shown in Table 2.