Rectocele: Anatomic and Functional Repair
Linda Cardozo, Staskin David in Textbook of Female Urology and Urogynecology - Two-Volume Set, 2017
In 2010, An estimAted 166,000 women underwent surgery for pelvic orgAn prolApse with A rectocele procedure occurring in ApproximAtely hAlf of the cAses [1]. The prevAlence of rectoceles rAnges from 12.9% to 18.6% with An AverAge AnnuAl incidence estimAted to be 5.7 cAses per 100 women yeArs [2,3]. A rectocele is An outpocketing of the Anterior rectAl And the posterior vAginAl wAll into the lumen of the vAginA And is fundAmentAlly A defect of the rectovAginAl septum, not of the rectum. some rectoceles mAy be AsymptomAtic, whereAs others mAy cAuse such symptoms As incomplete bowel emptying, sensAtion of A vAginAl mAss, pAin, And pressure. The size of the defect does not necessArily correlAte with the Amount of functionAl derAngement or severity of bowel symptomAtology [4,5]. This chApter reviews the AnAtomy, pAthophysiology, diAgnosis, And mAnAgement of rectoceles.
The lower gastrointestinal tract, common conditions, and recommended treatments
Simon R. Knowles, Laurie Keefer, Antonina A. Mikocka-Walus in 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].
The Express Procedure
P Ronan O’Connell, Robert D Madoff, Stanley M Goldberg, Michael J Solomon, Norman S Williams in Operative Surgery of the Colon, Rectum and Anus Operative Surgery of the Colon, Rectum and Anus, 2015
The primary indication for the procedure is severe rectal evacuatory dysfunction, associated with the presence of an obstructing rectal intussusception, with or without a concomitant rectocele of greater than 2 cm that traps neostool on proctography. Patients with symptoms including tenesmus or the sensation of a lump within the rectum after defecation (in association with an intussusception) and/or an uncomfortable swelling within the vagina, or the need for vaginal digitation (in association with a rectocele) may also be considered for surgery.
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.
The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial
Published in Journal of Obstetrics and Gynaecology, 2021
Alexandros Derpapas, Gopalan Vijaya, Kostis Nikolopoulos, Manolis Nikolopoulos, Dudley Robinson, Ruwan Fernando, Vik Khullar
To our knowledge, 3D translabial pelvic floor ultrasound has not been used before to compare the anatomical outcomes between different techniques for posterior wall prolapse repair. 3D US of the posterior vaginal wall does not seem to reproducibly depict discrete defects of the rectovaginal septum that are associated with rectocele formation (Dietz 2011). Hence, our efforts focussed on depicting the postoperative reduction in the urogenital and levator hiatal dimensions measured by 3D ultrasound as a means to assess the surgical outcome of posterior repair. The reasoning for selecting such ultrasound markers is based on previous evidence showing that not only is LH overdistension strongly associated with clinically evident prolapse and recurrence, but also on data suggesting that clinically measured enlarged urogenital hiatus is persistent in women with failed surgical repairs (Delancey and Hurd 1998; Barry et al. 2006; Model et al. 2010; Dietz et al. 2011).
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.
Related Knowledge Centers
- Childbirth
- Enterocele
- Hernia
- Pelvic Organ Prolapse
- Hysterectomy
- Vagina
- Rectum
- Gynaecology
- Prolapse
- Sigmoidocele