Chapter 8 Urogynecological Assessment and Perspective in Patients Presenting with Evacuatory Dysfunction

Chapter 8

Urogynecological Assessment and Perspective in Patients Presenting with Evacuatory Dysfunction

Jennifer T. Pollak and G. Willy Davila

Background

Enteroceles and rectoceles represent a herniation of the rectum or upper posterior vaginal wall and its underlying intraperitoneal contents into the vaginal canal resulting in a vaginal bulge. Women typically complain of perineal and vaginal pressure, obstructive defecation, or constipation, and many splint or digitally reduce the vagina in order to effectuate a bowel movement. These anatomic defects arise from either a tear or stretching of the rectovaginal fascia analogous to an abdominal wall ventral hernia. Although anatomic cure rates are high, there are conflicting reports with regard to functional outcome, postoperative defecatory symptoms, and sexual dysfunction, including dyspareunia. Marked differences exist between management approaches followed by urogynecologists and colorectal surgeons. This chapter should be read in conjunction with Chapter 6.3 concerning rectocele/enterocele pathogenesis and manage- ment. A gynecologist’s perspective of evacuatory dysfunction and the stan- dard nature of gynecological assessment of these patients is highlighted here.

Introduction

With the growth of the sub-specialty of urogynecology and its related

research, a growing number of clinicians are recognizing the concept of the

female pelvic floor. The pelvic floor is a single functional unit composed of

three compartments. The anterior compartment consists of the bladder and

urethra, the middle compartment consists of the vagina and uterus, and the

posterior compartment is comprised of the rectum and anus. Traditionally,

dysfunction of the different compartments is cared for by different clini-

cians, and thus, coexistent problems of the other organs often go unrecog-

nized. In addition, dysfunction in one compartment may be managed very

differently by those specialists who care for that specific compartment. This

636

lack of consensus is exemplified in the management of rectovaginal septum weakness by gynecologists and colorectal surgeons.

The coexistence of pelvic floor dysfunction in a single patient is extremely common. In a questionnaire study, 53% of patients with fecal incontinence also had urinary incontinence and 18% of them had genital prolapse (1).

In the same study, 66% of patients with rectal prolapse had urinary incon- tinence and 34% had genital prolapse. In another series, 31% of women surveyed with urinary incontinence also had fecal incontinence and 7% of women with genital prolapse had fecal incontinence (2). In a large series of over 800 women with urinary incontinence and/or genital prolapse, 20%

of patients had anal incontinence (3).

Both gynecologists and colorectal surgeons treat rectoceles and entero- celes, and rectocele repair represents one of the most commonly performed gynecologic pelvic reconstructive procedures in women. In fact, 100% of gynecologists surveyed manage rectoceles, whereas 68% of colorectal surgeons manage this disorder (4–6). Gynecologic surgeons frequently perform rectocele repairs as isolated procedures or in conjunction with other reconstructive procedures. The restoration of normal anatomy to the posterior vaginal wall is referred to as an enterocele repair if it involves a peritoneal bulge into the upper posterior vaginal wall. If the lower wall is involved, it is termed a posterior repair or posterior colporrhaphy. Although sometimes used interchangeably with the term rectocele repair, these two operations may have varying treatment goals. A rectocele repair focuses on correcting a hernia of the anterior rectal wall into the vaginal canal secondary to a weakened or torn rectovaginal septum, whereas a posterior colporrhaphy corrects a rectal bulge and normalizes vaginal caliber by restoring structural integrity to the posterior vaginal wall and introitus.

Unlike other reconstructive procedures, such as surgery to treat urinary stress incontinence, the gynecologic preoperative evaluation of a sympto- matic posterior vaginal bulge typically includes only a history and physical examination. Gynecologists generally have not adopted the performance of defecography or other evaluation techniques for the evaluation of this anatomic defect. While 80% of colorectal surgeons use defecography, only 6% of surveyed gynecologists use this investigation (4–6). In addition, dif- ferentiation between enterocele and rectocele components of posterior vaginal wall prolapse typically is performed on a clinical and intraoperative basis. It is unclear at this time whether surgical therapy outcomes are impacted negatively by the lack of preoperative evaluation beyond this history and physical examination. By far, gynecologists consider repair of the rectocele a commonly necessary procedure with low morbidity for their patients.

This chapter will cover various aspects of the gynecologic approach to

rectocele and enterocele repair, including physical examination and

anatomy, symptoms, indications for repair, surgical techniques, and treat-

ment outcomes.

Physical Examination

The typical physical finding in a woman with a symptomatic enterocele or rectocele is a lower posterior vaginal wall bulge. An enterocele is identified as a bulge of the superior posterior vaginal wall between the vaginal apex and the levator plate. It may extend superiorly to weaken the support of the vaginal apex, leading to vaginal vault prolapse. In an isolated rectocele, the bulge extends from the edge of the levator plate to the perineal body (Figure 8.1). As a rectocele enlarges, the perineal body may distend further and loose its bulk, leading to an evident perineocele. Enteroceles and rec- toceles frequently coexist. The physical examination should include not only a vaginal examination, but also a rectal examination, as a perineocele may not be evident on vaginal examination. At times, it can be identified only upon digital rectal examination, where an absence of fibromuscular tissue in the perineal body is confirmed.

Uter Utero-Sacral

Ligament

Anal Sphincter Perineal Body Transverse Perineii M.

Bulbocavernosus M.

Pelvic Floor Muscles (Levator Plate) Utero-Sacral

Ligament

Anal Sphincter Perineal Body Transverse Perineii M.

Bulbocavernosus M.

Pelvic Floor Muscles (Levator Plate)

CCF

©2002

Figure 8.1. Lateral view of pelvis. Rectoceles typically develop between the levator

plate and the perineal body due to weakness of the rectovaginal septum endopelvic

fascia.

Various classification schemes describe enterocele and rectocele severity.

In the traditional Baden–Walker system, which uses the mid-vaginal plane as a landmark, anatomic defects are graded from 0 to 4. Grade 0 is normal, whereas a grade 4 extends beyond the hymen. In the pelvic organ prolapse quantification (POPQ) system, two points along the posterior vaginal wall are identified (Ap, 3 cm proximal to the hymen; Bp, the most dependent part) and their distances from the hymenal ring are measured in centime- ters with maximum Valsalva effort. In the POPQ system, discrete points and their displacement are measured rather than the underlying prolapsing organ. The more traditional approach has a surgical focus, whereas the newer POPQ simply identifies specific vaginal site prolapse (7).

Additional factors that should be evaluated during the physical exami- nation include associated pelvic support defects such as vaginal vault prolapse or cystocele, pelvic neuromuscular function, and vaginal mucosal thickness and estrogenation. All pelvic floor anatomic defects should be repaired during a reconstructive surgical procedure because untreated small anatomical defects of the anterior and apical vagina may enlarge after repair of the posterior vaginal wall. Thus, preoperative identification of specific individual defects is crucial. Levator contraction strength and tone are important factors in enhancing the long-term success rate of pelvic reconstructive surgery. Regular Kegel exercises should be recommended following pelvic reconstructive procedures. Biofeedback therapy may be necessary to instruct patients how to adequately isolate and contract their pelvic floor muscles. Poorly estrogenized thin vaginal mucosa should be treated with local estrogen prior to surgical therapy.

Anatomy

Enterocele and rectocele result from defects in the integrity of the poste- rior vaginal wall and rectovaginal septum and herniation of the posterior wall into the vaginal lumen through these defects. The normal posterior vagina is lined by squamous epithelium that overlies the lamina propria, a layer of loose connective tissue. A fibromuscular layer of tissue composed of smooth muscle, collagen, and elastin underlies this lamina propria and is referred to as the rectovaginal fascia. This is an extension of the endopelvic fascia that surrounds and supports the pelvic organs and contains blood vessels, lymphatics, and nerves that supply and innervate the pelvic organs.

Denonvilliers originally described a dense tissue layer in men between

the bladder and the rectum and named it the rectovesical septum (8). Many

clinicians refer to this layer as Denonvilliers’ fascia. The layer of tissue

between the vagina and the rectum was felt to be analogous to the rec-

tovesical septum and became known as Denonvilliers’ fascia in the female,

or the rectovaginal septum (8). Others described the rectovaginal septum,

or rectovaginal fascia, as a support mechanism of the pelvic organs, and they

were successful in identifying this layer during surgical and autopsy dissections (8–11).

The normal vagina is stabilized and supported at three levels. Superiorly, the vaginal apical endopelvic fascia is attached to the cardinal uterosacral ligament complex (Level I). Laterally, the endopelvic fascia is connected to the arcus tendineus fasciae pelvis (Level II), with the lateral posterior vagina attaching to the fascia overlying the levator ani muscles. Inferiorly, the lower posterior vagina connects to the perineal body (Level III) (12).

The cervix—or vaginal cuff in the hysterectomized woman—is considered to be the superior attachment site or “central tendon,” and the perineal body the inferior attachment site or “central tendon.” The endopelvic fascia extends between these two “tendons,” comprising the rectovaginal septum (Figure 8.2). An enterocele or rectocele results from a stretching or actual separation or tear of the rectovaginal fascia, leading to a bulging of the posterior vaginal wall noted on examination during a Valsalva maneuver.

Trauma from vaginal childbirth commonly leads to transverse defects above the usual location of the connection to the perineal body (Figure 8.3) (8,13).

In addition, patients may present with lateral, midline, or high transverse fascial defects. Separation of the rectovaginal septum fascia from the vaginal apex results in the development of an enterocele as a hernia sac without fascial lining and filled with intraperitoneal contents (Figure 8.4).

Utero-Sacral Ligament

Cardinal Ligament

External Anal Sphincter

Transverse Perineii M.

Bulbocavernosus M.

Rectovaginal Septum Cervix

Superior Central Tendon

Inferior Central Tendon CCF

©2002

Figure 8.2. Diagrammatic representation of the rectovaginal septum including its

attachment to a “superior tendon” and an “inferior tendon.”

Recto Rectovaginal Septum Tear ginal Septum ear _CCF

©2002

Figure 8.3. Fascial tears of the rectovaginal septum can occur superiorly or inferi- orly at sites of attachment to a central tendon.

o-Sacral o-Sacral

les Enterocele

Rectocele

CCF

©2002

Figure 8.4. Enteroceles can develop from weakness of the rectovaginal septum

along its cephalad portion, whereas rectoceles develop from weakness along its infe-

rior portion.

The levator plate extends from the pubic bone to the sacrum/coccyx and provides support for the change in vaginal axis from vertical to horizontal along the mid vagina. A rectocele typically develops at, or below, the levator plate along the vertical vagina (Figure 8.1).

Symptoms

Symptoms of posterior wall weakness typically result in pelvic/perineal pressure or a bulge with associated lower back pain (enterocele) or a need to digitally reduce or splint the posterior vaginal bulge or perineum in order to either initiate or complete a bowel movement (rectocele). Accumulation of stool within the rectocele reservoir leads to increasing degrees of per- ineal pressure and obstructive defecation. In the absence of digital reduc- tion, women will note incomplete emptying, which leads to a high degree of frustration and a vicious cycle of increasing pelvic pressure, the need for stronger Valsalva efforts, enlargement of the rectocele bulge, and increas- ing perineal pressure. Rectal digitation is not commonly self-reported by patients with a symptomatic rectocele unless asked by the physician.

The symptom of constipation is not clearly understood by the practicing gynecologist. Its vague nature, coupled with a poor understanding of the complexity of colonic function, results in a lack of interest on the gynecol- ogists’ part to further evaluate the symptom of constipation. Unfortunately, this may result in surgical treatment of abnormal bowel function via a pos- terior colporrhaphy when conservative therapy for constipation may have otherwise achieved a satisfactory outcome. The persistence of abnormal defecation may be responsible for the high rectocele recurrence rate in some series with this operation (14).

An enlarging enterocele or rectocele will widen the levator hiatus and increase vaginal caliber (15). In addition, women with increasing degrees of prolapse have progressively larger genital hiatuses (16). This may lead to sexual difficulties, including symptoms of vaginal looseness and decreased sensation during intercourse. Whether this is due primarily to the enlarge- ment of the vaginal introitus and levator hiatus or coexistent damage to the pudendal nerve innervating the pelvic floor musculature is unclear. A large enterocele or rectocele may extend beyond the hymenal ring. Once exteri- orized, the patient is at risk for vaginal mucosal erosion and ulceration.

Hemorrhoids also can be associated with a rectocele (12). They typically

occur secondary to increased Valsalva efforts by the patient in order to

effectuate a bowel movement.

Surgery to Correct an Enterocele

The goals of surgery to repair an enterocele include correction of a supe- rior posterior vaginal wall bulge and restoration of fascial integrity to the entire posterior vaginal wall. Surgery for enterocele often is approached vaginally, but also may be performed abdominally. The choice of approach depends on concomitant pathology or additional types of pelvic organ pro- lapse that require repair, as well as the surgeon’s preference. No reports exist in the literature that compare the outcomes between the different types of repairs.

The traditional vaginal enterocele repair requires a midline incision in the posterior vaginal wall from the introitus to the level of the vaginal apex.

The enterocele sac is then dissected off the posterior vaginal mucosa, under- lying rectovaginal septum, and anterior rectal wall. The enterocele sac is sharply opened and explored to confirm the absence of intraperitoneal con- tents. If intraperitoneal contents are adherent to the sac, they are sharply dissected free. Nonabsorbable sutures are then placed in a purse-string fashion to close the enterocele sac. Several sutures may be required depend- ing on the size of the sac. The excess peritoneum is then trimmed. Other concomitant repairs may then be performed as clinically indicated, and the posterior vaginal wall is closed as described for rectocele repair (13) (vide infra).

The McCall culdoplasty is another vaginal technique designed to repair enteroceles. This procedure allows for apical support of the vagina and closes the cul-de-sac. Following a vaginal hysterectomy, previously cut uterosacral ligaments are plicated together along with the intervening peritoneum overlying the sigmoid colon and the apical posterior vaginal mucosa. The first suture is placed as high as possible on the uterosacral ligaments, and successive sutures are placed until the cul-de-sac is closed.

The number of sutures depends on the size of the enterocele and cul-de- sac. Permanent suture material is used. Reported complications have included ureteral injury, infection, and subsequent vault prolapse (17). If the patient had a previous hysterectomy, extra care must be taken in identifying the uterosacral ligaments and ureters prior to plicating the peritoneum.

Discrete fascial defect repair is growing in popularity as a means to

correct enteroceles akin to the concept as practiced endorectally by colo-

proctologists. The concept of this surgical repair is to identify and correct

discrete tears or breaks in the endopelvic fascia. Breaks in the fascial attach-

ments at the apex of the vagina will cause an enterocele so that intraperi-

toneal contents will protrude though the fascial defects (Figure 8.3). Similar

to hernia repairs performed by general surgeons, the technique involves

identifying the discrete fascial tears, reducing the hernia, and then clos-

ing the defect. This may be accomplished vaginally, abdominally, or

laparoscopically (13).

The Moschcowitz procedure, the Halban procedure, and uterosacral ligament plication are three types of enterocele repairs approached ab- dominally. The Moschcowitz procedure (18) involves placing a series of purse-string sutures to close the cul-de-sac. The sutures incorporate the posterior vaginal wall, the right and left pelvic sidewall peritoneum, and the anterior serosa of the sigmoid colon. Three or four sutures usually are required. One complication of this surgery is ureteral obstruction, as the ureter may be pulled medially in the suture. The Halban procedure also obliterates the cul-de-sac; however, the sutures are placed in a longitudinal fashion. Instead of incorporating peritoneum overlying the pelvic sidewalls, a series of sutures are placed along the anterior serosa of the sigmoid, down to the most inferior portion of the cul-de-sac, and then up along the poste- rior vaginal wall. This technique may decrease the chance of ureteral obstruction; however, there are no reported series comparing these tech- niques. Uterosacral ligament plication involves plicating the uterosacral ligaments together, along with the posterior vaginal wall, in a fashion analogous to the McCall technique. Three to five sutures usually are required to close the cul-de-sac.

Surgery to Correct a Rectocele

Gynecologic indications for rectocele repair extend beyond the presence of a symptomatic, non-emptying rectocele (Table 8-1). In recent surveys, 100%

of gynecologists would repair a rectocele in the absence of gastrointestinal symptoms, whereas only 6% of colorectal surgeons would repair these asymptomatic cases (4–6). As such, the gynecologic goals of rectocele repair procedures also vary (Table 8-2). While less than half of colorectal surgeons approach a rectocele repair vaginally, 95% to 100% of gynecologists repair rectoceles vaginally (4–6). The vaginal approach to rectocele repair poten- tially allows for correction of vaginal, as well as rectal, symptomatic dysfunction.

Posterior Colporrhaphy Technique

Posterior colporrhaphy commonly is performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum with a widened

Table 8-1. Indications for rectocele repair.

1. Obstructive defecation symptoms 2. Lower pelvic pressure and heaviness 3. Prolapse of posterior vaginal wall

4. Pelvic relaxation with enlarged vaginal hiatus

genital hiatus. Preoperatively, the severity of the rectocele is assessed, as well as the desired final vaginal caliber. Allis clamps are placed on the inner labia minora/hymen remnants bilaterally and then approximated in the midline. The resultant vagina should loosely admit two to three fingers. A triangular incision over the perineal body is made between the Allis clamps and sharp dissection is then performed to separate the posterior vagina from the underlying rectovaginal fascia. A midline incision is made along the length of the vagina to a site above the superior edge of the rectocele.

The dissection is carried laterally to the lateral vaginal sulcus and the medial margins of the puborectalis muscles (Figure 8.5). The rectovaginal fascia with or without the underlying levator ani muscles is then plicated with interrupted sutures while depressing the anterior rectal wall (Figure 8.6). Typically, absorbable sutures are placed along the length of the

Table 8-2. Goals of surgery to repair a rectocele.

Re-establish:

1. Endopelvic fascial integrity from apex to perineum 2. Levator plate integrity

3. Anterior rectal wall support 4. Normal vaginal caliber and length 5. Integrity of perineal body

Figure 8.5. Surgical dissection is carried to the lateral vaginal sulcus in order to

identify the fascia, which will be plicated for correction of posterior vaginal wall

weakness.

rectocele until plication to the level of the perineal body is complete. Excess vaginal mucosa is carefully trimmed and then re-approximated. A con- comitant perineoplasty may be performed by plicating the bulbocavernosus and transverse perineal muscles. This reinforces the perineal body—or inferior central tendon—and provides enhanced support to the corrected rectocele.

Discrete Fascial Defect Repair Technique

Discrete tears or breaks in the rectovaginal fascia or rectovaginal septum have been described and may contribute to the formation of rectoceles (Figure 8.3) (8). The intent of the discrete facial defect repair of rectoceles is to identify the fascial tears and re-approximate the edges. The surgical dissection is similar to the traditional posterior colporrhaphy, whereby the vaginal mucosa is dissected off the underlying rectovaginal fascia to the lateral border of the levator muscles. Instead of plicating the fascia and levator muscles in the midline, however, the fascial tears are identified and repaired with interrupted sutures. Richardson (8) described pushing ante- riorly with a finger in the rectum in order to identify areas of rectal mus- cularis that are not covered by the rectovaginal septum, thereby locating fascial defects and identifying fascial margins with re-approximation. A perineoplasty may be necessary if a widened vaginal hiatus is present.

Figure 8.6. Multiple interrupted sutures are used to approximate the endopelvic

fascia overlying the levator muscles in the midline.

Results of Surgical Repair

The posterior colporrhaphy has been the traditional approach to rectocele repair by gynecologists. Although commonly performed, it has been described as “among the most misunderstood and poorly performed” gyne- cologic surgeries (19). Although many authors have reported satisfactory anatomic results, conflicting effects on bowel and sexual function post- operatively have been noted (Table 8-3). Several authors have reported high sexual dysfunction rates—up to 50%—with women reporting dys- pareunia or apareunia after posterior colporrhaphy (24). Many authors have suggested that the significant rate of postoperative dyspareunia may be due to the plication of the levator ani muscles; this has led several authors to advocate (and popularize) the discrete fascial defect repair.

Several groups have reported a similar anatomic cure rate with this surgery, along with significant improvement in quality of life measures. Unlike the traditional posterior colporrhaphy, all these series have reported less post- operative dyspareunia (Table 8-4) with significant improvement in splint- Table 8-3. Outcomes for posterior colporrhaphy.

Author Number Mean Improvement Anatomic Improvement Postoperative of follow-up in pelvic correction in evacuation dyspareunia patients (months) pressure rates difficulty rates

symptoms

Paraiso (20) 102 10 89% 61% 82% Increased from

2% to 12%

Mellgren (21) 25 12 N/A 96% 88% Increased from

6% to 19%

Kahn (22) 171 42.5 51% 76% 62% Increased from

18% to 27%

Lopez (23) 25 61.2 75% 92% 91% Increased from

6% to 33%

Table 8-4. Outcomes for the discrete fascial defect repair.

Author Number Mean Improvement Anatomic Improvement Postoperative of follow-up in pelvic correction in evacuation dyspareunia patients (months) pressure rates difficulty rates

symptoms

Cundiff (25) 69 24 87% 82% 63% Decreased from

29% to 19%

Glavind (26) 67 3 N/A 100% 85% Decreased from

12% to 6%

Kenton (27) 46 12 90% 77% 54% Decreased from

26% to 2%

Porter (28) 125 18 73% 82% 55% Decreased from

67% to 46%

ing, vaginal pressure, and stooling difficulties. However, rates of fecal incon- tinence and constipation may be unchanged postoperatively.

These studies show promising anatomical and functional results; how- ever, long-term prospective studies are required. Thus far, the incidence of postoperative dyspareunia with the discrete fascial defect repair is less than the traditional posterior colporrhaphy in nonrandomized comparisons (12), with some reported skepticism about the ability to adequately demonstrate and repair discrete fascial tears (29).

Other Techniques and Results

The use of synthetic mesh interposition to correct a rectocele at the time of abdominal sacrocolpopexy for vaginal vault prolapse has been reported (29). This simplifies the surgical approach for patients with both vaginal vault prolapse and rectocele, as it eliminates the need for a concomitant vaginal procedure. A continuous piece of mesh is placed abdominally from the perineal body to the vaginal vault. The mesh is then attached to the anterior longitudinal ligament overlying the sacral promontory in a tension- free fashion. Fox and Stanton, using this technique, treated 29 patients and noted continued bowel symptoms, including constipation and incomplete defecation (29). Others have noted a similar persistence of—or even an increase in—bowel symptoms in 39% of patients who underwent this type of surgery (30).

Adopting the principles of hernia repair by the general surgeons, recon- structive pelvic surgeons have reported reinforcement of pelvic organ prolapse repairs with synthetic and biologic prostheses. Synthetic mesh is used widely for anti-incontinence surgery and abdominal sacrocolpopexy to repair vaginal vault prolapse. Although high success rates have been reported, erosion of the mesh and infection has been associated with these repairs (31,32). Autologous grafts and allograft prostheses, including fascia lata, rectus sheath, and dermal grafts, have been employed for these surg- eries, as well as reinforcement of cystocele repairs to reduce these com- plications (33). Few complications have been associated with these grafts, and they have a comparable success rate to synthetic materials. Xenograft materials—including bovine pericardium, porcine skin and small intestinal mucosa—also have been used to reinforce these repairs; however, no extended reports on complications and success rates exist in the literature.

Few studies have reported on the use of graft materials to reinforce pos-

terior compartment defects. Sand et al. reported on 132 women undergo-

ing either standard rectocele repairs or rectocele repairs reinforced with

Polyglactin 910 mesh (an absorbable mesh) and found no difference in

recurrence rates between the two groups (34). Two small observational

studies on the use of Marlex mesh for rectocele repair did not report

erosion or recurrence (35,36), whereas Sullivan and colleagues (37)

reported on 236 women undergoing total pelvic mesh repair with Marlex

for all types of pelvic support defects, including enteroceles and rectoceles.

Through an abdominal approach, a strip of Marlex was used to reinforce the rectovaginal septum. Defecation difficulty improved in 76% of patients, but 28% of patients required postoperative surgical correction of recto- celes. There were no recurrences of enteroceles and only 3% complained of postoperative dyspareunia.

Laparoscopic rectocele repair involves opening the rectovaginal space and dissecting inferiorly to the perineal body. The perineal body is sutured to the rectovaginal septum and rectovaginal fascial defects are identified and closed. The advantages reported include improved visualization and more rapid recovery with both decreased pain and hospitalization. Disad- vantages include difficulty with laparoscopic suturing, increased operating time and expense, and an extended “learning curve” time necessary to master the laparoscopic surgical techniques (38).

Few reports describing outcomes of laparoscopic surgery for pelvic organ prolapse exist in the literature. Lyons and Winer (39) described the use of polyglactin mesh in laparoscopic rectocele repair in 20 patients, with 80%

reporting relief of both prolapse symptoms and the need for manual assistance to defecate. Further studies are needed to assess this surgical approach for rectocele repair.

Transrectal Repairs

Colorectal surgeons typically prefer a transrectal or transperineal approach to rectocele correction. Initial reports described the procedure in the litho- tomy position (40). The rectal mucosa is mobilized and pulled outward until taut. A two-layer suture closure is performed of the defect underlying the rectal mucosa. The redundant anterior rectal mucosa is then removed to diminish a postoperative “mass effect” resulting in occasional persisting evacuatory difficulty. The formation of scars at the suture line adds to the support.

A transrectal repair of the rectocele with multilayer closure, but with resection of the lateral quadrants of the mucosal prolapse rather than the anterior quadrant, has been described (41). In addition, the rectovaginal septum can be repaired through a transanal approach, particularly if there is other associated anal pathology. The levator ani muscle and rectovaginal fascia are plicated separately. Ninety-eight percent of 355 patients reported improvement in this study by Sehapayak. In terms of bowel function, 14%

continued to use laxatives, 35% had occasional straining, and 49.5% were

asymptomatic. This study, however, did not report on postoperative sexual

function. Complications included infection and a rectovaginal fistula. This

author warns against performing this procedure for enteroceles or high rec-

toceles, or combining it with transvaginal surgery because of the risk of

infection and rectovaginal fistula—complications that are not seen with

vaginal rectocele repairs where the rectal mucosa is neither incised nor

excised. Maintaining rectal mucosal integrity appears to significantly reduce infectious morbidity.

Rectocele operations performed transanally versus transvaginally have been compared in only one study (42), where complications occurred equally in the two groups of patients. In all, 54% had postoperative consti- pation and 34% overall had incontinence to gas, liquid, or stool. Sexual dys- function was reported in 22% of patients. The only significant difference between the transvaginal and endorectal groups was that the patients undergoing transvaginal repair had more persistent pain.

Conclusions

The gynecologic indications for enterocele and rectocele repair are more numerous compared with the traditional colorectal indications because gynecologists primarily address vaginal symptoms when repairing a rectocele. Here, obstructive defecation symptoms are only some of a list of accepted indications. Preoperative evaluation typically only includes clini- cal assessment gained from the history and physical examination, and gyne- cologists rarely depend on defecography to plan a reconstructive procedure for rectoceles. Overall, surgical correction success rates are quite high when using a vaginal approach for rectocele correction. Vaginal dissection results in better visualization and access to the endopelvic fascia and levator mus- culature, which allows for a “firmer” anatomic correction. In addition, main- taining rectal mucosal integrity appears to reduce the risk of postoperative infection and fistula formation. More comprehensive data collection is nec- essary to better understand the effect of various surgical techniques on vaginal, sexual, and defecatory symptoms in these patients who may present with complex symptomatology where the rectocele and/or enterocele represent the dominant clinical finding.

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Editorial Commentary

The physical examination of these patients is geared towards the detection

of rectocele, enterocele, and graded uterovaginal prolapse. The surgical

treatment is tailored and needs to be multidisciplinary in the absence of

randomized controlled trials. Gynecologists have accepted that defect-

specific repair is a feature of rectocele treatment but long-term data are as

yet unavailable and it is also unclear whether transvaginal approaches

provide equivalent results to endorectal surgery. Here, although postoper-

ative sexual dysfunction appears more common following transvaginal

surgery, the transvaginal technique is probably indicated if there is a con- comitant cystocele or attendant vaginal prolapse. The somewhat traditional addition by gynecological surgeons of a levatorplasty to narrow the genital hiatus and provide a vaginal buttress is now recognized in many cases to worsen evacuatory dysfunction in these patients.

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