1. Consultant Colorectal Surgeon
Colorectal Cancer
Rectocele
Mr D.Kumar PhD FRCS
Consultant Colorectal Surgeon
St George’s NHS Trust

2. Rectocele
Prolapse of the anterior rectal and posterior vaginal wall into the lumen of the vagina

3. Rectocele Anatomy
Female equivalent of Denonvillier’s fascia - rectovaginal septum
Separates the rectal(dorsal) compartment
from the urogenital (ventral) compartment
Rectovaginal septum and uterosacral ligaments provide suspensory support to the perineal body
Further supported by the levator muscles

4. Rectocele Aetiology
Obstetric trauma – due to alteration in the functional and anatomical position of muscles
Pathological stretching of pudendal nerves during descent of the foetal head – denervation of the pelvic floor muscles
Persistent straining at stool

5. Rectocele Clinical presentation
Constipation (incomplete emptying) –75% of patients
Vaginal bulge
Sense of rectal pressure
Rectal/low back pain
Bleeding
Dyspareunia
Vaginal digitation/perineal support
Majority totally asymptomatic

6. Rectocele Classification
Low
Middle
High
Middle and high rectoceles often associated with cystoceles and enteroceles

7. Rectocele Evaluation History Examination Defaecography Barium Isotope
Endoanal U/S
Pudendal nerve motor latency/manometry

9. Rectocele Management
Conservative
Operative

10. Rectocele Conservative management
Bowel training
Oestrogen replacement therapy – post menopausal
Vaginal pessary

11. Rectocele Surgery Vaginal - Posterior Colporrhaphy (levatorplasty)
- Defect specific

12. Rectocele Surgery
Transanal

13. Results Vaginal Transanal Arnold et al 1990 – 50% still sympotomatic
Watson et al 1996 – removed the need to digitate in most patients
Murthy et al 1996 – excellent results (strict criteria)
Transanal
Sullivan et al 1968 – 97.5% success
Shapayak 1985 – % improvement
Jarsen’s et al 1994 – 92% success
Mellgren et al 1995 – 88% - complete resolution 52%

14. Rectocele Transanal 138 patients – symptomatic rectocele
58 had significant rectocele
45 decided to have surgery
Mean age -57 years
Duration of symptoms -52 months
Median follow-up -24 months

15. Rectocele Functional Outcome
Symptom Presurgery Post surgery p*
Straining / / p< 0.001
Incomplete evacuation / / p< 0.001
Vaginal digitation / / p< 0.001
Perineal digitation / / p= 0.004
Incontinence (Grades 3/4) 9/ / p= 0.688
Dyspareunia / / p= 0.020
Vaginal bulging / / p< 0.001
* McNemar test
Grade 1 normal incontinence, 2 incontinent to flatus, 3 incontinent to
liquid stool, 4 incontinent to solid stool
Heriot et al 2004

16. Rectocele Anorectal physiology assessment
Symptom Presurgery Post surgery p**
mean (SD) mean (SD)
Resting anal 80(23) 76(29)
pressure (cm H20)
Squeeze anal 136(42) 141( 40)
Anorectal reflex present 5/ / *
Threshold volume (cc) (23) 41(19)
Max. volume (cc) (87) 201(78)
** Wilcoxons signed rank test * McNemar test
Heriot et al 2004

17. Rectocele Comparison of PC vs TA
70 patients RCT- 40TA, 30PC
Matched for age, symptoms, % retention
Bowel Sx significantly better in the TA (p<0.01)
Bleeding significantly less in TA (p<0.01)
Analgesic requirement less in TA (p<0.02)
Dyspareunia worse in PC (p<0.001)
(Kahn et al 2001,unpublished)

18. Rectocele Complications
Infection
Bleeding
Dyspareunia
Recto –vaginal fistula

19. Summary Rectoceles are common Only a small % symptomatic
Even a smaller percentage clinically significant
Proper evaluation essential
Patients with a vaginal bulge as the main symptom should have post. Colporrhaphy
Those with bowel symptoms-transanal repair