Pelvic Prolapse: Diagnosing and Treating Cystoceles, Rectoceles, and Enteroceles

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Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Diagnosing and Treating a Rectocele

A rectocele is a bulge into the vagina caused by the rectum prolapsing through an attenuated rectovaginal septum (Fig. 6). The grading system shown in Table I can also be used for rectoceles. It is important to note that a rectocele is a defect of the vaginal supporting tissues; it is not a defect of the rectum. The etiology of a rectocele is believed to be due to stretching and disruption of the rectovaginal septum and surrounding vaginal tissues during childbirth.[20,21] Perhaps the most important fascia within the rectovaginal septum is Denonvilliers' fascia, which is fused to the inner layer of the posterior vaginal wall; during childbirth, Denonvilliers' fascia is believed to be disrupted at its caudal and lateral attachments to the perineal body.[22] Good evidence for this theory exists, since rectoceles are essentially found only in parous women.[20]

Figure 6. Diagram of rectocele.

Rectocele Diagnosis

Note that enterocele and rectocele formation may occur together, especially if the patient has had a hysterectomy; however, the enterocele will be located closer to the vaginal apex than will a rectocele. In some cases, when there is a deficient perineal body, which may occur after a poorly performed episiotomy closure, a small posterior vaginal wall bulge may be seen without a true rectocele. This is referred to as a pseudorectocele and can be confirmed by a rectal examination that demonstrates a strong posterior vaginal wall in the absence of protrusion below the hymenal ring.

A true rectocele typically forms a pocket just above the anal sphincter. This pocket is where stool can become trapped, leading to the typical rectocele symptom of straining to facilitate bowel movements.[23] It is important to differentiate between simple constipation, which is quite common in elderly women, and the symptoms indicating a rectocele. When a patient states that she has to place fingers in the vagina and exert pressure against its posterior wall of the vagina to effectively empty her bowels (also called "splinting"), this can be positively correlated with a symptomatic rectocele.[24] Notably, rectocele size does not always correlate with symptoms. Recently, Caps[25] reported that rectoceles were small in 8% of patients with symptomatic rectoceles.

Some patients will complain of sexual dysfunction or dissatisfaction and may attribute it to posterior-wall laxity. Sexual dysfunction, however, is rarely caused by pelvic-floor relaxation alone and is more likely due to psychological factors. Conversely, dyspareunia has previously been associated with anterior and posterior repair and, more specifically, with posterior repair. Jeffcoate[26] noted a 30% rate of postoperative dyspareunia after posterior repair; however, this is an older review, and the exact method of surgical repair performed by Jeffcoate is seldom used today. In more recent reviews, dyspareunia was reported in less than 10% of patients.[27,28]

Because of the possibility of postoperative dyspareunia, many surgeons repair only symptomatic rectoceles. Conversely, others believe that failure to repair a lax but asymptomatic posterior pelvic-floor defect may cause excessive pressure on other areas of the pelvic floor, eventually resulting in prolapse and requiring additional surgery at a later date.[18] This theory remains unproven.

Difficulty in distinguishing between a large, high rectocele and an enterocele may occur in some cases. This diagnostic quandary can sometimes be resolved by first performing the examination with the patient in the lithotomy position and placing one finger in the rectum and another finger in the vagina, and then instructing the patient to bear down. If the rectovaginal septum becomes thicker or pulses, this finding is consistent with an enterocele. If this maneuver does not yield a diagnosis, then the patient should be placed in the upright position with one leg on a low stool, and the evaluation should be repeated.

Note that an evaluation such as this cannot be better performed at the time of surgery. The patient cannot strain adequately and cannot be positioned appropriately and, therefore, cannot reproduce the problem that normally occurs. In addition, the muscles are more relaxed under general anesthesia; therefore, a complete evaluation and a definite plan of action should always exist prior to surgery.

Perineal body relaxation, an entity distinct from a rectocele, is usually repaired at the same time. Since the levator ani is attached at the perineal body, strengthening of the perineal body by perineorrhaphy may improve pelvic relaxation.

Rectocele Management

To cleanse the rectum, the patient typically is given enemas the night before the procedure; a full bowel prep is unnecessary. Preoperative intravenous antibiotics are also given.

The patient is placed in a lithotomy position and if other procedures are to be performed -- such as stress urinary incontinence procedures, anterior colporrhaphy, or hysterectomy -- these should be done first. Some clinicians place rectal packing soaked with povidone iodine (Betadine) to assist in the identification of the rectum and avoid rectal injury; however, we have not found this to be useful.[18]

The ultimate size of the vaginal orifice is determined by placing Allis clamps on the inner aspects of the labia on the posterior perineum and bringing the clamps together. Two fingers should be easily admitted. The skin between the Allis clamps is incised, then a triangular skin incision is made on the perineal body, with the apex pointing towards the anus. The overlying skin is removed, and a midline subepithelial tunnel is made in the rectovaginal space using Metzenbaum scissors and extending the dissection at least 1cm proximal to the rectocele.

The posterior vaginal mucosa is incised along the length of this submucosal tunnel. The underlying rectum and fascia are then dissected, both sharply and bluntly, from the posterior vaginal wall until the medial margins of the pubococcygeus muscle are seen.

Starting near the vaginal apex, the pararectal fascia is closed over the rectal wall using absorbable or nonabsorbable 2-0 or 0 suture in an interrupted fashion (Fig. 7). After the first or second suture is placed, an evaluation should permit 2 fingers to be admitted. If inadequate vaginal caliber is created, dyspareunia or an inability to engage in sexual intercourse may occur. Typically, the closure is performed in 2 layers; however, single-layer closures incorporating the fascia and mucosa have been described.[18] Our preference is to also attach the vaginal mucosa to the underlying pararectal fascia with the upper 1 or 2 sutures; this usually ensures good vaginal-wall fixation and elimination of dead space.

Figure 7. Rectocele repair using interrupted sutures to plicate pararectal fascia over rectum.

Some surgeons also plicate the medial portion of the pubococcygeus muscle across the midline, although this may create a transverse ridge in the posterior vaginal wall and lead to dyspareunia.[26] Closure of pararectal fascia is performed all the way to the perineal body. The perineal body is repaired by placing multiple 0 absorbable sutures deeply into the bulbocavernosus and superficial transverse perineal muscles to build up the perineal body. Again, it is important to assess vaginal diameter; at a minimum, 2 fingers should fit easily. The vaginal mucosa is closed with absorbable suture in a running, locking fashion. It is particularly important that patients be instructed how to keep their stools soft for approximately 4 to 6 weeks, to allow tissue healing.

An alternative surgical method of rectocele repair, described by Richardson,[22] requires advancement of the detached Denonvilliers' fascia caudally to cover the defect; however, we have rarely been able to find an intact edge of Denonvilliers' fascia to advance.

Long-term results of rectocele repair performed alone are currently unknown, as no long-term prospective studies have been performed. A retrospective review by Babiarz and Raz[29] reported a 0% failure rate with an unknown length of follow-up. Zimmern and colleagues[30] noted that recurrence is "extremely uncommon." Current thinking is that rectoceles rarely recur once they have been repaired.

Complications are uncommon, with one study reporting a 12.5% incidence of transient urinary retention but no rectal injuries, fecal incontinence, or hemorrhage.[23] Indeed, we have found that a rectocele repair at the time of an incontinence procedure lengthens the period of time for return to normal voiding function. Dyspareunia can also occur after a rectocele repair, as has been previously discussed, but it appears to occur in less than 10% of patients. Haase and Skivsted[28] found that approximately 9% of patients experience a deterioration in their satisfaction with sexual intercourse after pelvic-floor repair; on the other hand, approximately 24% reported an improvement in their sexual satisfaction. A rectovaginal fistula is a dreaded and fortunately rare complication; one study, however, reported a 5% incidence.[31]

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