Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era

Abstract

Background: More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.

Purpose: We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Keywords: constipation; defecatory disorder; defecography; enterocele; hysterectomy; pelvic organ prolapse.

Figure 1.

Sagittal magnetic resonance images at rest (A-D), during defecation (E-H), and while straining after defecation on the toilet (I-L) in 4 patients. Rectoceles (thin arrows) measuring 1.0 cm (E), 2.4 cm (F), 3.9 cm (G), and 6.7 cm (H) did not completely empty during defecation in the magnetic resonance image scanner (J, K, and L) or thereafter on the toilet (J and L). Approximately 90% (Patient 1), 70% (Patient 2), 95% (Patient 3), and 80% (Patient 4) of the ultrasound gel was emptied from the rectum during defecation. During defecation, the anorectal junction was 3.2 cm (E), 7.4 cm (F), 7.6 cm (G), and 7.5 cm (H) below the pubococcygeal line, i.e., perineal descent was increased in panels F, G, and H. Associated findings include a cystocele (J, filled arrow), excessive uterine descent (J, open arrow), enterocele (K, filled arrow), and peritoneocele (L, filled arrow).

Figure 2.

Transvaginal repair of rectocele. Left panel. Intra-operative of rectocele in posterior wall of vagina. Right panel. A T-shaped incision has been made in the posterior wall of the vagina to affect repair the rectocele.