Posterior vaginal wall prolapse, also known as rectocele, is common. It is the protrusion of the anterior rectal wall into the lumen of the vagina.
The majority are asymptomatic. Its prevalence is not clear.
It is usually seen in women who have given birth.
The rectovaginal septum (Dennonviller’s fascia) is a strongly fibrous septa extending from the uterus, upper vagina, and rectum to the perineal structures.
It consists of collagen, smooth muscle and elastin. This solid structure prevents herniation of the rectum towards the vagina during defecation.
Rectocele Incidence ?
Bartram (1988) found rectocele in 81% of asymptomatic women in defecography taken for any reason. Olsen (1997) describes rectocele in 76% of women presenting with pelvic organ prolapse. Shorvon (1989) detected 76% rectocele in defecography in asymptomatic nulliparous women. Goh (2002) detected 40% rectocele above 1 cm in asymptomatic nulliparous women.
Rectocele Etiology
Its etiology is still unclear. Birth is the most important known cause. At birth, the baby distorts and stretches the pelvic wall, causing endofacial tears involving the rectovaginal septum. In prolonged labor, there is pressure on the pudendal nerve in the pelvic wall and partial denervations occur in the levator ani muscle.
Causes of occurrence
Obcetric trauma (episotomies)
Unable to use or perform vacuum forceps
Returning to cesarean section after childbirth
chronic constipation
relaxation disorders such as puborectal syndrome
Postmenopausal connective tissue deficiencies
hysterectomy
Symptoms in Rectocele
constipation
Dyspareunia (pain during sexual intercourse)
Straining (Forced defecation)
chronic low back pain
Digitation (defecation with perineal or vaginal suppression)
Insufficient ejaculation sensation
Vaginal mass (stool after defecation, stuck feeling)
Incontinence (gas-stool incontinence)
Pelvic pain.
The majority of patients with rectocele are asymptomatic. Pressure-related pelvic pain, dyspareunia, and chronic low back pain may be seen in enlarged rectoceles, when the rectocele sac compresses.
Diagnosis in Rectocele
Patients should be checked with rectal touch during proctological evaluation on the proctology table. The possibility of rectocele being missed is high in the examination that is not performed on the proctological table. Detailed rectal examination should be performed for etiological factors.
Defecography
Defecography is 91-94% sensitive. It is especially safe in detecting rectoceles over 2-3 cm.
MRI
Dynamic MRI defecography is a superior examination. It gives information about the pelvic structures globally. It is used in the evaluation of other concomitant pelvic floor diseases.
Anorectal manometric evaluation
Many series have shown that anoractal manometry is not specific for rectocele. It is especially necessary in the evaluation of concomitant sphincter disorders in cases with fecal incontinence.
Endoanal Ultrasound
Endoanal-endorectal US (ERUS) can be performed in patients with symptomatic rectocele.
TREATMENT
Only symptomatic rectoceles should be treated. Asymptomatic cases can be treated during surgery on other pelvic organs.
medical treatment
Conservative treatment includes pelvic wall rehabilitation. More beneficial for small rectoceles Oral or topical estrogen is beneficial in women with vaginal wall atrophy.
botulinum toxin
In 14 patients with symptomatic rectocele and outlet obstruction, symptomatic improvement was achieved with the use of botox, paradoxically, by inhibition of puborectal contractions.
Surgical treatment
Common purpose of different surgical approaches
Ensuring symptomatic recovery
Correction of anatomy
Having a healthy defecation
Continuity of sexual functions
Repair with transvaginal suture
It is based on reconstruction by side-to-side plication of the rectovagian septum and plication of the levator ani in the anterior of the rectum. Since the vaginal anatomy cannot be fully corrected, recurrences are seen in defecation and sexual symptoms. Vaginal contraction causes dyspareunia with hiatus stenosis of the genitalia, while Levator anide causes atrophy and scar tissue
Francis (1961) described dyspareunia at a rate of 50% after postcolp.
Kahn (1997) post. colp. found that dyspareunia symptom, which was 18% before the treatment, was 28% after the treatment.
Paraiso (2001) states that no increase in dyspareunia was detected in a large series of 108 cases.
Transanal repair
It was developed by colorectal surgeons. It is based on the narrowing of the rectal lumen. It is especially recommended in patients with severe outlet obstruction. It is based on the strengthening of the rectal wall in two layers.
at 4-year follow-up
colp with transanal repair. between the posts
*constipation
*fecal incontinences
*There was no difference in terms of dyspareunia.
Repair with mesh
with severe symptoms
Recurrent posterior vaginal wall defect
Mesh is recommended for patients with insufficient quality tissue for repair.
Most of the time, patients go to the doctor with complaints of excessive straining, chronic constipation and pain and bleeding in the anus. Inadequate examination leads to unnecessary surgeries. The vast majority of women who are subsequently diagnosed with rectocele have previous hemorrhoids and anal fissure operations. Although rectocele is not a well-known entity, it is a disease that can be diagnosed by careful questioning and examination of the patients.
Transperineal mesh repair is preferred by our department in the treatment of symptomatic rectocele. In our large case series conducted and published in our clinic, the probability of recurrence of the disease was low and the patient satisfaction rate was found to be high in the disappearance of symptomatic complaints.
