Clinical:Rectocele

Rectocele (posterior prolapse of the vagina)

Introduction

Pelvic organ prolapse is a hernia of the vaginal walls. A defect in the support of the vagina leads to weakening of the connective and supportive tissue causing hernias. These defects can be in one of three compartments of the vagina: anterior, apical, or posterior. Approximately 40% of women over age 50 have pelvic organ prolapse.^[1]

Posterior prolapse, or rectocele, is a specific type of organ prolapse caused by a defect in the support of the posterior compartment of the vagina. This defect allows the rectum to protrude into the vagina. If the hernia defect is large enough, a bulge can be seen or felt outside the vagina. Women who have rectocele may experience a protrusion from the vaginal opening or the sensation of an uncomfortable bulge. Prolapse of the posterior compartment is present in approximately 45% of women who have prolapse, either alone (7.3%), in combination with anterior prolapse (15.6%), in combination with apical prolapse (4.7%), or in all three compartments (18.0%).^[2]

Because a rectocele is a hernia of the rectum into the posterior wall of the vagina, rectocele is often believed to cause an anatomic obstruction to defecation. However, there is no difference in obstructive bowel symptoms between women with prolapse and those without.^{[3] [4]} Surgical repair of rectocele inconsistently relieves symptoms of constipation.^[5] This is probably because the causes of constipation are complex and multi-factorial.^{[6] [7]}

Other Names

posterior vaginal prolapse, vaginal hernia, posterior prolapse

Types

primary or recurrent

Signs and Symptoms

visible bulge outside the hymen or uncomfortable protrusion through the vaginal hymen with straining

Causes

weakness of vaginal support

Risk factors

Both vaginal delivery and age are strongly associated with pelvic organ prolapse and rectocele.^[8][9][10]

Some, but not all, studies have found associations with rectocele and increasing body mass index (BMI) or chronic constipation.^[11][12]

Diagnosis

The diagnosis of pelvic organ prolapse of any compartment, including the posterior compartment, is primarily based on physical exam.^[13] The examination is typically performed with women in the dorsal lithotomy position. Provocative maneuvers to increase intra-abdominal pressure such as straining or Valsalva are recommended.^[14] The two most commonly utilized standardized techniques for quantifying the severity of prolapse in all three vaginal compartments are the Pelvic Organ Prolapse Quantification system (POP-Q) and the Baden-Walker Halfway Grading System.

Other exams used in the diagnosis of rectocele include defecography and dynamic pelvic MRI, which are sometimes used to confirm physical exam findings. Defecography is sometimes useful. This imaging modality will not only detect rectocele, but is also able to detect enterocele, rectal intussusception, and paradoxical contraction of the puborectalis muscles.

Treatment

Treatment for rectocele is primarily based on a woman’s bother by this condition. Some women will opt for expectant management.

Pessaries

The first-line treatment for any pelvic organ prolapse condition is non-surgical.^[15] This is often done by using a supportive device, also called a pessary, to support the walls of the vagina. All women can benefit from a pessary-fitting trial, as some women will experience enough symptom relief that they can avoid surgery. However, pessaries do not provide as much support to the posterior compartment of the vagina as other compartments.

Surgery

Surgery is often chosen by women seeking definitive treatment for their bothersome symptoms. Pelvic organ prolapse can happen in all three vaginal compartments: anterior, apical, and posterior. If a patient is undergoing surgery for prolapse, all three compartments should be assessed prior to formulating a surgical plan.^[16]

Surgery to address the posterior compartment may be accomplished with either the transvaginal or transanal approach.

Transvaginal repairs

The transvaginal approach may include a traditional colporrhaphy or a site-specific repair. Both surgical techniques are preformed by plicating a woman’s own tissue to scar into place to provide support. In a systematic review of evaluation and treatment of rectoceles, Cundiff and Fenner found that women who had traditional colporrhaphies reported 75 percent improvement in anatomic outcome, but at least 15 percent of women reported incidence of new dyspareunia.^[17] Women who had site specific repair had similar success anatomically and seemed to have less dyspareunia.

Augmentation with mesh or graft

A final technique utelizes either a biologic graft, a synthetic absorbable mesh, or a synthetic non-absorbable (permanent) mesh to augment a women’s own tissue. Because surgery using native tissue (repairs performed using a woman’s own tissue) may fail between 10 and 25% of the time, materials (either biologic, synthetic absorbable, or permanent) are sometimes used to augment these repairs. These materials are also used after a failure of a primary surgical repair with native tissue.

Unfortunately, these materials are not well studied in the posterior compartment of the vagina. The Society for Gynecologic Surgeons conducted a systematic review of all comparative trials utilizing vaginal mesh published in peer-reviewed literature on or before November 27, 2007.^[18] Four comparative trials were identified for the use of absorbable material in the posterior compartment. Two trials involved the use of cross-linked porcine dermis compared to native tissue repairs, one trial used acellular porcine small intestine submucosa graft and one trial used a synthetic absorbable polyglactin 910 mesh. The occurrence of anatomic failures (the recurrence of hernia or prolapse symptoms) was identical or worse in the mesh augment groups compared with women who underwent a native tissue (traditional) repair. No comparative trials have been published for the use of permanent mesh placed vaginally to augment repairs in the posterior compartment.

Due to the lack of evidence found in this systematic review, the Society of Gynecologic Surgeons developed and published clinical practice guidelines on the use of these materials in the vagina.^[19] They concluded, “It is suggested that native tissue repair remains appropriate in the posterior vaginal wall repair when compared with biologic graft. There are no comparative studies to guide any recommendation on the use of non-absorbable synthetic mesh in the posterior vaginal wall repair when compared with native tissue.”

Non-absorbable synthetic mesh (permanent mesh) placed in the vagina has lead to complications including mesh erosion, vaginal scarring, and dysparuenia (pain with intercourse). Because of these complications, the FDA issued a warning on the use of vaginal mesh in pelvic organ prolapse surgery in October, 2008.^[20] Non-absorbable synthetic mesh (permanent mesh) has been shown to have superior anatomic outcomes in the anterior compartment of the vagina in two randomized controlled trials.^{[21] [22]}

Transanal repairs

Transanal repairs are another approach to the repair of rectoceles, primarily employed by colo-rectal surgeons. The transanal approach allows for excision of redundant rectal mucosa and concurrent surgery on other anal pathology, however, success of transanal repairs is lower than transvaginal repairs.^[23][24] In addition, recto-vaginal fistula is a reported complication of the transanal rectocele repair in up to 3 percent of women.^[25]

Prevention

There is no known prevention for pelvic organ prolapse, however pelvic floor muscle exercises (Kegel exercises) have been shown to prevent or improve other pelvic floor disorders, namely urinary incontinence.

References

1. ↑ 1. Hendrix S, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the women's health initiative: Gravity and gravidity. Obstet Gynecol. 2002;186(6):1160.
2. ↑ 2. Olsen , Smith , Bergstrom , Colling , Clark . Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501.
3. ↑ 3. Cundiff GW , Nygaard I, Bland DR, Versi E. Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders. Am J Obstet Gynecol. 2000;182(1):S1.
4. ↑ 4. Weber , Walters , Ballard , Booher , Piedmonte . Posterior vaginal prolapse and bowel function. Obstet Gynecol. 1998;179(6):1446.
5. ↑ 3. Cundiff GW , Nygaard I , Bland DR, Versi E. Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders. Am J Obstet Gynecol. 2000;182(1):S1.
6. ↑ 5. Brandt L, Prather C, Quigley EMM, Schiller L, Schoenfeld P, Talley N. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100 Suppl 1:S5.
7. ↑ 6. Ternent C, Bastawrous A, Morin N, Ellis , Hyman N, Buie . Practice parameters for the evaluation and management of constipation. Diseases of the Colon & Rectum. 2007;50(12):2013.
8. ↑ Hendrix S, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the women's health initiative: Gravity and gravidity. Obstet Gynecol. 2002;186(6):1160.
9. ↑ Swift S, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic organ support study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Obstet Gynecol. 2005;192(3):795.
10. ↑ Nygaard I, Barber M, Burgio K, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311.
11. ↑ Swift S, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic organ support study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Obstet Gynecol. 2005;192(3):795.
12. ↑ Bradley C, Zimmerman , Qi Y, Nygaard I. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007;109(4):848.
13. ↑ ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007;110(3):717.
14. ↑ Bump RC , Mattiasson A , Bø K, Brubaker LP , DeLancey JO , Klarskov P , et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Obstet Gynecol. 1996;175(1):10.
15. ↑ ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007;110(3):717.
16. ↑ Olsen , Smith , Bergstrom , Colling , Clark . Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501.
17. ↑ Cundiff G, Fenner D. Evaluation and treatment of women with rectocele: Focus on associated defecatory and sexual dysfunction. Obstet Gynecol. 2004;104(6):1403.
18. ↑ Sung V, Rogers R, Schaffer J, Balk E, Uhlig K, Lau J, et al. Graft use in transvaginal pelvic organ prolapse repair: A systematic review. Obstet Gynecol. 2008;112(5):1131.
19. ↑ Murphy M. Clinical practice guidelines on vaginal graft use from the society of gynecologic surgeons. Obstet Gynecol. 2008;112(5):1123.
20. ↑ FDA public health notification: Serious complications associated with transvaginal placement of surgical mesh in repair of pelvic organ prolapse and stress urinary incontinence [homepage on the Internet]. FDA U.S. Food and Drug Administration. 2009 06/19/2009. Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm061976.htm.
21. ↑ Nguyen J, Burchette R. Outcome after anterior vaginal prolapse repair: A randomized controlled trial. Obstet Gynecol. 2008;111(4):891.
22. ↑ Hiltunen R, Nieminen K, Takala T, Heiskanen E, Merikari M, Niemi K, et al. Low-weight polypropylene mesh for anterior vaginal wall prolapse: A randomized controlled trial. Obstet Gynecol. 2007;110(2):455.
23. ↑ Cundiff G, Fenner D. Evaluation and treatment of women with rectocele: Focus on associated defecatory and sexual dysfunction. Obstet Gynecol. 2004;104(6):1403.
24. ↑ Nieminen K, Hiltunen K, Laitinen J, Oksala J, Heinonen P. Transanal or vaginal approach to rectocele repair: A prospective, randomized pilot study. Diseases of the Colon & Rectum. 2004;47(10):1636.
25. ↑ Cundiff G, Fenner D. Evaluation and treatment of women with rectocele: Focus on associated defecatory and sexual dysfunction. Obstet Gynecol. 2004;104(6):1403.