Perspective Chapter: Surgical Management of Symptomatic Rectocele

Abstract

Rectocele is defined as a herniation of the anterior rectal wall through the posterior vaginal wall into the vaginal lumen caused by rectovaginal septum weakness. This entity is more common in postmenopausal female patients. Approximately one-third of adult women affected with pelvic organ prolapse have a significant impact on their quality of life and emotional well-being. Up to more than 90% of woman can be asymptomatic. In symptomatic cases, constipation, defecatory disorders such as obstructed syndrome (ODS) or incontinence, vaginal mass, and pelvic discomfort are the main complaints. Surgical treatment is indicated after failure of conservative management. Talking about ODS, nearly 20% of the patients need surgery. Surgical options can be classified as abdominal (being laparoscopic colposacropexy the technique of choice) or perineal approach. In the latter group, the alternatives are transanal (TA), transperineal (TP), and transvaginal (TV) approaches with or without prosthetic material or grafts. Native-tissue transvaginal approach should be preferentially performed as it has shown better results. Nowadays, there is no consensus on what the gold-standard technique is given the lack of strong evidence.

1. Introduction

Rectocele is defined as a herniation of the anterior rectal wall through the posterior vagina wall into its lumen, caused by weakness of the rectovaginal septum. It is more common in postmenopausal women, and pelvic organ prolapse can occur in more than 50% of parous women [1, 2, 3, 4]. Usually secondary to multiple vaginal deliveries that may cause pelvic floor injuries, or damages in muscles such as the levator ani or at the rectovaginal septum, even or the pudendal nerve.

In many cases, more than 90%, it is asymptomatic [1]. The symptoms caused by the rectocele may be related to defecatory disorders, constipation, vaginal mass or bulge and pelvic discomfort, and even in some occasions mild fecal incontinence with soiling symptoms. It should be considered as a cause of the well-known Obstructed Defecation Syndrome (ODS) [4]. Thus, in a large percentage of women with rectocele, from 30 to 70% [5], they present symptoms such as difficulty in rectal emptying, excessive straining to defecation, or the need for vaginal digitation to complete defecation.

Despite this relationship, it should be remembered that ODS is a multifactorial entity, and many etiologies have already been related to it. For example, pelvic floor dyssynergia, rectal prolapse, intussusception, and pelvic floor prolapse are some of them. Thus, despite optimal surgical correction of the rectocele, part of the initial symptoms such as sexual dysfunction, dyspareunia, or constipation could persist (Figure 1 and Table 1).

Figure 1.

Physical examination of rectocele. The superior part of the picture shows the anterior part of the patient, and the inferior part of the picture shows the posterior part of the patient (anal area).

Transvaginal (TV)	Posterior colporrhaphy; +/− levatorplasty	Without mesh (longitudinal/transverse/purse-string closure)
		With mesh biologic/Synthetic (resorbable or non-absorbable)
	Site-specific repair
	Iliococcygeus fascia suspension
Transperineal (TP)	Manual suture
	Sperr
Transanal (TA)	Hand sewing	Sarles.
		Sullivan
		Khubchandani
	Stapled suture	Starr-transtar
		TRREMS
		Khubchandani’s procedure
Abdominal (laparoscopic/robotic/open)	Colpoperineopexy
	Iliococcygeus fascia suspension
Mixed	Sacral colpopexy or iliococcygeus fascia suspension + colporrhaphy

Table 1.

Classification scheme of surgical techniques for rectocele repair.

The diagnosis of rectocele is initially clinical, after a correct anamnesis and physical examination of the entire pelvic floor, ruling out other “celes” or associated pathologies. In addition, we must assess possible gynecological alterations, the integrity of the rectovaginal septum and anatomical defects or the tone of the anal sphincter and identify neurological lesions. An anoscopy can help to rule out a possible associated intussusception. The severity of symptoms should be evaluated with standardized scores such as the “Obstructed Defecation syndrome” score or the “Pelvic Organ Prolapse Scoring system” POP-SS. This should include associated symptoms such as urinary incontinence or fecal incontinence with validated scales, e.g., “Wexner Score” (Cleveland Clinic Incontinence Score). Additionally, the impact on the quality of life should be considered and measured through the numerous existing questionnaires.

Regarding the complementary examination, it may be useful to perform a defecography, currently considered the gold-standard test to diagnose pelvic organ prolapse or a dynamic pelvic resonance imaging (MRI). The latter have a high sensitivity of around 100% for the diagnosis of rectocele and a specificity of 57%. Rectocele is currently recognized as a classic indication for this test. Considering that the rectocele can be physiological when performing Valsalva maneuver, it is considered physiological in the imaging tests if it is asymptomatic and smaller than 2.5 cm (Figures 2 and 3).

Figure 2.

Videodefecography.

Figure 3.

Perineal ultrasound. It is usually performed in lithotomy position, with an empty rectum and with an optimums Valsalva maneuver of 6 seconds [6].

Another technique that can be performed in case of incontinence associated or alterations of the anal sphincter suspected is the endoanal of perineal ultrasound [3, 4].

2. Conservative treatment

Initial management is conservative and symptomatic. Different non-surgical options can be offered. Those conservative treatments are taken into consideration for cases with a mild degree of prolapse [7, 8]. The treatment choice depends on the profile of the patient (conservative treatment is considered too for frail patients), on how symptomatic is the prolapse, the severity of it, or the preferences of the patient.

The interventions can be physical or lifestyle. The first group is based on the hypothesis that an improvement of the structural support por pelvic organs will occur due to the improvement of the pelvic floor muscle function.

That means exercise to train strength, endurance, and coordination of the pelvic floor contractions, as the Cochrane review about conservative prevention and management of pelvic organ prolapse in women named as “pelvic floor muscle training” [8]. This way pelvic floor rehabilitation can be a successful treatment for rectocele or even recto-rectal intussusceptions.

In cases of small rectocele, there may be a regression in a percentage of cases, so observation should be considered while starting conservative treatment, not being the case in large rectoceles, which do not usually return. Talking about ODS, around 20% [2] of the cases need surgical treatment, taking into account that the cause of it can be the reflection of many other pathologies apart from rectocele, such as anismus, rectal hypo sensation, anxiety, or depression.

Hygienic-dietetic measures should be taken in case of constipation, such as increased water intake, a diet rich in fiber, even oral laxatives, which are the most used alternatives. Foods that increase the viscosity may be avoided.

Another alternative reported as effected for several authors is hydrocolontherapy or lavage. It consists in irrigation through a tube into the anorectum. We have to take into account that the abuse of enemas can cause microtrauma and anorectal fibrosis secondarily [2].

Biofeedback or pelvic floor training helps to increase the quality of the pelvic floor muscles and therefore the support of the pelvic organs, it is also a treatment with hardly any adverse effects [8], and it is more indicated in cases of anismus and rectal hypo sensation, as well as botulinum toxin A treatment [2]. The use of electrostimulation is used in pudendal neuropathy and rectal hyposensation. Physiological counseling should be offered and can be helpful in several patients with depression or anxiety. Psycho-echo-biofeedback has been recently proposed as a procedure that is successful in half of the cases [2].

The use of the pessary can be recommended, usually in patients older than 70 years, serving as a support, occupying the space in lieu of the rectocele. It can improve symptoms of pressure, feeling of occupation and mass, even urinary ones in up to 50% of cases. There are different types of pessaries that can be adapted to the patient situation as their sexual life, active or not.

3. Surgical indication

SDO can have many causes as already explained, one of them is the pudendal nerve injury and secondary pelvic floor denervation. One of the factors that can contribute to the development of fecal or urinary incontinence is denervation of the muscles such as puborectalis, pubococcygeus, and pelvic fascia [8, 9]. Some studies link decreased pudendal nerve function and incontinence in women [10]. In that sense, delivery-related pelvic floor trauma [9] can result in pelvic muscle or fascia trauma and pudendal nerve injury. There are electromyography and pudendal nerve conduction studies after childbirth showing denervation [11].

Other factors such as chronic straining at stool are related to pudendal nerve injury. This affection is being studied as it can have an association with genuine stress incontinence. Women with low urinary tract dysfunction have more chance of suffering from SDO symptoms, which makes think of benign joint hypermobility syndrome or other connective tissue disorders as an important factor [12].

Considered all the possible causes, surgical treatment in patients with obstructive defecation symptoms is indicated after having completed a conservative management, and this has not achieved control of the symptoms and, after it has been provided that there is an anatomical basis that justifies them.

In the specific case of patients with ODS, the origin could be a functional disorder, and we must demonstrate an anatomical cause through imaging that justifies the intervention. The surgical indications for a rectocele are normally a size longer than 3 cm [3], or a significant retention of the barium contrast within it, during defecography associated with important symptoms that affect quality of life, such as the need for frequent digitation to achieve defecation [13]. Prior to the indication for surgery, it is essential to inform the patient and determine the expectations that the patient has of the surgical treatment [14].

4. Surgical treatment techniques and approaches

Once surgery is indicated, the technique will be decided based on the characteristics of the rectocele and the patient, as well as their preferences. The approach could be abdominal or extra-abdominal (perineal) approach and within the latter group: transanal, transperineal, or transvaginal, with variations in each of them [1]. We could summarize them schematically as follows:

The main objective of the surgery is focused on correcting the anatomical defect, and secondarily improving the symptoms of obstructive defecation [15]. There is a wide variety of techniques described in the literature, including those referred to above, which can be associated with the performance of flaps or placement of prosthetic material such as meshes, either biological or synthetic [4].

There is not enough evidence available in most studies to suggest that one surgical technique or approach is better than another, and therefore, despite the data presented, it is important that each surgeon performs the technique with which you are more familiar and have more experience.

Existing data support the recommendation to consider posterior colporrhaphy of native tissue by transvaginal approach as first surgical option in cases of female patients with rectocele and obstructive defecation symptoms and with surgical indication. This improves anatomical defects and obstructive defecation symptoms. Although, evidence shows that the anatomical defect of the prolapse may persist over time, and symptomatic improvement may decrease in long-term follow-up. Despite this, more studies will be needed to recommend a surgical technique as the “gold standard.”

Therefore, overall, the advice given to patients may be given under the premise that most of the techniques described have an improvement from both the anatomical and symptomatic point of view in terms of ODS symptoms, without the existence of a single type of surgery that stands out above the others [15].

5. Abdominal approach

In the main abdominal approach (Colpoperineopexy), an opening of the pelvic peritoneum is performed, and a non-absorbable mesh is placed in the rectovaginal septum, attaching the top of the vagina on the sacral promontory. In the case of also performing the pexy of the rectum on its anterior or posterior face, it will be called colporectosacropexy (Figure 4). It can be performed using a minimally invasive approach such as laparoscopic or robotic, which is why this technique has been more popular in recent years.

Figure 4.

Rectocolposacropexy: (A), (B). Laparoscopic mesh placement and fixation with PDO stitches and tackers to sacral promontory. (C) Peritoneum closure.

This technique shows improvement in ODS (> 70%) with low morbidity and low recurrence rates (7.5 and 14.2% in 3 and 10 years, respectively) [3]. Although there is an anatomical improvement after surgery, there are studies that report that, however, this improvement is not reflected in defecation symptoms and may even worsen [15]. Thus, this technique is indicated mainly in patients with complex rectocele or invagination or associated rectal prolapse and symptoms of ODS.

In very few cases of ODS, no damage to the posterior wall is associated, which is corrected with vaginal apical pexy. In these cases, laparoscopic ventral rectopexy can be performed, indicated in patients with enterocele or ODS secondary to rectal intussusception [4].

When rectal prolapse is associated, techniques such as Frykman-Goldberg technique can be used. This technique, described in 1969, combines rectopexy and resection of the redundant sigma with anastomosis [16].

In this technique, a rectal dissection must be performed low on the posterior vaginal wall for a subsequent pexy “to the periosteum of the sacral promontory” once the rectum is freed and mobilized, as described in the reference [16]. After the pexy, the redundant sigmoid colon resection and the anastomosis are performed. It is therefore, a technique recommended in cases in which there is a constipation due to a redundant sigma existence or due to the rectum angulation. It is also used in cases in which the surgeon avoids placing meshes taking into account the associated risk as in pregnancies.

In the absence of an ideal mesh for intra-abdominal placement, we prefer the perineal approach in cases of celes in the posterior compartment and the abdominal approach with direct pexy to the sacrum in case of several compartments involvement, avoiding the use of mesh as much as possible.

Frykman-Goldberg surgery can be performed by open, laparoscopic, or robotic approach [17]. However, in this chapter we focus on extra-abdominal techniques.

6. Extra-abdominal approach

6.1 Transperineal approach

The transperineal extra-abdominal technique begins with the infiltration of saline serum and adrenaline at the level of the rectocele, to facilitate its dissection. After that, transverse perineal incision is performed, and the plane between the external anal sphincter and the posterior vaginal wall is dissected with either blunt or sharp dissection [13].

Once the apex of the vagina is reached and the exposure of the rectocele and the levator muscle is completed, the upper limit of the rectocele is identified as the point at which it differs from the longitudinal muscle of the lower rectus wall. A plication of the rectocele is performed in the midline from the most apical point downwards, successive plications can be performed. The plication can be vertical or horizontal, presenting better results the horizontal according to Waleed et al. [18]. Levatorplasty may or may not be associated. Finally, the cutaneous plane is closed after the reconstruction of the rectovaginal septum.

6.2 Transanal approach

Within the transanal approach, there are classic techniques performed by and sewing such as transanal rectoceleplasty, and others more innovative in which mechanical sutures are used.

6.2.1 Hand sewing

Transanal rectoceleplasty [19] is classically performed in the jackknife position and with prior retrograde preparation with a cleansing enema and an anal retractor. After infiltration of saline with epinephrine, a transverse incision is made in the dentate line, and a muco-muscular flap with a broad base is made about 7–10 cm proximally. After careful revision of hemostasis, successive plications are performed, first longitudinally and later transversely with absorbable material (plyglicolic acid) sutures. After resecting the excess part of the flap, it is completed with the closure of the flap with simple stitches also made of absorbable material.

Other transanal rectoceleplasties have specific variations in their technique, such as those described below: In the Sarles technique, an opening of the mucosa is performed over the rectocele and subsequently a transverse plication of the rectal muscle layer is performed.

In the Sullivan technique, a horizontal plication is performed with several sutures.

The Khubchandani technique is a mixed technique in which a stapler suture is performed on the posterior rectal wall and subsequently a U-shaped flap and after that transverse and vertical plicatures on the anterior wall [5].

Regarding results, transanal approach achieves an anatomical improvement of the defect and the symptoms of obstructive defecation. Infection is more common in this technique as a complication [15]. In addition, it can also compromise the function of the anal sphincter [19], which in this case may cause de novo incontinence.

6.2.2 Mechanical suture (stapled)

Continuing on the topic of transanal approach, we will discuss the technique of transanal rectal resection with stapler (stapled transanal rectal resection STARR) [15].

The STARR technique involves double stapling with a circular stapler and an anal dilator and a purse-string suture. It is performed through a transanal approach in order to achieve a circumferential resection of the entire thickness of the anterior and posterior rectal wall. There are modifications in which the resection of the rectal wall is performed with an endostapler, or with the CONTOUR®TRANSTARTM semicircular stapler, a technique called TRANSTAR, which can facilitate the resection of the entire thickness of the rectal wall and is considered a safe and effective treatment for ODS (STARR TRANSTAR) associated with rectal wall intussusception and/or rectocele in the hands of experienced surgeons [20].

The STARR technique has positive impact in anatomical and obstructive defecation symptoms. The most frequent adverse effects and complications are urgency fecal incontinence, in up to 40%, that usually improves with time and resolves in about 3 months, minor bleeding, and postoperative pain [15]. Other important but infrequent complications are rectal diverticulum, rectovaginal fistula, rectal obliteration, rectal wall hematoma, or perforation. These complications appear to be reduced by using a parachute suture instead of a purse-string suture [20]. The existence of various ways or tricks in this type of approach is a sign of the real need for standardization of the technique.

The TRREMS (transanal repair of rectocele and rectal mucosectomy with one circular stapler) [21] performs the section with a single circumferential stapler, and it is suggested as a safe, economic, and effective procedure for the treatment of rectocele associated with mucosal prolapse.

Within the techniques performed with a stapler, there is a transperineal variation that consists of the mechanical stapling of the rectocele with a GIA, after dissecting the rectovaginal septum, adding a reinforcing PLP mesh at this level. This technique is called SPERR (Stapled Perineal Rectocele Resection).

6.3 Transvaginal approach

For a century, posterior transvaginal colporrhaphy and its modifications have been the usual transvaginal approach with optimal anatomical results.

In lithotomy position, and after infiltration of the vaginal wall with saline and adrenaline to facilitate dissection and reduce bleeding, a transverse incision is made at the level of the mucocutaneous junction (vaginal introitus) in the posterior vaginal wall. Annex 1 shows the main steps of this technique shown in a real case.

Dissection of the rectovaginal septum is continued, combining blunt and sharp dissection, until reaching the proximal end of the rectocele and laterally until exposing the puborectal muscles [4, 13].

After completing the dissection, the rectovaginal septum and the rectal wall are plicated in a longitudinal direction with simple stitches, using a non-absorbable polypropylene suture (prolene®), long-term absorbable monofilament (PDO), or absorbable polyglycolic acid braided suture. 2/0.

In the case presented as an example in Annex 1, it was combined with the previous performance of purse-string plications with vicryl® suture at the point of maximum protrusion of the rectocele, given the large size of this specific case. In case of an associated enterocele, the sac is opened after dissection and subsequently closed, hence repositioning the Douglas sac.

Perineorrhaphy with horizontal sutures and levatorplasty may be associated or omitted. It is important to check both the consistency of the rectovaginal septum and the correct size of the vagina post plication by rectal and vaginal examination, some authors propose at least two fingers in diameter.

Finally, the excess tissue of the vaginal mucosa flap is excised, which is done in the exposed case after marking the section level using indocyanine green. However, the use of this technology is not imperative. Finally, the closure of the vaginal plasty is completed with simple absorbable sutures. It is not necessary to place drains in the closure.

Regarding the results [15] of posterior colporrhaphy with native tissue, the literature shows that an improvement in anatomical and obstructive defecation symptoms is achieved after this technique. Side effects or complications have a low incidence, being dyspareunia the most common.

After the exposition of the main techniques, the existence of Site-Specific Repair [15] should be explained. This technique also improves anatomical defects and most obstructive defecation symptoms, but its results in terms of constipation are unclear. The most common side effects are dyspareunia and also tenesmus.

Specifically in the transvaginal approach, with the use of non-absorbable synthetic meshes, post-surgical complications have been described. There is a wide variety in terms of the severity of these complications, from pain, infection, bleeding, granulomas, urinary tract infection, dyspareunia, and even extrusion of the mesh or formation of fistulas or visceral lesions such as rectal, bladder, or vaginal perforation (1–4%). In the long term, up to 30% of patients may present mesh contraction with pain and dyspareunia [22].

FDA (Food and Drug Administration) has made a safety communication concerning about this topic, making a recommendation for the use of mesh in the transvaginal approach only “after weighing the risks and benefits of surgery with mesh versus all surgical and non-surgical alternatives” [23]. So, it should be used only in complex cases after failures of other surgeries and providing information about the possibility of all possible complications.

7. Techniques comparison

Even though there is no clear conclusion that one surgical technique is superior to the rest, there are numerous studies that compare existing techniques to address the need for consensus on what the recommendation should be.

The inferiority of the site-specific repair technique is clear, since posterior colporrhaphy has shown better anatomical results and in terms of symptoms in comparison, so this technique should not be used as a first-choice technique.

Regarding the transperineal approach, it has been recommended in combination with sphincteroplasty or levatorplasty for the treatment of symptomatic rectocele. These procedures have resulted in improved evacuation and continence in 75% of patients. Regarding the transvaginal repair, it provides better results of anatomical repair of the rectocele and fewer recurrences. Both techniques are associated with significant postoperative dyspareunia rates [15].

In a 2020 randomized study [2, 13] comparing the transperineal approach with the transvaginal approach for the treatment of anterior rectocele, it was determined that the transvaginal repair of the rectocele achieved an improvement in constipation and quality of life related to function sexual compared with the transperineal approach. There were no significant changes in dyspareunia. From the point of view of intraoperative time, postoperative complications, and recurrence, no significant differences were found.

Posterior transvaginal colporrhaphy with native tissue compared with the transanal approach presents better anatomical results in vaginal examination but not in defecography, with improvement in terms of constipation and incomplete evacuation without changes in terms of digitation needs, with similar rates of complications [15].

It is important to consider certain anatomical aspects such as in the case of the transvaginal approach, there is no direct interference with the anal canal, so that the involvement of the anal sphincter is very unlikely, compared with the transanal approach. Therefore, this technique can be given priority in patients with previous damage or pathologies in the anal sphincter.

Certain authors attach importance to the caliber of the vagina in the face of post-surgical dyspareunia. This is not a trivial complication, and it occurs in more than 33% of sexually active women after performing different rectocele repair techniques. Other comparisons show a significant improvement in the sexual satisfaction of patients after a transvaginal approach but not after a trans perineal approach, possibly due to the change in the anatomy of the vagina or “rejuvenation” that occurs in the first technique and not in the second [15].

When it comes to the use of native tissue versus biological flaps, no anatomical improvements of the posterior compartment or symptomatic improvements of ODS have been observed, and there are no differences in terms of complications. There are also no better anatomical or symptomatic results with the use of synthetic meshes. Their use presents complications such as dyspareunia or erosions and even mesh extrusion in the case of a transvaginal approach.

8. Conclusion

There is not a superior technique that can be recommended as the only “gold standard.” For this reason, the surgical treatment of the rectocele must be individualized in each case according to the needs of the patient and surgeon’s experience.

A transvaginal approach with posterior colporrhaphy and native tissue is recommended in cases of women with ODS who require surgical treatment, reporting the rate of possible post-surgical dyspareunia.

In cases with multicompartmental prolapse or with a very high rectocele, an abdominal approach is more suitable (Figure 5).

Figure 5.

Option of rectocele treatment algorithm, ODS: Obstructive defecation syndrome, TV: Transvaginal, FI: Fecal incontinence, LVR: Laparoscopic ventral rectopexy, STARR: Stapled transanal rectal resection.

Non-absorbable mesh should not be used in the vaginal approach due to potential adverse effects.

An improvement in the results with the use of biological materials has not been demonstrated; however, their use increases the surgical costs.

Site-specific repair has a higher recurrence rate and is not recommended as the first technique of choice in patients with constipation.

Transanal approach for the treatment of posterior rectocele is associated with lower resolution of ODS symptoms and a higher recurrence rate with higher infection rates. This approach should be avoided in patients with fecal incontinence or known sphincteric damage, cases in which the association of perineoplasty or levatorplasty may be more indicated.

Appendices and nomenclature