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At least 19 recordsLinked to original sources

PubMed1993

Dyschezia and rectocele--a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation.

UNLABELLED: Herniation of the anterior rectal wall into the lumen of the vagina (so called rectocele) may be encountered in patients who complain of constipation and emptying difficulties but it is difficult to ascertain whether this anatomic abnormality is an etiologic factor or a consequence of the dyschezia. PURPOSE: The aim of our study was to assess symptomatic, anatomic, and physiologic features encountered in women with a clearly defined rectocele in order to determine the predisposing factors, symptoms, functional associations, and effects on quantified rectal emptying. METHODS: Clinical, physiologic (manometry), and anatomic (evacuation proctography) assessments were carried out in 26 consecutive women (mean age, 47.6 +/- 12 years) with dyschezia and a large rectocele as evidenced by radiography and compared with a group of 26 consecutive women complaining of dyschezia without a significant rectocele (mean age, 42.6 +/- 14 years). Both groups were similar with respect to mean age, parity, laxative abuse, manual anal evacuation, fecal incontinence, urgency, and weekly stool frequency. RESULTS: Patients having a rectocele differed significantly from those without a rectocele in having frequent endovaginal digitation during defecation (7 vs. 1, P < 0.05), more frequent symptoms of urinary incontinence (14 vs. 3, P < 0.001), and a surgical history of hysterectomy (9 vs. 2, P < 0.05). The rectocele group differed in having a delayed rectal emptying (55.5 +/- 38 vs. 30.3 +/- 23 seconds, P < 0.005), a more frequent incomplete rectal emptying (23 vs. 11, P < 0.0005), and was more often associated with a manometric anismus (16 vs. 6, P < 0.01). During the straining effort, there was a correlation between the depth of the rectocele and the duration of rectal emptying (rs = 0.3, P < 0.05). In the group without manometric anismus, women with a rectocele (n = 10) had a more incomplete rectal emptying than those without rectocele (8/10 vs. 8/19, P = 0.05). CONCLUSION: Some of our results indicate that the rectocele itself could be a contributory factor in difficult evacuation. These results also exhibit the importance of other disorders, such as anismus, in the occurrence of dyschezia. Physiologic examination therefore should be made before considering surgical repair in any patient with rectocele and dyschezia.

Adult↗

PubMed1993

The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair.

Using the descriptions of Uhlenhuth, and Milley and Nichols, we have been able to identify a sheet of strong connective-type tissue between the rectum and vagina. This layer has been named the rectovaginal septum, referred to, by some, as the rectovaginal fascia. As it is considered to be analogous to the rectovesical septum in men, first described by Denovilliers, some refer to it as Denonvilliers' fascia in the female. This layer is immediately beneath the vaginal mucosa and clearly is what many would consider part of the vaginal wall. Its principal attachments are peripheral--it merges superiorly with the cardinal/uterosacral complex, fuses laterally with the fascia over the levator muscle, and merges distally into the perineal body. Histologically, it contains collagen that is quite dense in places, some strands of smooth muscle, and a very dense network of heavy elastin fibers. It is this layer that acts as a supporting structure for the perineal body and prevents the rectum from bulging into the vagina. Rectoceles represent a defect in this layer that allows the rectum to bulge inward. The defects are usually isolated breaks that can be repaired directly with excellent and predictable results.

Fascia↗

PubMed1994

Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination.

PURPOSE: The aim of this study was to devise a measuring method for an anterior rectocele on standardized defecographies and magnetic resonance images (MRI) to quantify anterior rectocele and to test whether this could substantiate clinical decision making for operative treatment for anterior rectocele. METHODS: Quantitative analysis by the measuring method as proposed was compared with qualitative scores on defecographies and MRI from the same patients. Thirty-eight patients with symptoms compatible with an anterior rectocele were subjected to physical examination in the left decubitis position and supine position and to defecography. Findings on defecography were compared with findings on physical examination. Thirteen patients were examined before and after surgical correction of the anterior rectocele for a total of 51 qualitative and quantitative examinations. The group of operated patients was analyzed for treatment results. Nineteen controls were included. RESULTS: Sixty-six radiographs of 33 defecographies were qualified in three grading classes and quantified with the proposed method by two observers. The mean measured value of the anterior rectocele in the three subjective grading classes is significantly different (P < 0.001). Anterior rectoceles qualified as severe had a measured value of 20 mm or more in 96 percent of the radiographs. Lower gradings were never > 20 mm. On MRI severe anterior rectoceles were not scored and measured values did not correlate with qualitative scores. When findings on physical examination were compared with defecographic measurement, the coefficient of correlation (r) between the radiologic assessment and clinical examination in the left decubitis position is r = 0.87, for the examination in the supine position, r = 0.77. All 15 cases scored as severe anterior rectocele in the left decubitis position had a measured anterior rectocele of > or = 20 mm. In the 13 cases that received surgery, there was a significant reduction of the anterior rectocele (P < 0.001) and clinical improvement. Patients with small or moderate anterior rectocele on physical examination with a size > or = 20 mm on defecography were cured by surgical correction. None of the controls had an anterior rectocele on physical examination or an anterior rectocele > or = 20 mm on defecography. CONCLUSIONS: An anterior rectocele with a size of 20 mm or more corresponds with a qualitative score of "severe" on radiographic defecography. Physical examination for anterior rectocele in the left decubitis position corresponds best with quantitative radiographic assessment and anterior rectocele with a size > or = 20 mm on defecography is pathologic. Patients with complaints compatible with anterior rectocele can be assessed in objective and quantitative terms by radiography and can be successfully surgically treated, even if at physical examination the anterior rectocele is not classified as large, provided that dynamic defecography shows an anterior rectocele of > or = 20 mm. The potential of dynamic MRI with regard to anterior rectoceles presently seems absent.

Adult↗

PubMed2002

Anal manometric predictors of significant rectocele in constipated patients.

The diagnosis of significant rectocele is currently made on the basis of cinedefecographic findings. Clinical examination alone will only allow assessment of the presence but not the significance of a rectocele. Therefore, the aim of this study was to determine if anal manometric findings can predict the significance of a rectocele. All patients with a diagnosis of constipation and rectocele confirmed on cinedefecography between 1992 and 1998 were retrospectively reviewed. Significant rectocele was defined as the presence of three of the following five parameters: rectocele >4 cm in diameter as measured during the evacuatory phase of cinedefecography, rectal and/or vaginal symptoms present for longer than 12 months, persistence of rectal or vaginal symptoms for at least four weeks, despite increased dietary fiber (up to 35 g/day), need for rectal and/or vaginal digitation or perineal support maneuvers for rectal evacuation. Statistical analysis was performed using the Mann-Whitney test and Fisher's exact test. A logistic regression model with stepwise selection was used to determine significant prognostic factors. A total of 305 patients (31 men) with rectocele, with a median age of 68 years (range, 12-89) were identified. Of these, 89 (29.2%) had significant rectoceles. There was no difference in the frequency of significant and non-significant rectoceles with respect to gender or age. However, patients with a significant rectocele compared to those with a non-significant rectocele had higher median first sensation volume (45 vs. 30 ml, p=0.0005), median capacity (160 vs. 120 ml, p<0.0001), and median compliance (10 vs. 8 ml H(2)O/mmHg, p=0.05). Calculations based on a logistic regression model determined that with a first sensation of 100 ml, a capacity of 400 ml, and a compliance of 50 ml/mmHg, the probability of a significant rectocele would be 85%. In conclusion, anal manometric findings may be useful in predicting significant rectocele in constipated patients.

Adolescent↗

PubMed1998

Rectocele is associated with paradoxical anal sphincter reaction.

Rectocele is a frequent finding in constipated patients. However, constipation is not always relieved by rectocele repair, which may be due to other overlooked reasons for constipation. The study was designed to investigate patients with rectocele, in order to elucidate concomitant colorectal disorders and their association with rectocele. One hundred and twelve female patients suffering from severe constipation and rectal emptying difficulties were investigated using defecography, electrophysiology, anorectal manometry and colon transit time. Fifty-six patients with rectocele demonstrated by defecography were compared with 56 patients without rectocele, but with other abnormal findings at defecography. The frequency of paradoxical anal sphincter reaction (PSR) was higher in patients with rectocele (60%) than in patients without rectocele (24%). The present study supports an association between rectocele and PSR. We suggest that constipated patients with a rectocele should be investigated thoroughly before rectocele repair is considered. Further studies on the effect of biofeedback training in patients with rectocele and PSR are indicated.

Adult↗

PubMed1997

Role of defecography in predicting clinical outcome of rectocele repair.

PURPOSE: The aim of this study was to evaluate the role of defecography in predicting clinical outcome of rectocele repair. METHODS: Between January 1988 and July 1994, 74 consecutive patients (median age, 54 (range, 35-81) years) with a rectocele and symptoms of obstructed defecation were studied prospectively. After preoperative evaluation by a standardized questionnaire, physical examination, and defecography, a combined transvaginal/transanal rectocele repair was performed. At follow-up, all patients had defecography. Long-term results were qualified by an independent observer after a median follow-up of 58 (range, 14-89) months as "excellent," "good," or "poor." RESULTS: Rectocele repair was considered excellent in 37 patients and good in 13 patients. Defecography six months after surgery did not show persistent or recurrent rectocele in any of the patients. Size of the rectocele, barium-trapping in the rectocele, internal intussusception, rectal evacuation, and perineal descent did not appear to influence clinical outcome. Radiologic evidence of anismus did not correlate with long-term results of rectocele repair. CONCLUSIONS: Combined transanal/transvaginal repair of rectocele is an efficient therapy in patients with obstructed defecation. Various defecographic parameters (size of rectocele, internal intussusception, rectal evacuation, perineal descent, radiologic signs of anismus) do not appear to influence clinical outcome of surgery. The main value of defecography is the objective demonstration of rectocele and any associated abnormalities such as an enterocele preoperatively and again in objective assessment of the postoperative results.

Defecation↗

PubMed2000

Analysis of patients with poor outcome of rectocele repair.

PURPOSE: The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation. METHODS: Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35-81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12-92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome. RESULTS: Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal. CONCLUSIONS: Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.

Adult↗

PubMed2003

Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time.

BACKGROUND AND AIMS: Evacuation disorders associated with a rectocele can be improved by rectocele repair. This study investigated whether anorectal function tests results change after rectocele repair. PATIENTS AND METHODS: Fourteen patients with 2nd or 3rd degree rectocele and evacuation disorder were treated by posterior colporrhaphy and evaluated pre- and postoperatively (after 8 months, range 3-14) using questionnaires, anal manometry and endosonography, rectal barostat testing, and colonic transit time measurement with radio-opaque markers. Results from female controls were used for comparison. RESULTS: Preoperatively, rectocele patients had high maximal basal sphincter pressures, large sphincter lengths, and low maximal squeeze pressures, with an anal sphincter defect in seven and lower visceral sensitivity scores than in controls. Postprandial rectal responses (more than 10% decrease in postprandial volume after 1 h) were found in 3 of 14 patients compared to 2 of 11 parous and 9 of 11 nulliparous controls. After repair, a rectocele of 2nd degree was found in four patients. Questionnaire scores were significantly decreased for straining, evacuation disorder, manual support, and protrusion. Overall patient satisfaction with the operation scored 8.25 (range 3-10). Defecation frequencies and stool consistencies were unaltered. Anal pressures, rectal compliance-curves, visceral sensitivity, and colonic transit times were unaltered after the rectocele repair. CONCLUSION: Rectocele repair improved complaints of evacuation disorder and protrusion, but defecation frequency and stool consistency were not affected. Anorectal function was unaltered after rectocele repair. Selection of patients for rectocele repair should be performed based on evacuation and protrusion complaints, anorectal function, or colonic transit time measurements have a limited role.

Adult↗

PubMed2001

Rectoanal inhibition and rectocele: physiology versus categorization.

Some authors divide rectoceles into those with chronic evacuatory difficulty and normal genital position (type 1) and those with associated pelvic organ prolapse (type 2). This study assessed whether there are physiological differences between these two clinical rectocele types. Female patients were assessed by conventional anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex (RAIR), and defecography. Subjects included 33 volunteer controls without anorectal disease, 14 patients with type I rectocele, and 26 patients with type II rectocele. Significant differences were noted for resting pressure measurements (maximal resting anal pressure and vector volume) between rectocele types and between type I patients and controls. Significant differences were noted for squeeze parameters (maximal squeeze pressure and vector volume) only between rectocele types. There were minimal differences in parameters of the RAIR, with a reduced slope of inhibition in the proximal sphincter for both rectocele groups and a reduced maximal inhibitory pressure in the intermediate and distal sphincter of type 1 rectocele patients. There were no differences in transient excitation of the pressure wave during the RAIR reflex to account for pressure variations with no measured differences in rectocele depth (type 1, 2.87 +/- 0.7 cm; type 2, 2.84 +/- 1.4 cm) There are few physiological differences between the different clinical categories of rectocele patients based on the presence or absence of associated genital prolapse.

Adult↗

PubMed2005

Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study.

PURPOSE: This study was designed to evaluate rectocele repair using collagen mesh. METHODS: 32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography. RESULTS: Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele > or = Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele > or = Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced. CONCLUSIONS: Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.

Adult↗

PubMed2005

Rectocele repair using biomaterial augmentation: current documentation and clinical experience.

UNLABELLED: Although the etiology of rectocele remains debated, surgical innovations are currently promoted to improve anatomic outcome while avoiding dyspareunia and alleviating rectal emptying difficulties following rectocele surgery. Use of biomaterials in rectocele repair has become widespread in a short time, but the clinical documentation of their effectiveness and complications is limited. Medline and the Cochrane database were searched electronically from 1964 to May 2005 using the Pubmed and Ovid search engines. All English language publications including any of the search terms "rectocele," "implant," "mesh," "biomaterial," "prolapse," "synthetical," "pelvic floor," "biological," and "compatibility" were reviewed. This review outlines the basic principles for use of biomaterials in pelvic reconstructive surgery and provides a condensation of peer-reviewed articles describing clinical use of biomaterials in rectocele surgery. Historical and new concepts in rectocele surgery are discussed. Factors of importance for human in vivo biomaterial compatibility are presented together with current knowledge from clinical studies. Potential risks and problems associated with the use of biomaterials in rectocele and pelvic reconstructive surgery in general are described. Although use of biomaterials in rectocele and other pelvic organ prolapse surgery offers exciting possibilities, it raises treatment costs and may be associated with unknown and potentially severe complications at short and long term. Clinical benefits are currently unknown and need to be proven in clinical studies. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians TARGET AUDIENCE: After completion of this article, the reader should be able to explain that the objective of surgical treatment is to improve anatomic outcome and alleviate rectal emptying difficulties, describe the efficacy of biomaterials in rectocele repair, and summarize the potential risks and problems associated with use of biomaterials in rectocele and pelvic reconstructive surgery.

Biocompatible Materials↗

PubMed1995

Is barium trapping in rectoceles significant?

PURPOSE: This study was designed to determine whether rectocele size and contrast retention are significant. METHODS: Evacuation proctography and simultaneous intrarectal pressure measurements from a small, noncompliant balloon catheter were performed in three matched groups of 11 constipated female patients with rectoceles, rectoceles and contrast trapping of > 10 percent, and no rectocele. Computerized image analysis was used to measure rectocele area and evacuation. RESULTS: In the two groups with rectoceles, there was no significant difference in rectocele area or width pre-evacuation. The anorectal angle, pelvic floor descent, maximum anal canal width, evacuation time or completeness, maximum and distal intrarectal pressure, or need to digitate did not differ significantly between the groups. In seven patients with barium trapping (64 percent) the intrarectal pressure dropped abruptly as the balloon entered the rectocele, suggesting that trapping results from sequestration into the vagina, closing part of the rectocele from the normal intrarectal pressure zone. CONCLUSION: Because no impairment of evacuation appears to be associated with either a large rectocele or trapping, these evacuation problems should not be directly attributed to these proctographic findings.

Barium Sulfate↗

PubMed1996

Excellent outcome using selective criteria for rectocele repair.

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16-78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1-8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5-64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test, P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Constipation↗

PubMed2003

Rectocele: pathogenesis and surgical management.

BACKGROUND: Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty. DISCUSSION: The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation. CONCLUSION: The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Algorithms↗

PubMed2001

Results of anterior levatorplasty for rectocele.

OBJECTIVE: Transanal and transvaginal repair of rectocele have been advocated in the treatment of rectocele, with mixed results. The aim of this study was to assess our experience using anterior levatorplasty in the surgical management of rectocele. PATIENTS AND METHODS: Sixty of 90 women who had undergone anterior levatorplasty for rectocele over a seven year period were traced, and 44 (33 with rectocele only and 11 with rectocele and faecal incontinence) responded to a standardized questionnaire 6 months to 7 years (mean 3.5 years) after anterior levatorplasty. Results were expressed in general and specific improvement of symptoms and were classified as excellent, good, fair, or poor. The effects on social activities, sexual function, and employment were also assessed. RESULTS: General satisfaction with the operation was rated as good or excellent in 27 of 33 (82%) and 18 of 24 (75%) patients with rectocele only at 2 and 3.2 years follow-up, respectively, and in 7 of 11 (64%) and 5 of 11 (45%) patients with rectocele and faecal incontinence at 2 and 4 years follow-up, respectively. 31 (70%) and 34 (77%) of all patients reported an improvement in sensation and the ability to defaecate, respectively. An improvement in social activities, sexual satisfaction and employment was noted in 10 of 21 (48%), 10 of 23 (43%), and 7 of 12 (58%) patients, respectively. CONCLUSION: Anterior levatorplasty provides good short and long-term symptomatic improvement in patients with rectocele and avoids complications associated with rectal or vaginal approaches.

Journal Article↗

PubMed1999

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation.

PURPOSE: The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation. METHODS: All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5-54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair. RESULTS: Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19 vs. 10, preoperative vs. postoperative; P = 0.02) and the need to use digital assistance vaginally (13 vs. 6; P = 0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22 vs. 18 percent; P = 0.95), the percentage reduction in rectocele area (65 vs. 62 percent; P = 0.95), or a rectocele width of more than 2 cm (44 vs. 50 percent; P = 0.80), did vs. did not feel improved, respectively. CONCLUSION: Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.

Adult↗

PubMed1999

The anatomic and functional variability of rectoceles in women.

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

Adult↗

PubMed2003

On the pathogenesis of rectocele: the concept of the rectovaginal pressure gradient.

Coughing or straining evokes reflex bulbocavernosus (BCM) and puborectalis (PRM) muscle contraction, which apparently transforms the vagina into a closed high-pressure cavity. This elevated vaginal pressure counteracts the increased intra-abdominal pressure and the tendency of the uterus to prolapse, and also supports the rectovaginal septum against the high straining-induced intrarectal pressure and possible consequent rectocele (posterior vaginal prolapse) formation. We investigated the hypothesis that a weak BCM and PRM share in the genesis of rectocele by changing the rectovaginal pressure gradient. Twenty-three women with rectocele (mean age 43.2+/-6.6 years) and 12 healthy women volunteers (mean age 41.6+/-6.2 years) were studied. The response of the intrarectal (intra-abdominal) and intravaginal pressure, as well as the EMG activity of the BCM and PRM to straining or coughing, was recorded. In the healthy volunteers the rectal and vaginal pressures showed a significant increase on coughing or straining, with no significant difference between the rectal or vaginal pressures. Also, the BCM and PRM EMG activity exhibited a significant increase. Rectocele patients showed a significantly low resting vaginal pressure. The increase in rectal and vaginal pressure, as well as of the EMG activity of the BCM and PRM on straining or coughing, was significantly lower and the latency of the EMG response was significantly longer than those of the healthy volunteers. A difference in the rectovaginal pressure gradient showing a significant increase in the rectal against the vaginal pressure, particularly on coughing or straining, is suggested to be the basic factor in the genesis of rectocele. This pressure difference appears to be caused by diminished BCM and PRM contractile activity. A disrupted rectovaginal septum is not a prerequisite for rectocele formation, as the septum appears normal in obstructed defecation despite the common occurrence of rectocele. A histopathologic study of the septum in rectocele seems necessary.

Adult↗