Available online 10 December 2022, 100937

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Rectoceles are a common finding in female patients; they can be asymptomatic, or they can contribute to the sensation of pelvic pain, pressure, and difficulty with evacuation. Rectoceles coexist with anterior and mid compartment pelvic prolapse in up to 50% of patients. Defecatory dysfunction can be secondary to anismus, anatomic abnormalities such as rectocele or intussusception, and often are due to a complex interplay of both structural and functional abnormalities. Hence patients presenting with these symptoms are best evaluated with anorectal physiology testing and dynamic imaging. Nonoperative approaches include pelvic floor physical therapy, biofeedback therapy, and vaginal pessaries. Various operative approaches exist, each with different targets and measurements of successful repair.

Introduction

The clinical diagnosis of a rectocele refers to a bulging of the anterior rectal wall into the posterior vaginal wall due to a weakened rectovaginal septum.1 Despite the straightforward anatomic definition, there remains a lot of confusion about the diagnosis and management of rectoceles. A patient complaint of the need to splint the perineum to facilitate defecation may assign the diagnosis of rectocele from the gastroenterologist; the physical exam findings of a significant posterior vaginal wall prolapse may define the diagnosis from a gynecologist2 despite the possible etiologies of sigmoidocele or enterocele. An understanding of the etiology of rectoceles may suggest the optimal treatment strategy; but is it due to the loss of integrity of the rectovaginal fascia from childbirth, connective tissue deterioration related to age, or secondary to chronicity of a nonanatomic bowel dysfunction? Possibly all of the above?3 Even anatomists debate of the presence of a true rectovaginal fascia or discrete tissue layer amenable to dissection and discrete repair in the rectovaginal septum.4, 5, 6

This chapter will attempt to address the evaluation and treatment options in the management of rectocele from the perspective of a colorectal surgeon.

Section snippetsIncidence

The true incidence of rectoceles is impossible to measure, given the anatomic finding can be asymptomatic. Rectoceles may be found in anywhere from 20-80% of women7; asymptomatic rectocele can occur in approximately 40% of parous women.8 An observational cohort study reported rectovaginal septal defects in 12% of 178 nulliparous women aged 18-24 examined with the aid of translabial ultrasound.9 MR defecography may identify the presence of a rectocele in as many as 78% of women with significant

History and Surveys

A patient diagnosed with a rectocele will often present to a colorectal surgeon expecting a surgical treatment for what has been described to her as a surgical problem. It is best to go back to square one and take a detailed history eliciting the exact symptoms that are bothersome to the patient. Symptoms specific to a rectocele can be categorized into vaginal symptoms and defecatory dysfunction. Vaginal symptoms can include vaginal bulging, perineal pressure, vaginal bleeding from mucosal

Physical exam

A recently published web-based survey revealed significant differences in evaluation and treatment of patients with a rectocele based on the physician's specialty training. All gynecologists evaluated patients in the dorsal position compared to 49% of colorectal surgeons. 91% of gynecologists examine patients with a vaginal speculum versus 27% of colorectal surgeons. Digital rectal examination was reported in 90% of exams performed by colorectal surgeons compared to 57% of gynecologist exams.36

Evaluation of obstructed defecation

A large meta-analysis of 45 population-based surveys estimates the global prevalence of chronic constipation at 14% (95% confidence interval 12–17%).40 Chronic constipation is more commonly noted in women, older individuals and those of lower socioeconomic status.40,41 The American Gastroenterological Association (AGA) subcategorizes functional constipation into three subgroups: normal transit constipation, slow-transit constipation, and defecatory disorders.42 Obstructed defecation syndrome

Imaging of Rectocele and ODS

Traditionally, clinical examination has been the main diagnostic modality for rectocele. Prolapse of the posterior pelvic compartment, however, can be complex and components can be missed or underestimated by physical exam.79 Imaging has been shown to alter the operative plan in 40-70% of patients.80,81 A 2020 survey of radiologists with pelvic floor imaging experience reported defecatory dysfunction and pelvic organ prolapse as the most common indications for referral for dynamic pelvic floor

Nonsurgical Management of Rectocele

As previously stated, rectoceles are a common physical exam finding; treatment should only be pursued for symptomatic patients. Patients should be counseled appropriately regarding expectant management. Two longitudinal studies suggest that patients with mild posterior vaginal prolapse may regress more often than progress, whereas the opposite is true for more advanced stages of posterior vaginal prolapse.101,102 Increasing parity is also associated with rectocele progression.101

Surgical Management of Rectoceles

A variety of procedures exist and are utilized by surgeons of different specialties to surgically repair rectoceles. These procedures can be categorized broadly into procedures which reinforce the rectovaginal septum, procedures in which the anterior rectal wall is excised, and supportive vaginal and rectal wall procedures.

Summary

The clinical entity of a rectocele has disputed anatomic origins; it can present with a variety of symptoms to clinicians with a diversity in training. Selected treatments are best used to address symptoms; however additional clinical exam findings, anorectal physiology testing results, and dynamic imaging may further delineate medical decision making. Patients with obstructed defecation as a main concern benefit from optimal medical management and biofeedback therapy as first line therapies.

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