Transperineal Rectocele Correction
A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80%
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Giovanni Milito, Federica Cadeddu, and Giorgio Lisi
18.1
Introduction
A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80% of cases [1]. Symptomatic rectocele is less common, usually affects postmenopausal females, and results in obstructed defecation and constipation (Table 18.1) [2, 3]. Rectocele can be classified according to its position: low, middle, or high; and/or their size: small (< 2cm), medium (2–4cm), or large (4cm). Size is measured anteriorly from a line drawn upward from the anterior wall of the anal canal on proctography [4]. It can also be classified into three clinical stages at straining during defecation proctography (Table 18.2). Surgery should be considered when conservative therapy fails and careful patient selection, based on an accurate morphofunctional assessment, is crucial to obtain a satisfactory outcome [5]. The purposes of surgical repair in the management of rectocele repair are essentially the restoration of normal vaginal anatomy and the restoration or maintenance of normal bladder, bowel, and sexual function. Transperineal repair of the fascial defect may provide restoration of normal anatomy and symptomatic relief. A variety of synthetic and nonsynthetic graft materials have been used in rectocele repair to enhance anatomical and fuctional results, and improve long-term outcomes. Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief.
G. Milito () Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy e-mail: [email protected] A. L. Gaspari, P. Sileri (Eds), Pelvic Floor Disorders: Surgical Approach, Updates in Surgery DOI: 10.1007/978-88-470-5441-7_18, © Springer-Verlag Italia 2014
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G. Milito et al.
174 Table 18.1 Symptoms associated with rectocele Symptom
Prevalence (%)
Obstructed defecation
75–100
Manual assistance of defecation
20–75
Rectal pain
12–70
Rectal bleeding
20–60
Incontinence
10–30
Table 18.2 Classification of rectocele I
Digitiform rectocele of single hernia through the rectovaginal septum
II
Big sacculation, lax rectovaginal septum, anterior rectal mucosal prolapse, deep pouch of Douglas
III
Rectocele associated with intussusception and/or prolapse of the rectum
Recent advances in pelvic reconstructive surgery are due, in part, to the availability of new graft materials that allow reinforcement and repair of large pelvic fascial defects, minimizing adverse graft-related effects and postoperative complications [6].
18.2
Pretreatment Evaluation
Although rectoanal intussusception may be observed during physical examination, it is much more likely to be detected during defecography, which remains the most useful diagnostic tool when applied to a symptomatic subject. Defecography is crucial to document the presence of anatomica
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