Providing optimal care for a rectocele, or prolapse of the posterior vaginal wall, begins with recognition of the heterogeneous nature of pelvic organ prolapse, and a focus on the primary goal of intervention, relief of symptoms. Rectoceles frequently occur with concurrent prolapse of the anterior vaginal wall and vaginal apex, and a durable repair requires attention to these support defects as well.

While prolapse is ubiquitous in parous women, it does not warrant treatment unless it is symptomatic. The symptoms commonly attributed to posterior prolapse include pelvic pressure, and a sensation or visualization of protrusion, defecatory dysfunction, and sexual dysfunction. While symptoms of protrusion are almost always due to prolapse, predicting which patients will have relief from defecatory dysfunction and sexual dysfunction depends on a thorough understanding of the anatomy of support of the posterior wall as well as the differential diagnosis of these symptoms. Perineal rectoceles commonly present with complaints of defecatory dysfunction, including, a sense of incomplete emptying, tenesmus, and the need to splint or use digital manipulation for defecation. However, long-standing constipation can also be a contributing factor for prolapse, in which case surgical repair should not be expected to alleviate symptoms. Similarly, some techniques of surgical repair of rectocele can cause obstructed defecation or dyspareunia. Consequently, in the context of recurrent rectocele, the presence of these symptoms bears careful consideration.

There are a variety of surgical techniques available to the surgeon treating rectocele, including the posterior colporrhaphy, trans-anal repair, and the defect directed repair. Each of these approaches has strengths and limitations. The defect-directed repair, also known as the site-specific fascial repair, aims to maximize relief of symptoms without new functional symptoms, through recreating normal anatomy. The technique is based on Richardson’s observations at the time of rectocele repair and during cadaveric dissections, of discrete tears or breaks in the rectovaginal septum. He advocated an anatomical repair limited to repair of these fascial tears or defects without attempts to narrow the vaginal caliber or perineum. This approach appears to improve the relief of protrusion symptoms and obstructed defecation due to prolapse, without causing de novo defecatory dysfunction or dyspareunia. However, its reliance on native tissues that may be compromised in women with pelvic organ prolapse, may have a negative impact on its durability. Nevertheless, it is a good choice for a patient that desires a repair using native tissue, especially if she has no risk factors for recurrence.

Preoperative estrogen cream promotes a healthier mucosal epithelium in atrophic postmenopausal patients. A bowel prep is not generally indicated preoperatively, unless the patient has retained stool in the rectum after defecation. Antibiotic prophylaxis
with a second generation cephalosporin or metronidazole is recommended, although there is minimal data to show its efficacy. Deep venous thromboembolism prophylaxis is also recommended. The patient should be positioned in lithotomy or modified lithotomy position. Either regional anesthesia or general anesthesia is appropriate. Submucosal infiltration with injectable lidocaine with epinephrine simplifies postoperative pain and assists dissection and hemostasis. A Foley catheter should be placed during the surgery to drain the bladder. Following is a brief description of the surgical procedure used (see also video: Rectocele Repair Using the Defect-directed Approach).

The surgical approach begins with a transverse incision in the posterior fourchette from 4 o’clock to 8 o’clock (Figure 37.1). This divergence from the standard perineorrhaphy, usually performed with a posterior colporrhaphy to decrease the size of the genital hiatus, is possible as repairing the attachments of the rectovaginal fascia to the apical support and perineal body has been shown to decrease the gaping genital hiatus without a perineorrhaphy. Moreover, the lack of a perineorrhaphy may be why the defect-directed approach has a lower rate of post surgical dyspareunia.

The transverse incision is then joined by a midline longitudinal incision in the epithelium of the posterior vaginal wall (Figure 37.2). This incision is carried approximately two-thirds of the vaginal length. The vaginal epithelium is then dissected off the underlying tissue in the plane between the mucosa and the vaginal muscularis or rectovaginal septum (Figure 37.3). Finding this plane is essential to identifying the location of the rent in the rectovaginal septum. This dissection is facilitated by using sharp dissection combined with counter traction provided by Allis clamps, a self-retaining retractor, or by using a finger behind the vaginal mucosa. Moreover, as the rent can occur in the midline of the rectovaginal fascia or at its attachments, the dissection should be carried laterally to the normal attachment of the rectovaginal fascia to the levator ani

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