What are the treatment options for rectocele?

Rectocele Treatment Options

Rectoceles should initially be managed with conservative measures, with surgical intervention reserved for clinically significant and symptomatic cases that fail to respond to non-operative management. 1, 2

Conservative Management

• First-line treatment options:

  • Pelvic floor biofeedback therapy - shown to provide partial symptom relief in the majority of patients 3
  • Increased dietary fiber intake and adequate hydration
  • Stool softeners to facilitate evacuation without straining
  • Education on proper defecation habits to avoid excessive straining 2

• Benefits of conservative management:

  • Avoids surgical complications
  • May address underlying pelvic floor dysfunction
  • Particularly appropriate for asymptomatic or mildly symptomatic rectoceles 1

Indications for Surgical Management

Surgery should be considered for:

• Clinically significant rectoceles:
  • Large defects
  • Rectoceles that fill preferentially and/or fail to empty on defecating proctogram
  • Symptomatic rectoceles where patients resort to vaginal stenting during defecation 1
• Failure of conservative management with persistent symptoms affecting quality of life 4

Surgical Approaches

The choice of surgical approach depends on:

1. Location of the rectocele:

   • Low or mid-rectum rectocele: approach from below (transanal, transperineal, or transvaginal)
   • High rectocele or associated with other pelvic floor disorders: transabdominal approach 4

2. Specific surgical options:

   • Transanal approaches:

     • Stapled Transanal Rectal Resection (STARR)
       • Aims to exclude redundant rectal mucosa
       • Higher success rate than biofeedback (82% vs 33% reduction in obstructed defecation scores)
       • Potential complications: infection, pain, incontinence, bleeding, UTI, depression, fistula, peritonitis, and bowel perforation 1

   • Transperineal approaches:

     • Perineal rectal plication with levatorplasty
       • Anatomic correction achieved in 90% of cases
       • Restoration of normal rectal evacuation in 80% of cases 5

   • Transvaginal approaches:

     • Posterior colporrhaphy with fascial repair

   • Transabdominal approaches:

     • Ventral rectopexy
     • Laparoscopic anterior and posterior native tissue repair 6

Important Considerations

• Correlation between symptoms and rectocele size is weak 1
• Correlation between improvement in symptoms and anatomy after surgery is also weak - symptoms may improve despite modest anatomic correction and vice versa 1
• Underlying dysfunction - Anatomic abnormalities may result from underlying pelvic floor dysfunction (impaired relaxation and excessive straining), which surgery alone may not correct 1
• Long-term outcomes - Even for ideal surgical candidates, long-term outcomes can be disappointing 1

Treatment Algorithm

1. Initial assessment:

   • Evaluate symptom severity and impact on quality of life
   • Perform dynamic imaging (defecography) and anorectal manometry to assess functional status 4

2. For asymptomatic or mildly symptomatic rectoceles:

   • Conservative management with biofeedback, dietary modifications, and proper defecation habits

3. For symptomatic rectoceles after failed conservative management:

   • Low or mid-rectum rectocele: Consider transanal, transvaginal, or transperineal repair
   • High rectocele or with associated pelvic floor disorders: Consider transabdominal approach

4. For complicated rectoceles (incarceration, strangulation):

   • Attempt gentle manual reduction under mild sedation or anesthesia 1
   • If unsuccessful or signs of ischemia present, urgent surgical intervention is required 1

Pitfalls to Avoid

• Failing to identify and address underlying pelvic floor dysfunction
• Overestimating the correlation between anatomic correction and symptom improvement
• Performing surgery on asymptomatic rectoceles
• Neglecting to rule out associated conditions (cystocele, uterine prolapse) that may require simultaneous treatment 4
• Delaying surgical treatment when conservative management fails in cases with risk of ischemia or perforation 2

The prevalence of rectocele is high (30-50% in women over 50), but not all require intervention 4. The decision for surgical management should be based on symptom severity, anatomical findings, and failure of conservative measures.