What are the management options for a rectocele?

Management Options for Rectocele

Conservative management should be the first-line approach for rectocele, with surgical intervention reserved for symptomatic cases that fail to respond to non-operative measures. 1

Initial Assessment and Conservative Management

• Rectoceles are herniation of the rectum into the posterior vaginal wall, with an estimated prevalence of 30-50% in women over age 50 1
• Symptoms typically include:
  • Dyschezia (difficult or painful defecation)
  • Need for digital disimpaction or vaginal splinting
  • Pelvic heaviness
  • Incomplete evacuation
  • Anal incontinence
  • Dyspareunia 1, 2

Conservative Treatment Options

• Pelvic floor biofeedback therapy to correct underlying pelvic floor dysfunction 3, 4
• Bowel modifying agents to improve stool consistency 4
• These approaches should be exhausted before considering surgical intervention 1, 4

Indications for Surgical Management

• Failure of conservative measures with persistent symptoms 1
• Significant impact on quality of life 1
• Large rectocele (>3-4 cm) with symptomatic presentation 5, 4
• Presence of contrast trapping on defecography 6

Surgical Approaches

Selection of Surgical Approach

The approach should be determined based on:

1. Location of the rectocele:

   • Low or mid-rectum rectoceles: approach from below (transanal, transvaginal, or transperineal) 1
   • High rectoceles or those associated with other pelvic floor disorders: transabdominal approach 1

2. Patient characteristics:

   • Age and comorbidities
   • Associated pelvic floor disorders
   • Surgeon's expertise 3

Specific Surgical Techniques

Transvaginal Approach

• Posterior colporrhaphy (PC) with or without levatorplasty
  • Effective in reducing rectocele size (average reduction from 5.3 cm to 3.1 cm) 5
  • Good improvement in symptoms of vaginal bulge (80% improvement) 6
  • Moderate improvement in obstructed defecation symptoms (58% improvement) 6
  • Hospital stay averages 3.2 days with 11.2% complication rate (primarily urinary retention) 6

Transanal Approach

• Stapled Transanal Rectal Resection (STARR)
  • Aims to exclude redundant rectal mucosa associated with rectocele 3
  • Effective in reducing rectocele size (average reduction from 3.8 cm to 1.9 cm) 5
  • Good improvement in symptoms of incomplete evacuation and sense of obstruction 5
  • Higher risk of complications including infection, pain, incontinence, bleeding, and rarely fistula or peritonitis 3
  • Has not gained widespread acceptance in the United States 3

Transabdominal Approach

• Ventral rectopexy
  • Recommended for high rectoceles or those associated with other pelvic floor disorders 1
  • Can be performed open or laparoscopically based on patient characteristics and surgeon expertise 3

Outcomes and Considerations

• Overall patient satisfaction after transvaginal rectocele repair is approximately 88% 6
• Anatomical correction rates are generally high, but functional outcomes are more variable 2
• Recurrence rates after transvaginal repair are approximately 17% at 2 years 4
• The correlation between symptom improvement and anatomical correction is often weak 3
• Important to recognize that anatomical abnormalities may be caused by underlying functional disorders that are not corrected by surgery 3

Complications to Monitor

• Urinary retention (most common complication, 8.4% after transvaginal repair) 6
• Post-operative pain
• Infection
• Bleeding
• Incontinence
• Rare but serious complications after STARR include fistula, peritonitis, and bowel perforation 3

Clinical Pearls

• Multidisciplinary assessment involving colorectal surgeons and urogynecologists improves outcomes 4
• Preoperative defecography and physical examination are essential for proper surgical planning 1, 6
• Patients should be counseled that while anatomical correction is likely, functional improvement is less predictable 2
• Consider combined procedures when rectocele is associated with other pelvic floor disorders 1, 4