What is the treatment approach for rectocele surgery?

Rectocele Surgery Treatment Approach

The treatment approach for rectocele should begin with conservative management using pelvic floor biofeedback therapy, with surgical intervention reserved for patients with symptomatic rectoceles who fail conservative measures. 1

Initial Assessment and Management

• Rectocele is a herniation of the rectum into the posterior vaginal wall, commonly affecting women over 50 years of age with a prevalence of 30-50% 2
• Conservative management with pelvic floor biofeedback therapy should be the first-line treatment for rectoceles, especially for asymptomatic Grade 1-2 rectoceles 3, 1
• Surgical intervention should only be considered after failure of conservative measures for at least 3-6 months in patients with symptomatic rectoceles 4

Indications for Surgical Intervention

• Surgery is indicated for clinically significant rectoceles that:
  • Are large in size (typically >4 cm) 5
  • Show contrast trapping on defecography 5
  • Require digital assistance for evacuation 1
  • Cause significant symptoms affecting quality of life despite conservative management 2
• Symptomatic grade 3-4 rectal prolapse associated with rectocele requires surgical correction 3, 6

Surgical Approach Selection

The choice of surgical approach depends on several factors:

• Patient characteristics: Age, comorbidities, and associated pelvic floor disorders 1
• Location of rectocele:
  • Low or mid-rectum rectoceles: Approach from below (transanal, transvaginal, or transperineal) 2
  • High rectoceles or those associated with other pelvic floor disorders: Transabdominal rectopexy 1, 2

Specific Surgical Approaches

1. Transvaginal Approach:

   • Transvaginal rectal repair (TVRR) shows good outcomes with 87.9% global improvement of symptoms 5
   • Improvement of vaginal bulge symptoms in 80% of cases and obstructive defecation symptoms in 58% 5
   • Relatively short hospital stay (average 3.2 days) with 11.2% in-hospital complication rate 5

2. Transanal Approach:

   • Stapled Transanal Rectal Resection (STARR) aims to exclude redundant rectal mucosa 1
   • Can reduce rectocele size from average 3.8 cm to 1.9 cm 1
   • 82% of patients report >50% reduction in obstructed defecation scores at one year 3
   • Higher complication rate (15%) including infection, pain, incontinence, bleeding, and rarely fistula, peritonitis, or bowel perforation 3, 1

3. Abdominal Approach:

   • Ventral rectopexy recommended for high rectoceles or those associated with other pelvic floor disorders 1
   • Can be performed open or laparoscopically based on surgeon expertise 1
   • Posterior rectopexy should be avoided as it can result in severe constipation in up to 50% of patients 6

4. Novel Approaches:

   • Botulinum toxin injections into the puborectalis muscle and external anal sphincter have shown promising results in small studies, reducing rectocele depth from 4.3 cm to 1.8 cm with symptomatic improvement in 64% of patients 7

Important Considerations and Pitfalls

• The correlation between symptom improvement and anatomical correction is often weak; anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 3, 1
• Surgical repair does not always alleviate symptoms related to difficulty in defecation 7
• Some patients may experience impaired fecal continence after surgical treatment 7
• Common complications to monitor post-operatively include:
  • Pain (most common) 1
  • Urinary retention (8.4% in TVRR) 5
  • Infection, bleeding, and incontinence 1
  • Recurrence of rectocele (asymptomatic in some cases) 7

Follow-up and Outcomes

• Follow-up should assess both anatomical correction and functional improvement 8
• Long-term success rates vary by procedure:
  • TVRR: 70% symptom-free or improved at 18 months 4
  • STARR: Long-term outcomes are somewhat disappointing despite initial improvement 3
• Recurrent rectoceles may occur but can be asymptomatic 7