Management of Mild Posterior Compartment Prolapse
For mild posterior compartment prolapse (rectocele) at rest with the anorectal junction 4 cm below the pubococcygeal line, initiate conservative management with pelvic floor biofeedback therapy as first-line treatment, reserving surgery only for symptomatic cases that fail conservative measures. 1
Conservative Management Approach
Pelvic floor biofeedback therapy should be the initial treatment to correct underlying pelvic floor dysfunction in patients with rectocele. 1 This guided approach is more beneficial than self-taught Kegel exercises, though it may be less effective for high-stage prolapse. 2
- Observation is appropriate for asymptomatic mild prolapse, as anatomical findings do not always correlate with symptoms. 3, 4
- Lifestyle modifications and pelvic floor muscle training represent first-line conservative options that can be offered in combination. 5
- Pessaries are effective nonsurgical alternatives for patients not desiring or medically unfit for surgery. 4, 5
When to Consider Surgical Intervention
Surgery should only be considered if:
- Conservative measures fail to meet patient expectations after an adequate trial of pelvic floor therapy. 5
- Symptoms are disabling and clearly related to the prolapse detected on clinical examination. 5
- The prolapse is significant (stage 2 or more) on POP-Q classification. 5
Critical Pitfall to Avoid
Do not assume anatomic correction will correlate with symptom improvement—symptoms may persist despite successful anatomic repair because underlying functional disorders are not corrected by surgery alone. 1, 3 The correlation between symptom improvement and anatomical correction is often weak, and anatomical abnormalities may be caused by underlying functional disorders. 1
Surgical Options (If Conservative Management Fails)
For isolated symptomatic rectocele requiring surgery:
- Transvaginal repair with autologous tissue is preferred over transanal approaches for isolated rectocele. 5 Transvaginal repair is more effective than transanal repair in preventing recurrence based on both objective and subjective measures. 6
- Transanal approaches (including STARR) have higher recurrence rates (RR 4.12,95% CI 1.56 to 10.88) and increased postoperative obstructed defecation (RR 1.67,95% CI 1.00 to 2.79) compared to transvaginal repair. 6
- Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders, and can be performed open or laparoscopically. 1
Mesh Considerations
Evidence does not support the routine use of mesh or graft materials at the time of posterior vaginal repair. 6 Biological grafts have higher postoperative complication rates (RR 1.82,95% CI 1.22 to 2.72) without clear benefit in reducing recurrence. 6 Synthetic mesh has a 7% exposure rate. 6
Important Clinical Considerations
- STARR can reduce rectocele size (average reduction from 3.8 cm to 1.9 cm), with 82% of patients reporting >50% reduction in obstructed defecation scores at one year. 1
- Long-term outcomes of STARR are disappointing despite initial improvement, with variable success rates. 1
- Rare but serious complications after STARR include fistula, peritonitis, and bowel perforation, with higher risk of infection, pain, incontinence, and bleeding. 1