What is the management approach for a patient with fatty dissection of the rectovaginal septum concerning for peritoneocele during evacuation?

Management of Fatty Dissection of the Rectovaginal Septum with Peritoneocele During Evacuation

Conservative management with pelvic floor biofeedback therapy is the first-line treatment for peritoneocele associated with defecatory disorders, as this addresses the underlying pelvic floor dysfunction that causes these anatomic abnormalities. 1

Initial Assessment and Diagnostic Approach

The finding of fatty dissection of the rectovaginal septum concerning for peritoneocele represents a herniation of the peritoneal sac (pouch of Douglas) into the rectovaginal space, which may or may not contain bowel (enterocele). 2

Key diagnostic considerations:

• Peritoneocele can present as an unexplained widening of the rectovaginal space on defecography, and may exist with or without actual bowel herniation (enterocele). 2
• Three anatomic types exist: vaginal, septal, and rectal peritoneoceles, which can occur in combination. 2
• Peritoneoceles are commonly associated with rectal intussusception—all patients with rectal intussusception or prolapse demonstrate a rectal peritoneocele in the serosal ring-pocket. 2
• The peritoneocele may disappear or reduce significantly when the rectum is distended with contrast, so imaging should include views before rectal filling to capture the "daily life" anatomy. 2

Conservative Management (First-Line Treatment)

Pelvic floor biofeedback therapy should be initiated as the primary treatment to correct the underlying pelvic floor dysfunction that causes these structural abnormalities. 1

• Biofeedback therapy is the treatment of choice for defecatory disorders, as anatomic abnormalities like peritoneocele often result from excessive straining and impaired pelvic floor relaxation. 3
• The structural defects are frequently a consequence rather than a cause of the functional disorder, which explains why surgical correction of anatomy does not reliably improve symptoms. 3

Indications for Surgical Intervention

Surgery should be considered only after failure of conservative management for at least 3 months, and specifically when:

• Symptomatic peritoneocele with pelvic discomfort (feelings of prolapse, pelvic pressure, lower abdominal pain, false urge to defecate) that persists despite biofeedback therapy. 4
• Large rectoceles (>3 cm) with symptomatic obstructed defecation that fail conservative management, particularly when patients require vaginal digitation for defecation. 1, 5
• Associated rectal prolapse or intussusception with hemodynamic instability, signs of peritonitis, or bowel ischemia/perforation. 3, 6

Surgical Approach Selection

When surgery is indicated, the approach depends on the specific anatomic findings:

For Peritoneocele Without Significant Rectocele:

• Obliteration of the pelvic inlet with mesh effectively treats pelvic discomfort symptoms in patients with symptomatic enterocele. 4
• This approach eliminates symptoms of pelvic discomfort in the majority of patients, though it does not improve obstructed defecation symptoms. 4

For Peritoneocele With Significant Rectocele:

• Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders, and can be performed open or laparoscopically based on patient age, comorbidities, and surgeon expertise. 1
• Stapled Transanal Rectal Resection (STARR) may be considered for symptomatic rectoceles with intussusception, reducing rectocele size from an average of 3.8 cm to 1.9 cm. 1, 5
• The transvaginal approach (posterior colporrhaphy) is effective for larger rectoceles (mean 5.3 cm), reducing size to 3.1 cm postoperatively. 5

Critical Pitfalls and Caveats

The correlation between symptom improvement and anatomical correction is often weak—symptoms may persist despite anatomic repair, or improve without complete correction. 3, 1

• Anatomic abnormalities are frequently caused by the underlying functional disorder (impaired pelvic floor relaxation and excessive straining), which surgical repair does not address. 3
• Long-term outcomes after STARR are "somewhat disappointing" despite initial improvement, with 15% experiencing adverse events including infection, pain, incontinence, and bleeding. 3, 1
• Rare but serious complications include fistula, peritonitis, and bowel perforation. 3, 1
• Posterior rectopexy can cause severe constipation in up to 50% of patients. 6

Obstructed defecation symptoms are unlikely to improve with peritoneocele repair alone—all patients with evacuation difficulties in one series had persistent symptoms after enterocele repair. 4

Management Algorithm

1. Confirm diagnosis with defecography showing widening of rectovaginal space; consider advanced imaging if unclear. 2
2. Initiate pelvic floor biofeedback therapy for minimum 3 months. 1
3. Reassess symptoms after conservative management:
   • If pelvic discomfort persists without significant rectocele: consider pelvic inlet obliteration. 4
   • If symptomatic rectocele >3 cm persists: consider STARR or ventral rectopexy based on anatomy. 1, 5
   • If obstructed defecation persists without structural abnormality: continue conservative management as surgery is unlikely to help. 4
4. Emergency surgery only if complicated by prolapse with ischemia, perforation, or hemodynamic instability. 3, 6