To which specialty should a patient with fatty dissection of the rectovaginal septum and peritoneocele be referred?

Specialty Referral for Fatty Dissection of Rectovaginal Septum and Peritoneocele

Patients with fatty dissection of the rectovaginal septum and peritoneocele should be referred to a urogynecologist or colorectal surgeon with expertise in pelvic floor disorders, as these conditions represent complex posterior and middle compartment pelvic floor dysfunction requiring specialized surgical evaluation and management. 1

Rationale for Specialty Selection

Urogynecology as Primary Referral

• Urogynecologists specialize in comprehensive multicompartment pelvic floor dysfunction, including peritoneoceles and rectovaginal septum abnormalities, which fall within their core expertise 2, 3
• These specialists routinely manage middle and posterior compartment prolapse, with MR defecography showing 63% agreement with physical examination for middle compartment and 79% for posterior compartment abnormalities 1
• Peritoneoceles specifically represent herniation of the peritoneal sac into the rectovaginal space, a condition that urogynecologists are trained to diagnose and surgically repair 4, 5

Colorectal Surgery as Alternative or Co-Management

• Colorectal surgeons with pelvic floor expertise can manage posterior compartment defects, particularly when there is associated rectal dysfunction or defecatory disorders 1, 3
• The rectovaginal space contains loose areolar tissue without a distinct independent septum, making surgical dissection in this area require specialized anatomical knowledge 6
• Colorectal surgeons may be preferred when peritoneoceles are associated with rectoceles, rectal intussusception, or other anorectal pathology 1

Multidisciplinary Approach Considerations

When to Involve Multiple Specialists

• The Pelvic Floor Disorders Consortium recommends multidisciplinary collaboration between colorectal surgeons, urogynecologists, and radiologists for complex pelvic floor conditions 3
• Peritoneoceles can be classified as rectal, septal, or vaginal types, and may occur in combination, requiring expertise from different surgical specialties 5
• MR defecography demonstrates moderate to good correlation with surgical findings for peritoneocele detection, making pre-referral imaging valuable for surgical planning 1

Diagnostic Imaging Before Referral

Essential Pre-Referral Workup

• MR defecography is the imaging test of choice for comprehensive anatomic and functional evaluation of peritoneoceles and rectovaginal septum abnormalities 1
• Imaging should include rectal contrast and defecation phase acquisition, as peritoneoceles are best visualized at the end of defecation upon complete rectal emptying 1
• Defecoperitoneography (simultaneous defecography and peritoneography) can definitively diagnose peritoneoceles when standard defecography shows unexplained widening of the rectovaginal space 5

Clinical Pitfalls to Avoid

• Physical examination alone misses 70% of enteroceles detected on MR defecography and misdiagnoses 10% of enteroceles as rectoceles, making imaging essential before referral 1
• Not all widening of the rectovaginal space represents peritoneocele—only 64% (14/22) of cases with unexplained widening were completely due to peritoneocele in one study 5
• Fatty dissection of the rectovaginal septum may represent age-related degeneration rather than acute pathology requiring urgent intervention 6

Timing and Urgency of Referral

Non-Emergent Referral Pathway

• These conditions are typically managed electively unless there are signs of incarceration, strangulation, or acute obstruction 1
• Conservative management with pelvic floor biofeedback therapy should be considered first for symptomatic patients before surgical referral, as it may improve symptoms in 33% of cases 1
• Referral should be expedited if patients report progressive symptoms, vaginal bulging requiring manual reduction, or significant impact on quality of life 1