What are the treatment options for rectocele?

Treatment Options for Rectocele

Conservative management with pelvic floor biofeedback therapy should be the first-line treatment for symptomatic rectocele, with surgical intervention reserved for patients who fail conservative measures. 1

Initial Conservative Management

Pelvic floor biofeedback therapy is the recommended initial approach to correct underlying pelvic floor dysfunction in patients with rectocele 1. This behavioral retraining can provide:

• Major symptom relief in approximately 16% of patients and partial improvement in 56% of patients with large rectoceles (>2 cm) 2
• Significant normalization of bowel frequency and reduction in straining, incomplete evacuation, and need for digital assistance 2
• Reasonable first-line treatment before considering surgical options, even in patients with large rectoceles 2

Additional conservative measures include:

• Bowel modifying agents (stool softeners, fiber supplementation) 3
• Pessaries for anatomical support 4
• Medical management with emphasis on suppositories and enemas when biofeedback fails 5

Surgical Intervention Indications

Surgery should be considered only after failure of conservative treatment, based on:

• Intensity of symptoms and deterioration in quality of life 6
• Symptomatic grade 3-4 rectocele that does not respond to conservative management 1
• Presence of large rectoceles (>4 cm) with persistent obstructive defecation symptoms 3

Surgical Approach Selection Algorithm

The surgical approach depends on rectocele location and associated pelvic floor disorders 1, 6:

For Low or Mid Rectum Isolated Rectoceles:

Transanal approach (including STARR procedure):

• Excludes redundant rectal mucosa associated with rectocele 1
• Reduces rectocele size from average 3.8 cm to 1.9 cm 1
• Achieves >50% reduction in obstructed defecation scores in 82% of patients at one year 1
• Critical caveat: Long-term outcomes are somewhat disappointing despite initial improvement 1
• Serious complications include fistula, peritonitis, bowel perforation, infection, pain, incontinence, and bleeding 1

Alternative transperineal or transvaginal approaches:

• Anatomic success rates are high (67-78% good outcomes) 3
• Symptoms of difficult defecation improve in 30-50% of patients 3
• Recurrent rectocele occurs in 17% at 2 years post-surgery 3

For High Rectoceles or Associated Pelvic Floor Disorders:

Ventral rectopexy (open or laparoscopic):

• Recommended for high rectoceles or those with other pelvic floor disorders (cystocele, uterine prolapse) 1, 6
• Approach selection based on patient age, comorbidities, and surgeon expertise 1
• Perineal procedures generally have shorter recovery periods, making them preferable for elderly patients or those with significant comorbidities 7

Critical Pitfalls and Caveats

The correlation between symptom improvement and anatomical correction is often weak 1. This is the most important consideration when counseling patients:

• Anatomical abnormalities may be caused by underlying functional disorders that are not corrected by surgery 1
• Successful anatomic repair does not guarantee symptom resolution 1, 3
• Rectoceles may be secondary to pelvic floor dysfunction rather than the primary cause of symptoms 3

Patient selection is paramount:

• Careful evaluation to determine if symptoms are truly from the rectocele versus underlying pelvic floor dysfunction 3
• Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on surgical management 6
• Multidisciplinary assessment by colorectal and urogynecologic surgeons may optimize outcomes 3

Post-Operative Monitoring

Common complications requiring surveillance include:

• Post-operative pain affecting return to normal activities 1
• Infection, bleeding, and incontinence 1
• Recovery typically ranges 4-6 weeks with variations depending on surgical approach 7