What are the treatment options for a rectocele?

Treatment of 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 and have significant quality of life impairment. 1

Initial Conservative Management

• Pelvic floor biofeedback therapy is the primary conservative treatment to correct underlying pelvic floor dysfunction in patients with rectocele 1
• Medical management includes fiber supplementation, bulking laxatives, rectal irrigation, and suppositories/enemas when biofeedback fails 1, 2
• Conservative measures are effective in approximately 80% of patients, with only 20% requiring surgical intervention 2
• Treatment should address the "iceberg syndrome" concept—visible anatomical defects (rectocele) plus underlying functional disorders (anismus, rectal hyposensation, anxiety/depression) that require conservative rather than surgical management 2

Indications for Surgical Intervention

Surgery should be considered only after failure of conservative management and when symptoms significantly impair quality of life 1, 3

Key surgical indications include:

• Symptomatic rectoceles (typically >3 cm) causing obstructed defecation requiring digital disimpaction maneuvers 3, 4
• Grade 3-4 rectal prolapse associated with rectocele 1
• Persistent symptoms of pelvic heaviness, anal incontinence, or dyspareunia despite conservative therapy 3

Surgical Approach Selection Algorithm

The surgical approach should be determined by rectocele location and associated pelvic floor disorders 1, 3:

For Low or Mid Rectocele (Isolated)

• Transanal approach including Stapled Transanal Rectal Resection (STARR) is appropriate 1, 3
• STARR effectively reduces 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 1
• STARR shows superior symptom improvement compared to posterior colporrhaphy for obstructed defecation syndrome 4

For High Rectocele or Multiple Pelvic Floor Disorders

• Ventral rectopexy (laparoscopic or open) is the recommended approach 1, 2
• Laparoscopic ventral sacral colporectopexy is an effective surgical option for complex cases 2
• The choice between open or laparoscopic technique should be based on patient characteristics and surgeon expertise 1

Alternative Approaches

• Transvaginal posterior colporrhaphy can be considered, particularly for larger rectoceles (>5 cm) 4
• Transperineal approach is an option for isolated low rectoceles 3

Critical Pitfalls and Caveats

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

• Anatomical abnormalities may be caused by underlying functional disorders that surgery does not correct 1
• Long-term outcomes of STARR are somewhat disappointing despite initial improvement 1
• Successful anatomic repair rates are high, but functional outcomes are more variable 5
• Recurrent rectocele occurs in approximately 17% of patients 2 years after surgery 6

Complications to Monitor

STARR carries rare but serious complications that require careful patient counseling 1:

• Fistula formation, peritonitis, and bowel perforation (rare but serious) 1
• More common complications include infection, pain, incontinence, and bleeding 1
• Post-operative pain is common after rectocele repair 1

Transtar procedure appears safer than STARR when dealing with recto-rectal intussusception 2

Patient Selection Considerations

• Age, comorbidities, and associated pelvic floor disorders must guide surgical approach selection 1
• Patients should undergo dynamic imaging (defecography) and anorectal manometry before surgical decision-making 3
• A multidisciplinary approach involving colorectal and urogynecologic surgeons provides optimal results 2, 6
• Careful patient selection and realistic counseling about the weak correlation between anatomical correction and symptom relief is essential 1