What are the treatment options for a postmenopausal woman with a history of vaginal childbirth and a rectocele (rectal prolapse of the posterior vaginal wall)?

Treatment of Posterior Vaginal Wall Prolapse (Rectocele)

Begin with conservative management including pelvic floor biofeedback therapy, which should be attempted before considering any surgical intervention for symptomatic rectocele. 1, 2

Initial Conservative Management

• Start with conservative measures including dietary modifications, fluid management, bowel training programs, and management of constipation or diarrhea with medications if necessary 1
• Pelvic floor biofeedback therapy is the treatment of choice for defecatory disorders associated with rectocele and should be implemented when initial conservative measures fail 1, 2
• Approximately 25% of patients will benefit from conservative therapies alone 1
• Medical management with suppositories and enemas can be considered when biofeedback therapy fails 2

When to Consider Surgery

Surgery should only be considered after failure of conservative therapy and in patients with symptomatic grade 3-4 prolapse or rectoceles causing significant quality of life impairment. 1, 2

Critical Caveat

• The correlation between symptom improvement and anatomical correction is often weak - anatomical abnormalities may be caused by underlying functional disorders that surgery does not correct 2
• Many patients undergo surgery without a rigorous trial of conservative therapy, which should be avoided 1

Surgical Approach Selection Algorithm

For Low or Mid Rectocele (Isolated)

• Transanal approaches including Stapled Transanal Rectal Resection (STARR) can be considered 2, 3
• STARR effectively reduces 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 2
• However, STARR should NOT be routinely performed due to disappointing long-term outcomes and significant complication risks 1, 2

For High Rectocele or Multiple Pelvic Floor Disorders

• Ventral rectopexy (transabdominal approach) is the recommended surgical approach for high rectoceles or those associated with other pelvic floor disorders such as cystoceles, enteroceles, and vaginal vault prolapse 2, 4, 3
• Can be performed open or laparoscopically based on patient characteristics and surgeon expertise 2
• Laparoscopic rectopexy is associated with fewer post-operative complications and shorter hospital stay than open rectopexy 1

For Elderly or High-Risk Patients

• Perineal approach is preferred for elderly patients, those with significant medical comorbidities, or contraindications for abdominal surgery 1
• Perineal procedures have lower perioperative morbidity but higher recurrence rates (5-21%) compared to transabdominal rectopexy (0-8%) 1

Important Complications to Counsel Patients About

STARR Complications

• Common complications (up to 15% of patients): infection, pain, incontinence, and bleeding 4
• Rare but serious complications: fistula, peritonitis, and bowel perforation 2, 4

Rectopexy Complications

• After posterior rectopexy, 50% of patients develop severe constipation 1
• Bowel resection should be avoided in patients with preexisting diarrhea and/or incontinence as these symptoms may worsen 1

Multidisciplinary Approach

A collaborative approach between gynecologists and colorectal surgeons is ideal, particularly for complex cases with multiple pelvic floor disorders 4

• This allows for comprehensive evaluation of pelvic floor disorders and optimal choice of surgical approach 4
• Pouch of Douglas protrusion is best addressed with sacrocolpopexy, usually performed in conjunction with other gynecologic procedures 1

Key Pitfall to Avoid

Surgery is necessary in less than 5% of patients with defecatory disorders - the vast majority should be managed conservatively with biofeedback therapy 1