Rectocele Repair: Avoiding Posterior Pitfalls

The pelvic floor is a complex mechanical construct with multiple compartments expected to work in synergy to provide optimal function. Patients being evaluated for rectocele by urogynecologist should also undergo thorough history and physical to identify pelvic floor dysfunction as this concurrent diagnosis may affect postoperative results of any rectocele repair.

Pelvic floor dysfunction is a broad term that includes paradoxical contraction, puborectalis nonrelaxation (hypertonic pelvic floor), and levator spasm, all of which can contribute to or present as obstructive defecation, and pelvic pain. Pertinent history should be obtained including general pelvic pain or pressure, urologic, gynecologic, and defecatory symptoms. Specifically, in regard to defecation, patients should be asked about difficulty or straining to evacuate stool, splinting (assistant maneuvers such as pressure on the vagina or abdomen), bloating, fecal incontinence, and tissue prolapse. Anorectal exam initially should be performed in the lateral decubitus or jack-knife prone position with visualization for prolapse. On digital exam, the anal sphincter tone is first assessed then the patient should be asked to simulate defecation which should result in relaxation of the pelvic floor; increased tone with simulated defecation is indicative of paradoxical contraction whereas no change may indicate nonrelaxation. Manual palpation of the levator circumferentially should then be performed; pain elicited during this maneuver is consistent with levator spasm. Adjunct testing in evaluation of rectocele and pelvic floor dysfunction can be enhanced with defecography and anal manometry exams, though access to advanced testing may be limited.

If pelvic floor dysfunction is identified and characterized, the patient should be counseled on addressing this prior to or concurrently with rectocele repair. The first line treatment is biofeedback or pelvic floor therapy. When this fails, botulinum toxin injection or pain management modalities can be considered, usually after referral to a colorectal surgery specialist to further investigate underlying pelvic floor dysfunction and rule out concurrent pathologies.