Consultant Colorectal Surgeon Colorectal Cancer Rectocele Mr D.Kumar PhD FRCS Consultant Colorectal Surgeon St George’s NHS Trust

Rectocele Prolapse of the anterior rectal and posterior vaginal wall into the lumen of the vagina

Rectocele Anatomy Female equivalent of Denonvillier’s fascia - rectovaginal septum Separates the rectal(dorsal) compartment from the urogenital (ventral) compartment Rectovaginal septum and uterosacral ligaments provide suspensory support to the perineal body Further supported by the levator muscles

Rectocele Aetiology Obstetric trauma – due to alteration in the functional and anatomical position of muscles Pathological stretching of pudendal nerves during descent of the foetal head – denervation of the pelvic floor muscles Persistent straining at stool

Rectocele Clinical presentation Constipation (incomplete emptying) –75% of patients Vaginal bulge Sense of rectal pressure Rectal/low back pain Bleeding Dyspareunia Vaginal digitation/perineal support Majority totally asymptomatic

Rectocele Classification Low Middle High Middle and high rectoceles often associated with cystoceles and enteroceles

Rectocele Evaluation History Examination Defaecography Barium Isotope Endoanal U/S Pudendal nerve motor latency/manometry

Rectocele Management Conservative Operative

Rectocele Conservative management Bowel training Oestrogen replacement therapy – post menopausal Vaginal pessary

Rectocele Surgery Vaginal - Posterior Colporrhaphy (levatorplasty) - Defect specific

Rectocele Surgery Transanal

Results Vaginal Transanal Arnold et al 1990 – 50% still sympotomatic Watson et al 1996 – removed the need to digitate in most patients Murthy et al 1996 – excellent results (strict criteria) Transanal Sullivan et al 1968 – 97.5% success Shapayak 1985 – 98% improvement Jarsen’s et al 1994 – 92% success Mellgren et al 1995 – 88% - complete resolution 52%

Rectocele Transanal 138 patients – symptomatic rectocele 58 had significant rectocele 45 decided to have surgery Mean age -57 years Duration of symptoms -52 months Median follow-up -24 months

Rectocele Functional Outcome Symptom Presurgery Post surgery p* Straining 40/45 16/45 p< 0.001 Incomplete evacuation 40/45 27/45 p< 0.001 Vaginal digitation 28/45 6/45 p< 0.001 Perineal digitation 22/45 10/45 p= 0.004 Incontinence (Grades 3/4) 9/45 7/45 p= 0.688 Dyspareunia 11/45 3/45 p= 0.020 Vaginal bulging 43/45 10/45 p< 0.001 * McNemar test Grade 1 normal incontinence, 2 incontinent to flatus, 3 incontinent to liquid stool, 4 incontinent to solid stool Heriot et al 2004

Rectocele Anorectal physiology assessment Symptom Presurgery Post surgery p** mean (SD) mean (SD) Resting anal 80(23) 76(29) 0.0370 pressure (cm H20) Squeeze anal 136(42) 141( 40) 0.911 Anorectal reflex present 5/17 7/17 0.050* Threshold volume (cc) 51(23) 41(19) 0.025 Max. volume (cc) 204(87) 201(78) 0.619 ** Wilcoxons signed rank test * McNemar test Heriot et al 2004

Rectocele Comparison of PC vs TA 70 patients RCT- 40TA, 30PC Matched for age, symptoms, % retention Bowel Sx significantly better in the TA (p<0.01) Bleeding significantly less in TA (p<0.01) Analgesic requirement less in TA (p<0.02) Dyspareunia worse in PC (p<0.001) (Kahn et al 2001,unpublished)

Rectocele Complications Infection Bleeding Dyspareunia Recto –vaginal fistula

Summary Rectoceles are common Only a small % symptomatic Even a smaller percentage clinically significant Proper evaluation essential Patients with a vaginal bulge as the main symptom should have post. Colporrhaphy Those with bowel symptoms-transanal repair