1. The Forgotten Posterior Pelvic Floor; Rectocele Repair, Perineoplasty, & Defecatory Dysfunction
Mickey Karram M.D. Director of Urogynecology The Christ Hospital Professor of Ob/Gyn & Urology University of Cincinnati

2. ANATOMY OF THE POSTERIOR VAGINAL WALL
RECTOVAGINAL SEPTUM???
WHAT IS FASCIA???
DOES IT TRULY EXTEND FROM SACRUM TO PERINEUM???
IS RICHARDSON’S CLASSIFICATION OF DEFECTS CLINICALLY APPLICABLE???

4. Anatomy of Posterior Wall

5. GOALS OF RECTOCELE REPAIR
PROVIDE DURABLE SUPPORT FROM POSTERIOR FOURCHETTE TO POSTERIOR VAGINAL FORNIX
Identfy and correct enterocele if present
Rebuild Perineum and correct Anal Sphincter if appropriate
Narrow vaginal calibar if needed

6. POSTERIOR VAGINAL COMPARTMENT DEFECTS
KEYS TO SURGICAL SUCCESS
Avoid Distortion Of Vaginal Access
Avoid Vaginal Constriction
Appropriate Use Of Levatoroplasty
Appropriate Use Of Perineorraphy
Defect Specific Repairs
Tight Repairs In Sexually Inactive Women

7. POSTERIOR VAGINAL COMPARTMENT
SURGICAL CHALLENGES
High Recurrent Rectocele
Large Symptomatic Rectocele With A Foreshortened Vagina
The Entercele That You Can’t find
Recurrent Cystocele And Rectocele

8. PROLAPSE SYMPTOMS THAT MAY COEXIST WITH RECTOCELES
Pelvic Pressure and Tissue Protrusion
Feeling of a Gaping Introitus
Sexual Dysfunction

9. DEFECATORY DYSFUNCTION THAT MAY COEXIST WITH RECTOCELES
Fecal Incontinence
Paradoxical Sphincter Reaction
Fecal Urgency
Stool Clustering
OUTLET OBSTRUCTION

10. EVALUATION OF RECTOCELES
CLINICAL
Imaging
Radiographic
Electrophysiologic
Endoscopic
Transit Studies

12. SURGICAL APPROACHES TO RECTOCELE
Gynecologist
Traditional
Defect-Specific
Colorectal Surgeon
Transrectal Repair

13. SEXUAL DYSFUNCTION AFTER TRADITIONAL POSTERIOR COLPORRAPHY
Francis + Jeffcoate (1961) 50%
Kahn + Stanton (1997) 18% To 27%
Paraiso et al. (2001) Worsening Dysparaenia

14. POSTERIOR COLPORRHAPHY: ITS EFFECTS ON BOWEL AND SEXUAL FUNCTION
Kahn & Stanton: Br J Obstet Gynecol 1997, 104: 82-86
Levatorplasty Performed On 231 Patients
Vaginal Defects Corrected In 76%
Worsening Of Bowel And Sexual Function

22. Posterior; Sutton

23. Clip 3

24. POSTERIOR COMPARTMENT DEFECTS
CASE
A.S. is a 51 yr old nulliparous female with 5 yr hx of difficulty evacuating bowels; symptom’s onset with abd hyst for severe endometriosis. O/E small rectocele and cystocele. Defcography showed rectocele 2.5 cm on straining to 3.7 cm on evacuation, also enterocele seen. All other colorectal evaluation normal

25. Posterior/enterocele; andrea

26. POSTERIOR COMPARTMENT DEFECTS
CASE 77 yr old with complete procidentia and vaginal eversion Has significant bowel dysfunction with difficulty evacuating her stools as well as mild fecal incontinence. Desires to maintain a functional vagina

27. Complete Procidentia (1)

28. TREATMENT OF RECTOCELE
CONCLUSIONS
Correlation between anatomic defect and functional derangement is poor to non-existent
Enteroceles need to be routinely looked for when correcting rectoceles
Unsure of clinical utility of colorectal testing prior to rectocele repair