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Director, The Center for Urogynecology of Saint Barnabas Medical
Center
Pelvic organ prolapse is a prevalent condition involving a relaxation
or defect of pelvic organ support and may involve a dropped bladder,
rectum, uterus or vagina. It is estimated that 11 percent of American
women will require surgery for either prolapse or incontinence.
A rectocele is a form of pelvic organ prolapse in which there is
a herniation or bulging of the posterior vaginal wall. Childbirth
is a known risk factor which can result in stretching and tearing
of the support structures of the pelvic floor as well as damaging
the nerves that innervate these muscles. Other risk factors include
chronic constipation, postmenopausal status and connective tissue
disorders.
Common symptoms include the feeling of a bulge or mass in the vagina,
pressure or heaviness in the vagina that is typically worse at the
end of the day, and symptoms of defecatory dysfunction, including
incomplete rectal emptying or stool trapping, the need to manually
compress the vagina or perineum to complete a bowel movement, as
well as constipation. The diagnosis is confirmed in the office by
an examination of the vaginal support using a half speculum.
Only rectoceles that are symptomatic require treatment. A pessary
is a vaginal prosthesis that comes in different shapes and sizes
and is a good option to temporize symptoms for patients who may not
wish to have surgery or are high surgical risks. A pessary should
fit comfortably and needs to be removed and cleaned every 2 to 3
months. Topical estrogen may also be beneficial for menopausal patients.
The treatment for fixing rectoceles, however, is surgical. The
goals of surgery are to relieve symptoms, to restore anatomy, and
to restore normal bowel and sexual function. The surgery of choice
that I utilize involves a defect specific rectocele repair. This
is done vaginally and involves only fixing identified tears or breaks
in the connective tissue support of the posterior vagina. The procedure
can safely be performed under general anesthesia or with intravenous
sedation and local anesthesia.
In reviewing the literature, recurrence rates vary from 18-23 percent
with a mean follow-up between 12-18 months. For patients who present
with recurrent rectoceles or for those with little or no supportive
tissue to use in the repair, the use of mesh or an outside material
has been suggested as a means to improve the strength of the repair.
Over the last several decades a better understanding of the anatomic
relationships of the pelvic floor and posterior vaginal wall has
altered the way we approach rectoceles, which has resulted in improved
anatomic and functional outcomes for patients.
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