Rectocele Repair

Introduction to Procedure

We know that undergoing any procedure is a scary experience. We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd. We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

A rectocele is the result of a defect in the rectovaginal septum (a tough fibrous layer), which separates the vagina (anteriorly) from the rectum (posteriorly). This defect results in the protrusion of the rectum into the vagina and the resultant symptoms.

The primary indication for repair of a rectocele is obstructive defecation with objective evidence of faecal trapping demonstrated through a defecating proctogram. Other indications include a subjective sensation of “pressure” in the vagina and a feeling of incomplete evacuation post-defecation. This may progress to difficult or painful defecation or sexual intercourse, constipation, incontinence, vaginal bleeding, and even prolapse of the bulge through the opening of the vagina.

Various approaches are employed in the repair of a rectocele including posterior colporrhaphy, trans-anal and transperineally.

Operative techniques

Trans-anal Rectocele Repair: The procedure is performed under general anaesthesia. An incision is generally made just proximal to the dentate line, the redundant rectal mucosa is either removed or plicated and the rectal submucosa and mucosa are closed in separate layers.

Trans-perineal Rectocele Repair: This approach is also performed under general anaesthesia. The recto-vaginal septum is repaired through an incision in the perineum and a decision whether or not to use a prosthetic mesh is made.

Additional procedures that may become necessary

Cystocoele repair
Suprapubic catheter insertion
Pelvic floor reconstruction
Defunctioning colostomy / ileostomy

Benefits

Therapeutic: Symptomatic improvement from rectocoele (e.g. constipation, incontinence, painful vaginal bulge, painful intercourse, vaginal bleeding).

Alternative procedures/conservative measures

Conservative: Pelvic floor strengthening exercises should be advised.
Biofeedback devices.
Vaginal pessaries.
Transvaginal / transcutaneous electrical stimulation to allow muscle contraction.

Serious/frequently occurring risks

Trans-anal rectocele repair: Bleeding, infection 3.3%, incomplete evacuation, faecal impaction, faecal incontinence, recto-vaginal fistula, dyspareunia, sexual dysfunction, failure of procedure, recurrence.
Trans-perineal rectocoele repair: Anatomical cure 89.2%, bleeding 3.6%, infection 4.8%, incomplete evacuation, faecal impaction, faecal incontinence, recto-vaginal fistula, dyspareunia, sexual dysfunction, failure of procedure, recurrence, if a mesh is used there is potential for mesh erosion and infection.

Blood transfusion necessary

Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions in emergency situations.

Type of anaesthesia/sedation

General anaesthesia.

Follow-up or need for further procedure

Monitor patient in hospital until patient passes urine and faeces prior to discharge.
Symptomatic review in outpatient clinic.