Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era

Abstract

Background More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2–4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. Purpose We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%–78%), symptoms of difficult defecation improved (30%–50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

The influence of defaecating proctograms on clinical decision‐making in pelvic floor disorders

“…DP is recommended in the routine work‐up of patients with pelvic floor disorders [12–14]. The cause of faecal incontinence in patients may not be obvious on routine work‐up, and DP can reveal occult pelvic floor disorders.…”

“…While there was a trend towards performing more surgery as a result of DP findings, it is important to remember, that expert recommendations are to trial conservative management of bowel symptoms prior to surgery [18,19]. Therefore, DP findings should be contextualized with modern-day best practice whereby surgery is reserved for patients whose symptoms are secondary to confirmed rectocele and refractory to conservative approaches [14].…”

Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation

“…Retaining rectocele refers to rectocele containing the contrast material on images obtained immediately after defecation (12). The Oxford grading system was used for the description of RI as shown in Figure 1.…”