Rectocel Cundiff and Fenenr

CLINICAL EXPERT SERIES

Evaluation and Treatment of Women With Rectocele:Focus on Associated Defecatory and SexualDysfunction

Geoffrey W. Cundiff, MD, and Dee Fenner, MD

Pelvic organ prolapse is a common and growing conditionfor which women seek help and frequently undergo surgi-cal management. Prolapse of the posterior vaginal wall,alone or in combination with other compartment defects,can be a challenge for the pelvic surgeon. A clear under-standing of the normal anatomy, interactions of the con-nective tissue and muscular supports of the pelvis, and therelationship or lack of relationship between anatomy andfunction is required. Vaginal support defects occur withand without symptoms, and many of the symptoms attrib-uted to pelvic organ prolapse can result from other causes.Pelvic pressure, the need to splint the perineum to defecate,impaired sexual relations, difficult defecation, and fecalincontinence are some of the symptoms that have beencorrelated with rectoceles. Whether the prolapse is thecause of these symptoms or is a result of straining andstretching of support tissues in women with defecationdisorders is still unknown. We will present the currentliterature on these relationships and what evaluations areuseful when caring for a woman with a rectocele anddefecation disorders. Either pessaries or surgery can beused for treating rectoceles. Several surgical techniqueshave been described, including transvaginal, transanal,abdominal, and the use of graft materials to treat bothanatomical defects and functional symptoms. The success,rationale, and complications of each approach, includinganatomic cure, impact on defecation, and sexual function,are presented. (Obstet Gynecol 2004;104:1403–21.© 2004 by The American College of Obstetricians andGynecologists.)

Pelvic organ prolapse is the indication for more than300,000 surgeries in the United States annually, at aprice tag of more than $1 billion.1Moreover, the numberof women seeking care for disorders of the pelvic floorare predicted to increase by 45% in the near future,suggesting that the evaluation and treatment of thesedisorders will dominate a large portion of gynecologiccare in the coming years.2

Recent studies provide insights into the epidemiologyof pelvic organ prolapse, but significant gaps remain.Among studies of ambulatory women, the prevalence ofpelvic organ prolapse varies widely from 30% to 93%.3–6

Some of the variation reflects methodological differ-ences, but there are other factors that affect the reportedprevalence too. One is the heterogeneous nature ofpelvic support defects. Pelvic organ prolapse includessupport defects of the vaginal apex, anterior wall, andposterior wall, although most patients have support de-fects at multiple locations. Among ambulatory women,most pelvic organ prolapse is mild, remaining inside thevagina, with pelvic organ prolapse beyond the vaginalintroitus being found in fewer than 5% of cases.4 Lastly,reporting anatomical defects alone fails to account for thefact that pelvic support defects can be quite symptomaticin some women, yet minimally symptomatic in others.Although there is a paucity of data to describe asymp-tomatic pelvic organ prolapse, there is better data todefine the prevalence of symptomatic pelvic organ pro-lapse. Olsen et al7 defined symptoms in terms of care-seeking by investigating women seeking surgery forpelvic organ prolapse or urinary incontinence. In anintegrated health care program serving 149,544 women,there was an 11.1% lifetime risk for surgery for pelvicorgan prolapse or urinary incontinence. Importantly, thereoperation rate in this cohort was 29.9%, suggestingthat our surgical interventions are not always optimal.Another suggestion of less than optimal effectiveness forsurgical intervention is the number of techniques advo-cated for treatment. Surgical procedures for posteriorpelvic organ prolapse are a good example. There aremultiple techniques from multiple surgical approachespresently in use, each with its own advocates, yet thereare no direct comparisons to define if one repair issuperior overall or even more appropriate for specificpopulations of patients. The literature on the treatmentof posterior pelvic organ prolapse is predominantly com-prised of retrospective case series, frequently with smallsample sizes. Outcome measures are inconsistent, which

From Johns Hopkins Medicine, Baltimore, Maryland; and University of Michi-gan, Ann Arbor, Michigan.

VOL. 104, NO. 6, DECEMBER 20041403© 2004 by The American College of Obstetricians and Gynecologists. 0029-7844/04/$30.00

Published by Lippincott Williams & Wilkins. doi:10.1097/01.AOG.0000147598.50638.15

complicates information synthesis. In this article we willpresent the available data, noting shortcomings, to helpthe pelvic surgeon treating posterior pelvic organ pro-lapse.The pelvic surgeon who provides optimal care forpelvic organ prolapse must recognize the heterogenousnature of pelvic organ prolapse, accounting not only forsupport defects in different compartments, but also di-recting treatment to relieving symptoms attributable tospecific support defects. The symptoms commonly at-tributed to posterior pelvic organ prolapse include her-niation symptoms, defecatory dysfunction, and sexualdysfunction. Predicting which patients will have reliefdepends on a thorough understanding of the anatomy ofthe support of the posterior wall as well as the differentialdiagnosis of defecatory dysfunction and sexual dysfunc-tion.

POSTERIOR VAGINAL WALL ANATOMY

The anatomy of the posterior vaginal wall cannot beclearly conceptualized separately from the anatomicalsupports of the rest of the vagina. Moreover, it is essen-tial to understand that vaginal support arises from inter-actions between the pelvic musculature and connectivetissue.The muscular support results from the pelvic dia-phragm, a group of paired muscles including the levatorani and coccygeus (ischiococcygeus) muscles. The leva-tor ani are subdivided, from medial to lateral, into thepuborectalis, pubococcygeus, and ileococcygeus mus-cles. These muscles originate from the pubic rami oneither side of the midline at the level of the arcus tendi-neus levator ani. The muscle fibers pass laterally to thevagina and rectum creating a U-shaped sling surround-ing the genital hiatus medially, but fanning out to createthe pelvic floor posteriorly and laterally. These musclesare comprised of a unique type of striated muscles thatcontain a majority of type I (slow twitch) muscle fibers,maintaining a constant resting tone over time. Eachmuscle group also contains a smaller proportion of typeII (fast twitch) fibers, permitting them to respond quicklyduring sudden increases in intra-abdominal pressures.8

Contraction of the pelvic diaphragm provides a horizon-tal levator plate on which the pelvic viscera lie, as well ascloses the genital hiatus. The constant resting tone of thepuborectalis and pubococcygeus not only closes the gen-ital hiatus but also pulls the distal vagina and anorectaljunction toward the pubic symphysis, creating a near 90°angle between the anal and rectal canals, referred to asthe anorectal angle.A connective tissue layer known as the endopelvicfascia invests the vaginal walls and apex. The term fascia

is ambiguous because this fibromuscular tissue layerincludes fibroblasts, smooth muscle cells, and elastin inaddition to type III collagen, all loosely arrayed to createan elastic fibromuscular layer.9 At the vaginal apex, thisfibromuscular layer coalesces to create the cardinal anduterosacral ligaments. The fan-shaped cardinal ligamentcreates a sheath that envelops the uterine artery andvein, fusing with the paracervical ring medially. Theuterosacral portion inserts into the posterior and lateralaspect of the paracervical ring and then curves laterallyalong the pelvic sidewall to attach to the presacral fasciaoverlying the second, third, and fourth sacral verte-brae.10 Together the cardinal and uterosacral ligamentspull the vagina horizontally toward the sacrum, suspend-ing it over the muscular levator plate.The endopelvic fascia of the posterior vaginal wall isalso known as Denonvillier’s fascia or the rectovaginalseptum. It arises from fusion of the 2 walls of the embry-ological peritoneal cul-de-sac.11 This creates a fibromus-cular sheet that spans the posterior vaginal wall andcoalesces with surrounding structures to provide a bar-rier to prolapse. Superiorly, it attaches to the cervix andthe cardinal uterosacral support of the vaginal apex.Laterally, the rectovaginal fascia attaches to the pelvicsidewall (Fig. 1).12 In the upper vagina, the lateral attach-ment coalesces with the lateral support of the anteriorvaginal wall to create the fascia endopelvina.13 This webof connective tissue coalesces with the fascia of theobturator internus muscle to create the arcus tendineusfascia pelvis or white line. The lower half of the recto-vaginal fascia fuses with the aponeurosis of the levatorani muscle along a line referred to as the arcus tendineusfascia rectovaginalis.12 It converges with the arcus tendi-neus fascia pelvis at a point approximately midway

Fig. 1. Oblique sagittal view of anatomy of the lateralattachments of the vaginal connective tissue. Illustration:Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.

1404 Cundiff and Fenner Rectocele and Defecatory Dysfunction OBSTETRICS & GYNECOLOGY

between the pubic symphysis and the ischial spine toform a “y” configuration on the sidewall of the pelvis(Fig. 1). The point of convergence of the 2 lines is at thepoint along the tube of the vagina where the pelvic floorbecomes wider than the vagina. Superior to this point,the fascia endopelvina bridges the gap between the vag-inal tube and the pelvic sidewall. At its most inferiorportion, the rectovaginal septum fuses with the perinealbody.The perineal body is a pyramidal structure locatedbetween the vaginal introitus and anus with the base ofthe pyramid on the perineum (Fig. 2). Much like the hubof a wheel, it is a confluence of the perineal membrane(comprised of the bulbocavernosus muscles, superficialtransverse perineal muscles, and investing fascia), a por-tion of the levator ani muscles, the external anal sphinc-ter, and the rectovaginal fascia. Through its attachmentto the cardinal and uterosacral ligaments, the rectovagi-nal septum stabilizes the perineal body, which is essen-tially suspended from the sacrum. The perineal body isfurther stabilized through the lateral attachments of theperineal membrane to the ischiopubic rami.14 Betweenthe lateral and superior support, there is limited down-ward mobility of the perineal body, which normally lieswithin 2 cm of an imaginary line between the ischialtuberosities.15

DeLancey’s14 analysis of the posterior vaginal wallprovides the best evidence of the interrelationships be-tween muscular and connective tissue support of thevagina. Through its attachments to the lateral rectovagi-nal fascia and the perineal body, the resting tone of thepelvic diaphragm augments the support of the posteriorvaginal wall and perineal body. Moreover, under nor-mal conditions the anterior displacement provided bythe resting tone of the puborectalis muscles brings the

posterior vaginal wall into direct contact with the ante-rior vaginal wall. With this arrangement, pressure ap-plied to the anterior and posterior vaginal walls is bal-anced, and the force is carried to the levator ani musclesand perineal body. Denervation of the pelvic diaphragmresults in opening of the genital hiatus and separation ofthe anterior and posterior vaginal walls. In this circum-stance, pressures applied to the anterior and posteriorvaginal walls must be borne by the connective tissuealone. Because of its lateral attachments to the levator animuscles (Fig. 1), the loss of muscular tone also produceslaxity in the rectovaginal fascia.The connective tissue response to constant pressure isattenuation or tearing, and both have been described inthe rectovaginal fascia. Based on cadaveric dissections,Richardson16 hypothesized that most rectoceles weredue to discrete tears in the rectovaginal fascia. Thisopinion was corroborated by a study based on surgicalfindings that showed that these tears occur at lateral,superior, and inferior attachments, as well as within therectovaginal fascia itself (Fig. 3).17 In this series, leftlateral detachments, inferior detachments, and superiordetachments were the most common, with each compris-ing approximately a third of tears, although combina-tions were also common.Importantly, detachments of the rectovaginal fasciafrom the perineal body can compromise the support ofthe perineum, resulting in perineal descent. Excessiveperineal descent was first described in the colorectalliterature by Parks et al in 1966.18 Since that time,multiple studies have associated perineal descent with avariety of defecatory disorders, including constipation,solitary rectal ulcer syndrome, rectal pain, and fecalincontinence.19–22 Neurophysiologic studies have dem-onstrated that one mechanism for fecal incontinence ispudendal neuropathy.23 This is not surprising becauseexcessive perineal descent has been associated with 20%elongation of the pudendal nerve.24 Although recentstudies have demonstrated an association of perinealdescent with posterior wall prolapse, perineal descent iscommonly overlooked in the gynecologic descriptions ofrepairs. This has led to what Richardson25 refers to as a“perineal rectocele,” which occurs following a rectocelerepair that fails to re-establish the normal support of theperineum. In these patients the posterior wall supportmay appear normal, but the rectum continues to bulgeinto the perineal body. Perineal rectoceles commonlypresent with complaints of defecatory dysfunction, in-cluding a sense of incomplete emptying, tenesmus, andthe need to splint or use digital manipulation for defeca-tion.

Fig. 2. Oblique view of the anatomy of the perineal bodyand its attachments to the rectovaginal fascia. Illustration:Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.

1405VOL. 104, NO. 6, DECEMBER 2004 Cundiff and Fenner Rectocele and Defecatory Dysfunction

DIAGNOSTIC APPROACH

There are several key principals that inform the clinicalevaluation of rectocele. Firstly, vaginal support defectsoccur with and without symptoms. Secondly, many ofthe symptoms attributed to pelvic organ prolapse canresult from other causes. Consequently, the clinical eval-uation focuses on eliciting the patient’s complaints, de-fining the location and severity of support defects, andestablishing a relationship between the symptoms andthe support defects through elimination of other causesof pelvic floor symptomatology. Recent studies havesought to define symptoms associated with pelvic organprolapse. Ellerkman et al26 investigated symptoms com-monly attributed to pelvic organ prolapse, categorizingsymptoms according to both prolapse severity and asso-ciated anatomic compartment. Pelvic pressure and dis-comfort, along with visualization of prolapse, werestrongly associated with worsening stages of pelvic organprolapse in all compartments. Impairment of sexual re-lations, including dyspareunia and urinary incontinence

associated with coitus, as well as duration of abstinence,was also strongly associated with worsening pelvic organprolapse. Defecatory dysfunction, including incompleteevacuation and digital manipulation, was associated withworsening posterior pelvic organ prolapse.Weber et al27

also described defecatory dysfunction in association withposterior pelvic organ prolapse. The majority of thesample in this study had stage I or greater posteriorpelvic organ prolapse. Although most (92%) reportednormal stool frequency, 74% reported straining and 24%strained usually or always. Similarly, 31% requiredsplinting of the posterior vaginal wall or digitation of therectum during bowel movement, and 16% reported fecalincontinence. Not surprisingly, on a 10-point botherscale, the impact of bowel function was greater than 5points in 50% and 8 or more points in 28%. Althoughthese symptoms occur with posterior pelvic organ pro-lapse, they also result from other forms of defecatorydysfunction, requiring the pelvic surgeon treating poste-rior pelvic organ prolapse to understand the differentialdiagnosis of defecatory dysfunction.

Defecatory Dysfunction

Voluntary storage and defecation of the rectal contents isa complex neuromuscular mechanism that involves co-ordinated physiologic processes, including intestinaltransit and absorption, colonic transit, rectal compliance,anorectal sensation, and the continence mechanism. Co-lonic motility is complex, with regional heterogeneity.The colon is responsible for absorption of water andassociated electrolytes, as well as peristaltic movement ofstool. The rectosigmoid is uniquely adapted for reab-sorption, as stool transit is significantly delayed in thisregion to permit complete reabsorption of fecal waterand electrolytes before elimination. As stool enters therectal vault, there is a transient decrease in internal analsphincter tone and an increase in external sphincter tone,known as the rectoanal inhibitory reflex. This allows forsampling, in which the sensory-rich anal canal determineswhether the rectal contents are solid, liquid, or gas. Thisis followed by accommodation, whereby relaxation of therectum permits it to accept the increased rectal volume.As rectal volume increases, an urge to defecate is expe-rienced. If this urge is voluntarily suppressed, the rectumrelaxes to continue the accommodation of stool. If it isnot suppressed, defecation of solid stool is initiated by aValsalva maneuver, which raises intra-abdominal andintrarectal pressure. Voluntary inhibition of the externalanal sphincter and puborectalis enables the rectum toempty. This is assisted by coordinated peristaltic activityof the rectosigmoid. When evacuation is completed theexternal anal sphincter and puborectalis contract

Fig. 3. Surgical view showing the defect-directed rectocelerepair. The upper inset (cross section) delineates surgicallayers, while the lower inset demonstrates the potentiallocations for tears in the rectovaginal fascia. Illustration:Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.


(termed the closing reflex), and the continence mechanismis initiated again.Although patients frequently complain of constipa-tion, the term has limited clinical utility because of itsbroad meaning. When patients complain of the symp-tom constipation, they can refer to infrequency of defe-cation, hard stool, or incomplete evacuation. The termdefecatory dysfunction is a preferable diagnostic term. Def-ecatory dysfunction refers to any difficulty with defeca-tion, but does not include fecal incontinence. The com-plexity of the normal physiology translates to a lengthydifferential diagnosis, and defecatory dysfunction is fre-quently multifactorial (Table 1). Systemic disorders suchas diabetes mellitus, thyroid disorders, and neuromuscu-lar diseases are common causes. Some of the most com-monly used medications also result in defecatory dys-function, including aluminum antacids, �-blockers,calcium channel blockers, anticholinergics, antidepres-sants, and opiates. Defecatory dysfunction can also re-sult from mechanical obstruction due to malignancy,inflammatory bowel disease, or Hirschsprung’s disease.Lifestyle issues such as inadequate fiber intake, insuffi-cient fluid intake, and lack of mobility can result indefecatory dysfunction by themselves, or they may ex-acerbate other causes. Bowel function can also be af-

fected by psychiatric disorders, including depression,dementia, and anorexia.Initial evaluation and treatment should be directed atthese most common causes. In the absence of one ofthese causes, a diagnosis of idiopathic constipation ismade. Idiopathic is a misnomer in this context, because thepathophysiology of idiopathic constipation is clear (Ta-ble 2). There are 2 categories: motility disorders andoutlet obstruction. The motility disorders include disor-ders with and without dilation. Outlet obstruction in-cludes support defects of the posterior vaginal wall,perineum, and rectum, as well as anismus, or failure ofthe puborectalis to relax during defecation. In treating

Table 1. Differential Diagnosis of Defecatory Dysfunction by Category of Disease

Disease category Subcategory Diagnosis

Metabolic HypercalcemiaHypokalemia

Endocrine Diabetes mellitusPanhypopituitarismPheochromocytomaGlucagonomaPorphyria

Neurologic Central Spinal cord trauma, multiple sclerosis, Parkinson’s disease, Shy-Dragersyndrome

Peripheral Chagas disease, paraneoplastic neuropathyCongenital Hirschsprung’s disease, colonic agangliosis, hypergangliosis, sphincter

achalasia, intestinal pseudoobstruction

Pharmacologic Analgesics Naproxen, ibuprofenAnticholinergics Antispasmodics, antidepressants, antipsychotics, antiparkinsonian

drugsNeurally active compounds Opiates, antihypertensives, ganglionic blockers, vinca alkaloids,

calcium-channel blockers, diureticsCation-containing agents Iron supplements, aluminum antacids, barium sulfate

Systemic disorders Systemic sclerosisAmyloidosisMyotonic muscular dystrophy

Functional Irritable bowel syndromeCognitive disordersLimited mobilityNutritionPsychological causes

Table 2. Idiopathic Causes of Defecatory Dysfunction

Type ofdysfunction Details Causes

Motilitydisorders

With dilation Megacolon,megarectum

Without dilation Colonic inertia, globalmotility disorder

Outletobstruction

AnismusPelvic organsupportdefects

Rectocele, enteroceles,perineal descent,rectal prolapse


idiopathic constipation, the distinction between disor-ders of motility and outlet obstruction is an importantone, because women with disorders of motility are besttreated with dietary or pharmacologic modalities, or inextreme cases, with colectomy. Those with outlet ob-struction are not. Similarly, pelvic support defects can becured surgically, whereas anismus responds best tobiofeedback. Distinguishing between these subcategoriesof idiopathic constipation, therefore, has important con-ceptual as well as therapeutic implications. Difficultiesarise in the patient who has findings indicatingmore thanone of these etiologies. Because support defects can arisefrom chronic straining, it can be difficult to determine theprimary basis for constipation in women who have sup-port defects in combination with disorders of motility oranismus. There is evidence that patients with anismuscombined with support defects do not have a higherfailure rate for surgical correction of support defectswhen compared with women with isolated support de-fects.28 The literature does not address whether womenwith slow transit constipation combined with supportdefects should have surgery that addresses both of theseentities. We recommend optimizing nonsurgical treat-ment for either anismus or slow transit constipationbefore pursuing surgical repair of support defects.

Sexual Dysfunction

Although academic efforts to describe, define, and treatfemale sexual dysfunction are in their infancy, it is clearthat the prevalence of this disorder is significant. TheNational Health and Social Life Survey, a population-based survey of U.S. adults, aged 18–59 years, reportedsexual dysfunction in 43% of women.29 Like defecatorydysfunction, the differential diagnosis is complex. How-ever, prolapse in general (not specifically posterior pelvicorgan prolapse) has been strongly associated with sexualcomplaints in studies of women seeking treatment ofpelvic floor disorders.30 Common sexual complaints in-clude dyspareunia, decreased sexual desire, and anorgas-mia.31 It is also common for patients to report abstentionfrom coitus because of concern by the patient or herpartner that coitus will worsen the pelvic organ prolapse.It is unclear whether these sexual complaints are due tothe physical or emotional impact of the pelvic floordisorder or to other factors, such as the effects of meno-pause, prior surgeries, or the presence of other comorbidconditions.28 Age has also been identified as an impor-tant confounder.28,32 Nevertheless, there are theoreticalbases for sexual dysfunction due to posterior wall pelvicorgan prolapse. Immunohistochemical studies haveshown increased density of free intraepithelial nerveendings in the distal vagina and vaginal introitus, whichhave been hypothesized to be important to sexual re-

sponse.33 The function of these nerve endings may beaffected by loss of support of the perineum and distalvagina. Conversely, they may be negatively affected bysurgical dissection. Vasculogenic female sexual dysfunc-tion because of diminished pelvic blood flow can alsopresent with vaginal wall dryness and dyspareunia andshould be considered in the differential diagnosis.34 Psy-chogenic female dysfunction can occur with or withoutorganic disease and may reflect problems of self-esteem,body image, or partner relationship. The complexity ofthe interplay of physical and psychological factors infemale sexual dysfunction makes it difficult to predictoutcomes following repair.

Pelvic Examination

The goals of the pelvic examination are to objectivelydefine the degree of prolapse and determine the integrityof the connective tissue and muscular support of thepelvic organs. The pelvic examination is performed inthe dorsal lithotomy position, although it is importantthat the patient confirms maximal protrusion, and thismay require further examination on a commode or inthe standing position. Valsalva with hard straining facil-itates maximal protrusion, and a hand mirror can beused for patient confirmation.It is important to objectively document the extent ofprolapse, both before and after interventions. In definingthe extent of prolapse, the degree of descent is measuredwith respect to the hymenal ring. There are a number ofordinal staging systems to describe the degree of descent,although the Pelvic Organ Prolapse Quantitation exam-ination is the most widely accepted. A full description ofthis system is beyond the scope of this article, but it iseasily learned and is reproducible. It has been adoptedby the American Urogynecologic Society and the Inter-national Continence Society.35 Generally, it includes 6topographical points on the vaginal walls and 2 on theperineum, as well as the vaginal length.Vaginal support should be evaluated independently atall sites, including the vaginal apex, the anterior wall, andthe posterior wall. The posterior wall is assessed whilesupporting the vaginal apex and anterior wall with aSims speculum or with a disarticulated posterior blade ofa Grave’s speculum. This permits the examiner to focuson the specific location of the rent in the rectovaginalfascia. Careful attention to the rugations in the vaginalepithelium can provide clues to the location of the recto-vaginal fascia tears because the rugation pattern is fre-quently lost overlying the defect.36 This technique isespecially useful for enteroceles caused by tears in thesuperior rectovaginal fascia, which have a smooth thinepithelium over the enteroceles sac or peritoneum. Care-ful inspection in some patients with enteroceles will


reveal peristaltic movements beneath the vaginal epithe-lium. A rectovaginal examination also provides informa-tion regarding the integrity of the rectovaginal fascia aswell as the perineal body.Normally, the perineum should be located at the levelof the ischial tuberosities or within 2 cm of this landmark(Fig. 2). A perineum below this level, either at rest orwith straining, represents perineal descent. Subjectivefindings of perineal descent include widening of thegenital hiatus and perineal body and flattening of theintergluteal sulcus. Women with perineal descent alsotend to have less severe pelvic organ prolapse based onthe Pelvic Organ Prolapse Quantitation staging system,because it measures descent from the hymenal ring,which is not a fixed point in perineal descent. One of theunique aspects of the Pelvic Organ Prolapse Quantita-tion system is the assessment of the perineum, includingmeasurement the length of the genital hiatus and peri-neal body with and without straining. An increase inthese values with straining suggests perineal descent.The degree of perineal descent can also be objectivelymeasured with a thin ruler placed in the posterior introi-tus at the level of the ischial tuberosities. Descent ismeasured as the distance the perineal body moves whenthe patient strains, although pelvic floor fluoroscopy isthe gold standard for measuring perineal descent. Weusually reserve fluoroscopy for patients with symptomsof severe defecatory dysfunction and evidence of peri-neal descent on pelvic examination.The bimanual examination investigates the location,size, and tenderness of the bladder, uterus, cervix, andadnexa. The pelvic diaphragm should be assessed forintegrity of the muscle body and insertion, as well as thestrength, duration of a contraction, and the anterior liftof the contraction. Several standardized systems havebeen described to assess muscle strength objectively, butnone are universally accepted.37 The integrity of thepelvic diaphragm muscles can be evaluated by observa-tion and palpation of these structures during voluntarycontraction. The firm muscular sling of the puborectalisshould be readily palpable posteriorly because it createsa 90° angle between the anal and rectal canals. Voluntarycontraction of this muscle pulls the examining fingeranteriorly toward of the muscle’s insertion on the pubicrami. Neuropathy affecting the puborectalis can likewisebe recognized if the anorectal angle is obtuse and if thereis a palpable weakness with voluntary contraction. Aspreviously mentioned, a rectovaginal examination pro-vides useful information regarding the integrity of therectovaginal septum and can demonstrate laxity in thesupport of the perineal body. The rectovaginal examina-tion also helps in the diagnosis of a high enteroceles,which can be felt filling the rectovaginal septum between

the vaginal and rectal fingers during patient straining.The presence of fecal material in the anal canal maysuggest fecal impaction or neuromuscular weakness ofthe anal continence mechanism.

Ancillary Tests

A number of ancillary tests are commonly used to aug-ment the physical examination of pelvic organ prolapse.These include physiological tests of bladder and rectalfunction and imaging tests to clarify anatomical derange-ments. Urodynamics are commonly used for patientswho have urinary incontinence in addition to pelvicorgan prolapse, although the benefit of urodynamics forwomen without urinary incontinence is controversial. Ina study to assess the benefit of urodynamics in womenwith posterior pelvic organ prolapse, Myers et al38 notedthat severe posterior pelvic organ prolapse impactedurodynamic parameters and masked urinary stress in-continence. They recommended urodynamics with re-duction of the posterior vaginal wall in these patients.Similarly, anorectal physiologic testing is useful forwomen with suspected anismus or concurrent fecal in-continence.

Fig. 4. Surgical view showing the posterior colporrhaphy.(The diamond-shaped skin from the perineorrhaphy isdiscarded.) The cross section inset delineates surgicallayers. Illustration: Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.


Patients presenting with defecatory dysfunctionshould undergo a standard gastrointestinal evaluation,including a barium enema or colonoscopy, to eliminatecolorectal malignancy from the differential diagnosis.Anoscopy may reveal anorectal pathology such as pro-lapsing hemorrhoids, and proctosigmoidoscopy helps toexclude intrarectal prolapse or a solitary rectal ulcer.Referral to an anorectal physiology laboratory may benecessary to differentiate between patients with colonicmotility disorders and those with predominant pelvicoutlet symptoms. Standard evaluation in these laborato-ries includes colonic transit studies, pelvic floor fluoros-copy, anorectal manometry, and electromyography.

Useful radiologic studies include the colonic transitstudy, pelvic floor fluoroscopy, and dynamic magneticresonance imaging. Colonic transit studies involve theuse of ingested radio-opaque markers, followed by serialabdominal radiographs over a 5-day period. The patientingests a capsule with 24 radio-opaque markers, fol-lowed by serial abdominal radiographs every other dayuntil all the markers are gone. Specific regimens vary,but 80% of markers should be passed by day 5, and lessthan this suggests a motility disorder. Collection of themarkers in the sigmoid is suggestive of outlet obstructionbut is not diagnostic. The colonic motility test is primar-ily indicated for patients with a suspected motility disor-

Table 3. Posterior Colporrhaphy

Study n

Meanfollow-up

(mo)Levator

plicationAnatomiccure (%)

Constipation(%)

Vaginalbulge(%)

Vaginaldigitation

(%)

Fecalincontinence

(%)

De novo dyspareuniain sexually activepatients (n �%�)

Arnold et al50

Preoperative 29 75 20Postoperative 24 Yes 80 54 36 5 (23)Mellgren et al51*Preoperative 25 100 21 50 8Postoperative 25 12 Yes 96 88 4 0 8 2 (8)Kahn & Stanton52

Preoperative 231 22 64 4Postoperative 171 42 Yes 76 33 31 33 11 27 (16)Weber et al53*Preoperative 53 12Postoperative 53 No† 14 (26)Sand et al54*Preoperative 70 12Postoperative 67 No 90

* Prospective.† One of 53 patients did have plication.

Table 4. Defect-Directed Repair

Study n

Meanfollow-up

(mo)Anatomiccure (%)

Constipation(%)

Difficultevacuation

(%)

Vaginalbulge(%)

Vaginaldigitation

(%)

Cundiff et al55

Preoperative 69 12 46 32 100 39Postoperative 61 82 13 15 18 25Porter et al56

Preoperative 125 6 60 61 38 24Postoperative 72 82 50 44 14 21Kenton et al57

Preoperative 66 12 41 53 86 30Postoperative 46 90 57 46 9 15Glavind & Madsen58

Preoperative 67 3 40Postoperative 67 100 4Singh et al59*Preoperative 42 18 57 78Postoperative 33 92 27 7

* Prospective.


der based on abnormal stool frequency (greater thanevery 3 days).Pelvic floor fluoroscopy is useful for women withpelvic organ prolapse and severe defecatory dysfunction.It is especially useful for women with complaints ofincomplete evacuation because it helps to differentiatecauses of outlet obstruction: anismus and support de-fects. In this study, the small bowel is opacified with oralcontrast, the vagina and bladder with liquid contrast,and the rectum with contrast paste. A series of sagittalstill films and, in some laboratories, cinevideography, aremade with fluoroscopy while the patient sits and defe-cates on a radiolucent commode. The patient is filmed atrest, during defecation, and while squeezing the analsphincters. Measurements are taken of the size of therectal ampulla, length of the anal canal, size of theanorectal angle, motion of the puborectalis, and degreeof pelvic floor descent. This not only provides radiologicevidence of herniation of the surrounding organs intothe vagina but also provides dynamic assessment ofpelvic floor function during defecation. Rectoceles, de-fined as an extension of the anterior rectal wall, arecommonly found on proctograms, and small bulges ofthe anterior rectal wall detected on evacuation proctog-raphy might be normal findings because they are fre-quently asymptomatic. The consensus is that theyshould be considered abnormal if there is barium trap-ping, that is to say that the rectocele does not completelyempty on evacuation.39 Although pelvic floor fluoros-copy is the gold standard for measuring perineal descentand is more accurate than physical examination fordefining which organ is herniating into the vagina,40 it isusually reserved for patients with marked defecatorydysfunction.41 Dynamic magnetic resonance imaging

provides a similar evaluation but also provides multipla-nar information about the soft tissues of the pelvicfloor.42 It is most appropriate for patients with complexpelvic organ prolapse or symptoms that are not ex-plained by the physical examination.42

Because anismus can mimic the defecatory symptomsof posterior pelvic organ prolapse, as well as causeposterior pelvic organ prolapse as a result of outletobstruction, it is an important component of the differ-ential diagnosis. Anismus can be suspected in the patientwith tender, hypercontracted puborectalis muscles onbimanual examination, especially if she cannot relaxthesemuscles on command. Pelvic floor fluoroscopy alsoprovides evidence of anismus, including lack of straight-ening of the anorectal angle and failure to evacuate twothirds of contrast after 30 seconds of straining. However,the balloon expulsion test and surface electromyogramare anorectal physiological tests that are superior meth-ods for diagnosing anismus.33

In planning the therapeutic evaluation of a patientwith posterior pelvic organ prolapse, the most importantconsideration is the presenting symptoms. Isolated her-niation symptoms are easily attributable to the posteriorpelvic organ prolapse and do not usually warrant furthertesting. Patients with defecatory dysfunction have amore extensive differential diagnosis that may benefitfrom further evaluation. Suspicions of amotility disorderwarrant a colonic transit study. Anorectal physiologictesting is important to evaluate fecal incontinence andsuspected anismus. Imaging studies are useful for pa-tients with perineal descent, poorly defined outlet ob-struction, or physical examination findings that do notcorrelate with symptoms.

THERAPEUTIC APPROACHES

Rectoceles may present as an asymptomatic bulge foundat the time of pelvic examination or with a myriad ofsymptoms. For patients without symptoms, expectantmanagement of the prolapse is recommended. Treat-ment options for women with symptomatic rectocelesinclude nonsurgical management with pessaries and avariety of surgical techniques, including posterior col-porrhaphy, defect-directed repair, posterior fascial re-placement, transanal repair, and abdominal approaches.

Pessaries

Pessaries have been used for centuries for the treatmentof pelvic organ prolapse, yet despite their utility andminimal risk, there is a paucity of data on their use,fitting, and management. Adams et al43 attempted aCochrane Database review in 2004 and could not find asingle randomized trial to evaluate effectiveness of pes-

Fecalincontinence

(%)Dyspareunia

(%)

De novo dyspareuniain sexually activepatients (n �%�)

13 298 19 1 (2)

24 6721 46 3 (4)

30 288 3 (7)

123 2 (3)

9 315 15 0


saries for pelvic organ prolapse. Therefore, the type andsize of pessary that is best for posterior compartmentprolapse, and specifically rectoceles, is not known.There are 2 basic types of pessaries: supportive andspace occupying. The ring pessary, with or withoutfloor, is a common supportive pessary, whereas theGelhorn and cube pessaries are common space-occupy-ing pessaries.44 Clemons et al45 evaluated 100 consecu-tive womenwith pelvic organ prolapse and found that 73women could successfully retain a pessary for at least 1week. A short vaginal length (� 6 cm) and awide vaginalintroitus (4 finger breadths accommodated) were associ-ated with unsuccessful trial (P � .02 and P � .04,respectively). Ring pessaries were used more with stageII and III prolapse, whereas Gelhorn pessaries were usedwith stage IV prolapse. Descent of the leading edge of theprolapse and whether the leading compartment wasanterior wall, apical, or posterior wall had no impact onsuccessful pessary trial. Thus, women with rectoceleswere just as likely to be able to wear a pessary as thosewith predominantly cystoceles or uterine prolapse.There is no data relating patient’s symptoms, specifi-cally constipation or need to splint to defecate, and theability to retain a pessary. Heit et al46 found that womenover the age of 70 years with less severe prolapse aremore likely to choose a pessary over surgery. But somewomen of all ages and stages of prolapse may choose totry a pessary, so nonsurgical management should bemade an option for all women. Large, randomized trialsare needed to determine the type and size of pessary best

Fig. 5. Surgical view showing the transanal rectocele re-pair. The cross section inset delineates surgical layers.Illustration: Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.

Table 5. Transanal Repair

Study n

Meanfollow-up


Constipation(%)

Difficultevacuation

(%)

Vaginalbulge(%)

Vaginaldigitation

(%)

Sullivan et al61

Preoperative 137 58 27Postoperative 117 18 96 2Sehapayak64

Preoperative 355 82 26Postoperative 204 98 15Janssen & van Dijke65*Preoperative 64 72 38 26Postoperative 64 12 70 16 3 4van Dam et al66*†

Preoperative 89 63 92 40 23Postoperative 89 52 72 33 27 28 0Ayabaca et all67*Preoperative 49 83 38Postoperative 34 48 90 32

RV, rectovaginal.* Prospective.† Combined transanal and transvaginal repair.


suited for the treatment of rectoceles and whether bowelfunction or other symptoms relate to success.

Posterior Colporrhaphy

The traditional posterior colporrhaphy was an operationdevised in the early 19th century to deal mainly withperineal tears incurred during vaginal delivery. Theperineal closure was designed to narrow the caliber ofthe vaginal introitus, develop a perineal shelf, and par-tially close the genital hiatus.47 The original descriptionincluded plication of the pubococcygeus muscles alongwith plication of the posterior vaginal wall (colporrha-phy) and reconstruction of the perineal body (perineor-rhaphy) as a single procedure known as posterior col-poperineorrhaphy. Posterior colpoperineorrhaphy hasbeen used for all forms of genital and related rectalprolapse without any real understanding of the uterineand vaginal supports and defecation process, leading to afundamentally nonanatomical approach.48

A posterior colporrhaphy begins with a midline inci-sion extended to the apex of the vagina for a “high” orlarge rectocele or to the cephalad border of a smaller ordistal rectocele. The rectovaginal fascia is mobilizedfrom the vaginal epithelium and plicated in the midlinewith interrupted or continuous absorbable suture (Fig.4). Alternatively, a wedge incision with excision of vag-inal epithelium and rectovaginal fascia can be performedin block to simply narrow the vagina. Plication of thelevator ani muscles may be performed. Excess vaginalepithelium is trimmed, and the vaginal epithelium isclosed with a running, absorbable suture. A perineorrha-

phy is frequently performed in conjunction with thisprocedure by reconstructing the perineal body. Theintrinsic muscles of the perineal body, including thesuperficial perineal muscles and the bulbocavernosusmuscles, may be separated or damaged from childbirth.They are brought to the midline using fine absorbablesuture to reconstruct the perineum.Despite the fact that transvaginal colporrhaphies havebeen the preferred surgical procedure for rectocele repairamong gynecologic surgeons for over 100 years, there isa paucity of data reporting long-term anatomical success.Evenmore concerning is that, despite the fact the Francisand Jeffcoate49 reported in 1961 the high incidence ofdyspareunia following colporrhaphy with levator plica-tion, even less information is known about sexual func-tion following this procedure. The operation was notevaluated for its effect or impact on bowel function until1987.50 Table 3 summarizes the literature on posteriorcolporrhaphy with and without levator plication. Mostof the studies report a greater than 75% improvement inanatomical outcome or bulge and the need to splint theperineum to defecate. However, the studies suggest thatthere is at least a 15% incidence of new dyspareunia afterposterior colporrhaphy, with or without levator plica-tion. Patients with symptoms of slow-transit constipationhave little improvement in defecation dysfunction. In thelargest retrospective review, Kahn and Stanton52 re-ported on 171 women with a mean follow-up of 42.5months. Twenty-four percent had recurrent rectoceleson vaginal examination. Except for the symptom oflump or pressure, all other symptoms, including incom-plete bowel emptying, fecal incontinence, and sexualdysfunction, increased after colpoperineorrhaphy.There was also a strong association between fecal incon-tinence and a history of more than one posterior colpor-rhaphy (P � .001).Mellgren et al51 published the first prospective study

on posterior colporrhaphy with levator plication. At12-month follow-up, 5 of 25 (20%) had a recurrentrectocele on defecography, whereas only 1 was diag-nosed by pelvic examination (4%). Twenty-four womencomplained of constipation before surgery, and whileimprovement was seen in most (88%), resolution ofconstipation was noted in only half the patients. Weberand colleagues53 at the Cleveland Clinic prospectivelyfollowed 81 women with pelvic organ prolapse andurinary incontinence before and after surgery for sexualfunction and vaginal anatomy. Dyspareunia occurred in14 (25%) women after posterior colporrhaphy (P � .01)and in 8 (38%) of 21 women who had Burch colposus-pension and posterior colporrhaphy performed together(P � .01). When comparing the women with and with-out dyspareunia, the postoperative introital caliber was

Fecalincontinence

(%)Dyspareunia

(%) Complications

39 1 RV fistula3 0

20 19 Infections, 1 RV fistula

40 None9

10 28 None16 44

7127 1 infection, 1 pyogenic

granuloma, 4 dehiscence,1 anal fissure


the same. While this prospective study is well done, oneshould not make broad conclusions from a small seriesof patients. Dyspareunia is not only dependent on thecaliber of the vagina but can result from scarring orlevator spasm. However, surgeons should be cautiouswhen decreasing the vaginal caliber with transvaginalcolporrhaphy. Of the 53 patients who had posteriorcolporrhaphy, 9 (17%) complained of introital tightnesscompared with none of the 27 women who did not haveposterior colporrhaphy (P � .03). In summary, the tra-ditional transvaginal colpoperineorrhaphy providesgood anatomical support with moderate relief of func-tional symptoms and a high rate of de novo dyspareunia.

Defect-Directed Repair

More recently, repair of the discrete fascial defects re-sponsible for rectoceles has been advocated. Richard-son16 described discrete tears or breaks in the rectovagi-nal septum found and studied during cadavericdissections and at the time of rectocele repair. Withmeticulous technique and keen observation, he noted avariety of defects in the rectovaginal septum, with themost common being the transverse separation of recto-vaginal septum from the perineal body.The defect-directed repair, or site-specific fascial repairas it is also referred to, aims for an anatomical repair toclose these fascial tears of defects. The surgical approachbegins with amidline epithelial incision and separation ofthe epithelium from the rectovaginal fascia. With thenondominant index finger in the rectum, the edges of thefascial defects or tears are located. The defect is thenrepaired with interrupted delayed absorbable sutures(Fig. 3). Often the stitches are placed from cephalad tocaudad, in contrast to the traditional side-to-side plica-tion. Richardson16 also strongly advocated that, if sepa-rated, the intrinsic muscles of the perineal body shouldbe repaired and the perineal body reconstructed. Thevaginal epithelium is then reapproximated but not inten-tionally narrowed as with the posterior colporrhaphy.Table 4 gives the anatomical and functional outcomesof the defect-directed rectocele repairs reported in theliterature. Singh et al59 is the only prospective study andreports on patients undergoing a rectocele repair alone.The other retrospective series include patients with rec-tocele repairs performed along with concomitant repairof other pelvic floor defects. None of the series reportedplication of levator muscles in the midline. Singh et alnoted that 9 of the 42 patients in her series requiredperineorrhaphy because of an attenuated perineal body.Cundiff et al55 excluded patients who had a perineorrha-phy or sacrocolpopexy but still noted reduction in thesize of the genital hiatus. The decrease was believed to besecondary to reattachment and stabilization of the peri-

neal body to the rectovaginal septum. Two thirds of thepatients noted an improvement in bowel function anddyspareunia in this series. Both Porter et al56 and Kentonet al57 reported similar anatomical successes at 82% and90%, respectively. But Kenton et al reported only half ofher patients had improvements in constipation and man-ual evacuation. All patients in this series had a rectoceledocumented preoperatively by defecography, but nopostoperative assessment by defecography was per-formed. Improvement in sexual dysfunction ranges from38% to 92%, with variability again indicating a broadrange of definitions for sexual dysfunction and dyspareu-nia used in the studies. All studies report very low ratesof de novo dyspareunia with good functional and ana-tomical outcomes, but the long-term durability is un-known.

Transanal Repair

Marks,60 a colorectal surgeon in the late 1960s, was oneof the first to note the persistent difficulty with rectalevacuation following traditional colpoperineorrhaphy.He also noted that many women diagnosed with recto-celes had a “thinning” of the anterior rectal wall, includ-ing the circular and longitudinal muscles, and an en-larged rectal ampulla. Based on these observations, headvocated repair of the rectal side of the rectocele. Al-though there are several variations and modifications ofthe transanal repair, the aim of the procedure is toremove or plicate the redundant rectal mucosa, thusdecreasing the size of the rectal vault, and to plicate orrepair the anterior rectal wall musculature.The basic technique is frequently preformed in theprone jackknife position. A U-shaped or T incision ismade transanally just above the dentate line. A mucosalflap is raised, separated from the rectovaginal septum,and excised. The rectovaginal septum is plicated fromthe rectal side with absorbable sutures. The plicationincludes the anterior rectal musculature. The rectal mu-cosa and submucosa are closed in a separate layer (Fig.5).61 Block62 reported a similar technique but did notopen the rectal wall, simply plicating the excess mucosawithout excision. This technique is less popular becausesome patients complain of persistent tenesmus and urgeto defecate if the mucosa is not removed. In addition,necrosis of the plicated rectal mucosa has led to postop-erative infection.The advantages of the transanal repair include theability to deal with coincident anorectal pathology, suchas hemorrhoids or anterior rectal wall prolapse, and theexcision of redundant rectal mucosa.48 Disadvantagesinclude the inability to reconstruct the perineal bodyunless a second incision is made, inability to correct ananal sphincter defect if present, and difficulty accessing a


high rectocele.63 Other complications include infection(6%) and rectovaginal fistula (3%), which, while serious,appear to be rare.64

Because transanal repairs were developed and areprimarily performed by colorectal surgeons, the majoroutcomes of this procedure are bowel related and in-clude both defecatory disorders and fecal incontinence.In most series, the indications for surgery are constipa-tion or obstructed defecation, and the surgery is per-formed for only “low” or distal rectoceles. Vaginal bulgeor protrusion is noted but not critical for surgical man-agement. Retrospective series report improvement ofthese symptoms in 32–98% of patients. Successful reso-lution of defecatory disorders and the need to splint donot correlate with the size of rectocele or inability tocompletely evacuate on defecography. Arnold et al50

retrospectively reported on 64 nonrandomized patients,35 of whom underwent transanal repair and 29 of whomunderwent transvaginal repair. The indication for sur-gery was defecatory dysfunction by symptoms only.Forty-six of the 64 were contacted after a minimum of 2years. Before surgery 75% of the patients complained ofconstipation and 20% complained of the need for vaginaldigitalization. In the long term, there was no difference inconstipation, anal incontinence, sexual dysfunction, orpatient satisfaction between groups. Postoperatively,23% of the transvaginal group and 21% of the transanalgroup complained of sexual dysfunction. There was nodifference in postoperative complications between thegroups. Significantly more patients in the transvaginalgroup, 32% versus 4% in the transanal group, com-plained of postoperative pain. Because of the small num-ber of patients reported in this series, the study lackspower to detect statistically significant differences be-tween transvaginal and transanal repairs. Table 5 re-ports on the larger retrospective series and the fewprospective series of transanal rectoceles repairs. A pro-spective study by Janssen and van Dijke65 in 1994 re-ported on 64 women with either symptomatic rectocelesand/or anterior rectal wall prolapse on defecography asinclusion criteria. Seventy-two percent had obstructeddefecation on defecography, and 40% also complained offecal incontinence. Postoperatively, half had no com-plaints and showed improved rectal sensation, defeca-tion at lower stool volumes, and improvement in bothconstipation and incontinence.A major concern after transanal rectocele repair is denovo anal incontinence. Arnold et al50 reported that 38%of patients developed fecal incontinence after transanalrepair. Fecal incontinence may occur because of an oc-cult sphincter laceration that becomes symptomatic withaging or may develop as a result of the anal dilation andstretching during the rectocele repair.65

It is impossible, with the current literature, to reliablycompare the transanal rectocele repair with any of thevaginal approaches. Transanal repairs are generally per-formed for defecation disorders, and transvaginal repairsare generally performed for prolapse of the posteriorvaginal wall. A prospective, randomized trial with ade-quate power to evaluate the impact on bowel and sexualfunction along with anatomical cure is warranted.

Combined Transvaginal/Transanal Repair

van Dam and colleagues66 have reported on 89 womenhaving a combined transvaginal and transanal rectocelerepair who were followed for a mean of 52 months.Seventy-one percent of the women had successful out-come by defecography, physical examination, and defe-cation symptoms. Seven patients developed fecal incon-tinence and 41% developed dyspareunia. A secondanalysis of these patients found that no parameters suchas vaginal splinting, barium entrapment, or rectocele sizeaffected outcome. Poor functional outcome was signifi-cantly correlated with preoperative loss of anal sensation

Fig. 6. Surgical view showing the posterior fascial replace-ment. The graft is connected superiorly but has not yetbeen attached laterally or inferiorly, permitting visualiza-tion of the defect-directed rectocele repair beneath thegraft. The cross section inset delineates surgical layers.Illustration: Lianne Krueger Sullivan.Cundiff. Rectocele and Defecatory Dysfunction. Obstet Gynecol 2004.


on anal manometry and absence of a daily urge todefecate or infrequent bowel movement (specifically, forwomen who reported less than one bowel movement perweek). Moreover, while uncommon, the risk of recto-vaginal fistula must be recognized with this combinationof repairs.

Posterior Fascial Replacement

In an attempt to reduce the risk of rectocele recurrence, avariety of graft materials and meshes has been used inattempts to strengthen the repairs. Graft materials havebeen used with both the traditional method of colporrha-phy and the defect-directed repair. Kohli and Miklos68

recently described the use of a dermal allograft to aug-ment the defect-directed repair. After a defect-directedrepair as described above, a second layer of support iscreated with a rectangular dermal allograft placed overthe repair and secured to the rectovaginal fascia cepha-lad, laterally to the arcus tendineus fascia rectovaginalis,and distally to the perineal body. (Fig. 6)When placing agraft, it is important to remember that graft materialsmay shrink after placement. A repair that is too tight canlead to loss of flexibility of the posterior wall and restric-

tion of the rectum, such that it cannot expand duringaccommodation or during coitus. This “stiffness” in theposterior wall can lead to fecal urgency and dyspareunia.The use of a graft, either allograft or xenograft, is acommon technique employed in repairing other facialdefects or hernias. The purpose of the graft is either toreplace the fascia as a permanent barrier to herniation orto act as an absorbable “collagen scaffold” for fibroblastinfiltration and scar formation. Both types of grafts havebeen used in rectocele repairs. The use of grafts inreconstructive gynecologic surgery has gained popular-ity in recent years and many new products are available.The ideal material for a posterior fascial replacementshould have a very low rejection rate, be relativelyinexpensive, decrease recurrence rates, and cause noharm with respect to bowel and sexual function. Anautologous graft is an alternative to commercially avail-able grafts but needs to be easy to harvest with littleadded morbidity. It remains to be determined which, ifany, of the current grafts available today is best suited forrectocele repair in terms of safety and efficacy. Manymaterials have been used without proper trials and are

Table 6. Repairs With Graft Materials

Study n Graft material

Meanfollow-up


Constipation(%)

Difficultevacuation

(%)

Vaginalbulge(%)

TransvaginalOster & Astrup69

Preoperative 15 Autologous 30 47 80Postoperative 15 Dermis 100 33 0 0Sand et al54*Preoperative 73 Polyglactin 12Postoperative 65 Mesh 92Goh & Dwyer70*Preoperative 43 Polypropylene 100Postoperative 43 Mesh 12 100 0Kohli & Miklos68

Preoperative 43 Cadaveric 12Postoperative 30 Dermis 93

TransperinealWatson et al71*Preoperative 9 Polypropylene 29 100 100Postoperative 9 Mesh 89 12 0Mercer-Jones et al72

Preoperative 22 14 Polypropylene 50 95 86Postoperative 22 8 Polyvinyl chloride 12 95 14 32 23

AbdominalCundiff et al73

Preoperative 19 Polyester 58Postoperative 19 Mesh 3 100 16Sullivan et al74

Preoperative 236 Polypropylene 32 57Postoperative 205 Mesh 60 100 9 0

RV, rectovaginal.* Prospective.


recommended by manufacturers rather than by datashowing long-term improvement of patients’ symptomsor decreased recurrence rates. When using any graftmaterial, whether synthetic, allograft, or autograft, thesurgeon should be as familiar as possible with the prod-uct and discuss current knowledge of risks and benefitswith the patient before using it. Prospective, randomizedtrials performed with institutional review board ap-proval are urgently needed before any recommendationsusing graft materials can be made.Oster and Astrup69 in 1981 first reported the use of a

10 � 5 cm dermal autograft for the repair of “large”rectoceles with a thin lax walls in 15 patients. Patientswere followed for 1–4 years, with a mean of 2.6 years.No patients had a recurrence of the rectocele, but 1patient had a postoperative vaginal infection, 5 hadconstipation, and 3 complained of dyspareunia. Over thelast 20 years, there have been few additional case series,but with the increased used of graft materials for herniarepairs, many pelvic surgeons are using graft materialsregardless of the evidence. Table 6 lists the rectocelerepairs that use graft materials placed either vaginally orabdominally.

Watson et al71 reported on 9 women selected becauseof the need to vaginally splint at the time of defecation.He placed a Marlex mesh transperineally and plicatedthe levators in the midline. With a median follow-up of29 months, 8 of the 9 women were able to successfullyevacuate without manual vaginal splinting. One patienthad a wound infection that was treated with antibioticswithout graft removal, and one patient developed dys-pareunia.Sand et al54 reported the largest prospective study todate using absorbable vaginal mesh. Preoperatively, 143women had rectoceles diagnosed by physical examina-tion, and of these, 91 had rectocele to the midvagina, 31to the hymenal ring, and 22 beyond the introitus. Pa-tients were randomly selected on the day of surgery bycomputer-generated, random-number table to receive ornot receive polyglactin 910 mesh during anterior colpor-rhaphy and posterior colporrhaphy.Mesh was placed byincorporating a strip within the imbricating fold of theendopelvic fascia as it was plicated in the midline duringa traditional colporrhaphy. The authors found no differ-ence in recurrence rates when comparing 70 womenwith a traditional colpoperineorrhaphy with 73 womenhaving a traditional repair with the placement of a poly-glactin mesh, 10% versus 8% respectively. Bowel orsexual function was not described.As seen in the Goh and Dwyer70 series, mesh erosionand rectovaginal fistula are uncommon but serious com-plications. Rectal erosion may require a diverting colos-tomy to remove and repair the erosion site, with signifi-cant and perhaps life-long morbidity for the patient.Erosion of vaginal mesh causes significant morbidity,including vaginal discharge and bleeding in the patientand dyspareunia for the patient and her partner.The use of nonsynthetic grafts to augment the defect-directed repair aims to achieve its functional and anatom-ical success with improved longevity, but without graft-associated complications. Kohli andMiklos68 performed43 defect-directed repairs with the placement of dermalgrafts over a 1-year period. Thirty womenwere followedfor an average of 12.9 months. Inclusion criteria wasbased on intraoperative assessment of weak tissue orincreased risks for failure, such as prior repair, obesity,chronic constipation, or advanced prolapse that was notdefined. There were no major intraoperative complica-tions. Postoperatively, no patients had a graft infection,erosion, or fistula formation. No patients reported dys-pareunia, and 2 of 30, or 7% of patients, had an anatom-ical failure with the posterior wall at 0.5 cm above thehymen or greater. Additional cost was not reported.Nonsynthetic grafts appear to be safer and have fewererosions than synthetics, but prospective, randomizedtrials are needed to evaluate their effect on defecation

Vaginaldigitations

(%)

De Novo dyspareuniain sexually activepatients (n�%�)

Number ofcomplications

100 1 infection12 3 (20)

None

1 R/V fistula3 Erosions

None

100 None12 1 (14)

64 None23 1 (5)

None

4 (3) 11 Erosions


and sexual function as well as improved long-term reduc-tion in recurrences.

Abdominal Approach

The abdominal approach to the correction of a rectoceleis most often employed when correction of an accompa-nying enterocele or vault prolapse is indicated. Ad-vanced pelvic organ prolapse results from a combinationof support defects and neuromuscular dysfunction of thepelvic floor. Patients often present with apical prolapse, arectocele, and defecatory problems, including chronicconstipation or fecal incontinence. When an abdominalapproach, such as a sacral colpopexy, is planned for therepair of the apical support defect, there is an advantageto completing the surgery with a single surgical ap-proach. If the defect in the rectovaginal fascia is in thesuperior portion of the posterior vaginal wall, it can berepaired through the cul-de-sac via a laparotomy. Somesurgeons have advocated extending the posterior graft ofthe sacral colpopexy down the posterior wall to correctsuch high defects.75,76

The sacral colpoperineopexy is another modificationof the sacral colpopexy developed to treat perineal de-scent with concurrent posterior and apical pelvic organprolapse.73 The aim of this surgery is to reconstruct andreplace the normal suspensory ligaments of the vaginaand the continuous “fascial sheet” that runs from thesacrum to the perineal body. The sacral colpoperin-eopexy can be performed totally abdominally or as acombined abdominal and vaginal procedure. First, fromthe abdominal approach, the peritoneum overlying theapex and posterior wall of the vagina is incised to openthe rectovaginal space. Stitches are placed the length ofthe posterior wall from the apex to the perineal body.The perineal body is palpated and elevated with thesurgeon’s nondominant hand. Stitches are placed ab-dominally into, or as close to, the perineal body aspossible. The permanent graft is placed abdominallybetween the posterior vaginal wall and rectum. Thesacrocolpopexy is completed with attachment of theanterior wall graft and posterior wall graft to the previ-ously placed sacral sutures.In the combined abdominal/vaginal approach, the sa-cral colpoperineopexy is performed as above, except thatthe perineal body stitches are placed transvaginally. Theposterior vaginal wall is opened and fully dissected asdescribed for the defect-directed repair. The vaginaldissection is then opened superiorly to connect with theabdominal dissection, permitting a graft to be pulledfrom the abdominal field into the vaginal field. Here, it isanchored to the perineal body and bilaterally to the arcustendineus fascia rectovaginalis. An alternative method isto place the perineal body stitches transvaginally and

then open the posterior wall and pass only the suturesabdominally and attach them to caudad edge of the graft.This technique decreases exposure of the graft materialto the vagina and may decrease vaginal erosion rates.Both Cundiff et al73 and Sullivan et al74 have reportedon the sacral colpoperineopexy but for different indica-tions. Sullivan et al74 reported on 205 women who had asacral colpoperineopexy using Marlex for apical pro-lapse, rectocele, and enterocele. His technique includedplacing a trapezoidal piece of Marlex mesh posteriorlyfrom the sacrum to the perineum. He used a needlecarrier from above to pass the perineal body stitchesfrom the cul-de-sac to the perineum. In addition, headded 2 straps of mesh on each side around the vaginalaterally, and these were then sutured to Cooper’s liga-ment. With 10-year follow-up, he reported a 25% failurerate with a 5%mesh erosion rate. Cundiff et al73 reportedon early results in 19 women who underwent the sacralcolpoperineopexy for apical prolapse and perineal de-scent. The anatomical results for apical and posteriorprolapse, as well as perineal descent, were excellent.Defecatory dysfunction resolved in 66% of patients.Four years after Cundiff’s initial report from the Dukeexperience, Visco et al77 reported follow-up of 150 sacralcolpopexies and 88 abdominal sacral colpoperineopexiesvia a laparotomy and with no vaginal incision. Amongthe 88 colpoperineopexies, 30 also had a vaginal incision.Of these 30 colpoperineopexies with vaginal incision, 5had the mesh placed via the vaginal incision and 25 hadsutures placed vaginally, which were passed into theabdominal cavity and then attached to the permanentmesh. All used Merselene mesh. The erosion rate for atraditional sacrocolpopexy and the abdominal sacral col-poperineopexy when the vagina was not opened werenot statistically different at 3.2% versus 4.5%. The ero-sion rates were higher when the vagina was opened: 16%for vaginally placed sutures and 40% for vaginally placedmesh. Cundiff and coauthors73 reported a subsequentseries of 11 patients with apical and posterior pelvicorgan prolapse combined with perineal descent and rec-tal prolapse who were treated with sacral colpoperin-eopexy and suture rectopexy. In this series all grafts wereplaced vaginally, but using a dermal allograft. The ana-tomical cure rate was 82%. Symptom improvement in-cluded prolapse 75%, constipation 70%, incomplete def-ecation 60%, and assisted defecation in 70%. There wereno graft erosions in this series.

CONCLUSION

The demographics of our aging population predict thatgynecologists will see increasing numbers of womenwith rectoceles. Rectoceles can produce a variety of


symptoms, including herniation, defecatory dysfunc-tion, and sexual dysfunction. To provide optimal carefor these patients, the gynecologist should confirm thatpelvic organ prolapse symptoms are due to a rectocele byeliminating other causes of the differential diagnosis.Asymptomatic rectoceles are best managed expectantly.There is minimal data to define optimal pessary use, butthe virtual absence of associatedmorbidity with properlymanaged pessaries, coupled with the absence of alterna-tive nonsurgical treatment options, recommends it forpatients who want to avoid surgery. There are a variety ofsurgical options for patients who want to pursue surgicalcorrection with significantly different functional outcomes.The traditional posterior colporrhaphy, with or withoutlevator plication, in prospective studies has been found tohave good anatomical results, but high rates of de novodyspareunia. When choosing this surgical approach, thecurrent and potential coital activity of the patient must beconsidered. There are no direct comparisons of the differ-ent surgical techniques to date, but the available data sug-gest that better functional results, both in terms of defeca-tory function and sexual function, are found with thedefect-directed repair. The posterior fascial replacementtheoretically should have the functional results of the de-fect-directed repair with enhanced durability, although thisis unproven presently. The sacral colpoperineopexy mayprovide better relief of defecatory symptoms associatedwith perineal descent, although the use of a synthetic graftwith this procedure has high graft-related morbidity. Re-gardless of the type of vaginal repair, resolution of the bulgecorrelates well with correcting the need to splint or supportthe perineum to defecate. Other symptoms that have beenattributed to rectoceles, including impaired sexual relations,loss of the sensation to defecate, and fecal incontinence,appear less amenable to surgical correction. Both the sur-geon and patient should be aware that restoring structurewith a surgical repair may not restore defecatory or sexualfunction.58,67,72

REFERENCES1. Subak LL, Waetjen LE, van den Eeden S, Thom DH,Vittinghoff E, Brown JS. Cost of pelvic organ prolapsesurgery in the United States. Obstet Gynecol 2001;98:646–51.

2. Luber KM, Boero S, Choe JY. The demographics of pelvicfloor disorders: current observations and future projec-tions. Am J Obstet Gynecol 2001;184:1496–501.

3. Samuelsson EC, Arne Victor FT, Tibblin G, SvardsuddKF. Signs of genital prolapse in a Swedish population ofwomen 20 to 59 years of age and possible related factors.Am J Obstet Gynecol 1999;180:299–305.

4. Swift SE, Pound T, Dias JK. Case-control study of etio-logic factors in the development of severe pelvic organ

prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:187–92.

5. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V,McTiernan A. Pelvic organ prolapse in the Women’sHealth Initiative: gravity and gravidity. Am J ObstetGynecol 2002;186:1160–6.

6. Handa VL, Garrett E, Hendrix S, Gold E, Robbins J.Progression and remission of pelvic organ prolapse: alongitudinal study of menopausal women. Am J ObstetGynecol 2004;190:27–32.

7. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL.Epidemiology of surgically managed pelvic organ prolapseand urinary incontinence. Obstet Gynecol 1997;89:501–6.

8. Gosling JA, Dixson JS, Critchey HOD, Thompson SA. Acomparative study of the human external sphincter andperiurethral levator ani muscles. Br J Urol 1981;53:35–41.

9. Strohbehn K. Normal pelvic floor anatomy. ObstetGynecol Clin North Am 1998;25:683–705.

10. Buller JL, Thompson JR, Cundiff GW, Krueger SullivanL, Schon Ybarra MA, Bent AE. Uterosacral ligament:description of anatomic relationships to optimize surgicalsafety. Obstet Gynecol 2001;97:873–9.

11. van Ophoven A, Roth S. The anatomy and embryologicalorigins of the fascia of Denonvilliers: a medico-historicaldebate. J Urol 1997;157:3–9.

12. Leffler KS, Thompson JR, Cundiff GW, Buller JL, Bur-rows LJ, Schon Ybarra MA. Attachment of the rectovagi-nal septum to the pelvic sidewall. Am J Obstet Gynecol2001;185:41–3.

13. Uhlenhuth E, Day EC, Smith RD, Middleton EB. Thevisceral endopelvic fascia and the hypogastric sheath. SurgGynecol Obstet 1948;86:9–28.

14. DeLancey JOL. Structural anatomy of the posterior pelviccompartment as it relates to rectocele. Am J ObstetGynecol 1999;180:815–23.

15. Skomorowska E, Hegedus V, Christiansen J. Evaluationof perineal descent by defaecography. Int J Colorectal Dis1988;3:191–4.

16. Richardson AC. The rectovaginal septum revisited: itsrelationship to rectocele and its importance in rectocelerepair. Clin Obstet Gynecol 1993;36:976–83.

17. Burrows LJ, Sewell C, Leffler KS, Cundiff GW. Theaccuracy of clinical evaluation of posterior vaginal walldefects. Int Urogynecol J 2003;14:160–3.

18. Parks AG, Porter NH, Hardcastle J. The syndrome of thedescending perineum. Proc R Soc Med 1966;59:477–82.

19. Henry MM, Parks AG, Swash M. The pelvic floor mus-culature in the descending perineum syndrome. Br J Surg1982;69:470–2.

20. Bartolo DC, Read NW, Jarrett JA, Read MG, DonnellyTC, Johnson AG. Differences in anal sphincter functionand clinical presentation in patients with pelvic floordescent. Gastroenterology 1983;85:68–75.


21. Snooks SJ, Nicholls RJ, Henry MM, Swash M. Electro-physiological and manometric assessment of the pelvic floorin solitary rectal ulcer syndrome. Br J Surg 1985;72:131–3.

22. Hudson CN. Female genital prolapse and pelvic floordeficiency. Int J Colorectal Dis 1988;3:181–5.

23. Ho YH, Goh HS. The neurophysiological significance ofperineal descent. Int J Colorectal Dis 1995;10:107–11.

24. Henry MM, Parks AG, Swash M. The anal reflex inidiopathic fecal incontinence: an electrophysiologicalstudy. Br J Surg 1980;67:781–3.

25. Richardson AC. The anatomic defects in rectocele andenterocele. J Pelvic Surg 1995;4:214–21.

26. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA,Leffler K, Bent AE. Correlation of symptoms with locationand severity of pelvic organ prolapse. Am J ObstetGynecol 2001;185:1332–8.

27. Weber AM, Walters MD, Ballard LA, Booher DL, Pied-monteMR. Posterior vaginal prolapse and bowel function.Am J Obstet Gynecol 1998;179:1446–9.

28. van Dam JH, Hop WC, Schouten WR. Analysis ofpatients with poor outcome of rectocele repair. Dis ColonRectum 2000;43:1556–60.

29. Laumann E, Paik A, Rosen R. Sexual dysfunction in theUnited States: prevalence and predictors �published erra-tum appears in JAMA 1999;281:1174�. JAMA 1999;281:537–44.

30. Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC.Sexual function in women with urinary incontinence andpelvic organ prolapse. Obstet Gynecol 2002;99:281–9.

31. Handa VL, Harvey L, Cundiff GW, Siddique SA, KjerulffKH. Sexual function among women with urinary inconti-nence and pelvic organ prolapse. Am J Obstet Gynecol2004;191:751–6.

32. Weber AM, Walters MD, Schover LR, Mitchnson A.Sexual function in women with uterovaginal prolapse andurinary incontinence. Obstet Gynecol 1995;85:483–7.

33. HilligesM, Falconer C, Ekman-Ordeberg G, JohanssonO.Innervation of the human vaginal mucosa as revealed byPGP 9.5 immunohistochemistry. Acta Anat (Basel) 1995;153:119–26.

34. Goldstein I, Berman JR. Vasculogenic female sexual dys-function: vaginal engorgement and clitoral erectile insuffi-ciency syndromes. Int J Impot Res 1998;10(suppl2):S84–90; discussion S98-101.

35. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLanceyJO, Klarskov P, et al. The standardization of terminologyof female pelvic organ prolapse and pelvic floor dysfunc-tion. Am J Obstet Gynecol 1996;175:10–7.

36. Richardson AC. Female pelvic floor support defects �edi-torial�. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:241.

37. Brink C, Wells TJ, Sampselle CM, Tallie ER, Mayer R. Adigital test for pelvic muscle strength in women withurinary incontinence. Nurs Res 1994;43:352–6.

38. Myers DL, Lasala CA, Hogan JW, Rosenblatt PL. Theeffect of posterior wall support defects on urodynamicindices in stress urinary incontinence. Obstet Gynecol1998;91:710–4.

39. Cundiff GW, Nygaard I, Bland D, Versi E. Proceedings ofthe American Urogynecologic Society MultidisciplinarySymposium on Defecatory Disorders. Am J ObstetGynecol 2000;182:S1–10.

40. Kelvin FM, Maglinte DD. Dynamic evaluation of femalepelvic organ prolapse by extended proctography. RadiolClin North Am 2003;41:395–407.

41. Kaufman HS, Buller JL, Thompson JR, Pannu HK,DeMeester SL, Genadry RR, et al. Dynamic pelvic mag-netic resonance imaging and cystocolpoproctography altersurgical management of pelvic floor disorders. Dis ColonRectum 2001;44:1575–83.

42. PannuHK,Genadry R, Gearhart S, KaufmanHS, CundiffGW, Fishman EK. Focal levator ani eventrations: detec-tion and characterization by magnetic resonance inpatients with pelvic floor dysfunction. Int Urogynecol JPelvic Floor Dysfunct 2003;14:89–93.

43. Adams E, Thomson A, Maher C, Hagen S. Mechanicaldevices for pelvic organ prolapse in women (CochraneReview). In: The Cochrane Library, Issue 2, 2004.Oxford: Update Software.

44. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addi-son WA. A survey of pessary use by members of theAmerican Urogynecologic Society. Obstet Gynecol 2000;95:931–5.

45. Clemons JL, Aquitar VC, Tillinghast TA, Jackson ND,Myers DL. Risk factors associated with an unsuccessfulpessary fitting trial in women with pelvic organ prolapse.Am J Obstet Gynecol 2004;190:345–50.

46. HeitM, Rosenquist C, Culligan P, GrahamC,MurphyM,Shott S. Predicting treatment choice for patients with pelvicorgan prolapse. Obstet Gynecol 2003;101:1279–84.

47. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J ObstetGynecol 1959;77:490–502.

48. Zbar AP, Leinemann A, Fritsch H, Beer-Gabel M, Pesca-tori M. Rectocele: pathogenesis and surgical management.Int J Colorectal Dis 2003;18:369–84.

49. Francis WJA, Jeffcoate TNA. Dyspareunia following vag-inal operations. J Opt Soc Am 1961;68:1–10.

50. Arnold MW, Stewart WR, Aguilar PS. Rectocele repair:four years’ experience. Dis Colon Rectum 1990;33:684–7.

51. Mellgren A, Anzen B, Nilsson BY, Johansson C, Dolk A,Gillgren P, et al. Results of rectocele repair: a prospectivestudy. Dis Colon Rectum 1995;38:7–13.

52. Kahn MA, Stanton SL. Posterior colporrhaphy: its effectson bowel and sexual function. Br J Obstet Gynaecol 1997;104:82–6.

53. Weber AM, Walters MD, Piedmonte MR. Sexual func-tion and vaginal anatomy in women before and aftersurgery for pelvic organ prolapse and urinary inconti-nence. Am J Obstet Gynecol 2000;182:1610–5.


54. Sand PK, Koduri A, Lobel RW,WinklerHA, Tomezsko J,Culligan PJ, et al. Prospective randomized trial of polygla-ctin 910 mesh to prevent recurrence of cystoceles andrectoceles. Am J Obstet Gynecol 2001;184:1357–64.

55. Cundiff GW, Weidner AC, Visco AG, Addison WA,Bump RC. An anatomic and functional assessment of thediscrete4 defect rectocele repair. Am J Obstet Gynecol1998;179:1451–7.

56. PorterWE, Steele A,Walsh P, Kohli N, KarramMM.Theanatomic and functional outcomes of defect-specific recto-cele repairs. Am J Obstet Gynecol 1999;181:1353–9.

57. Kenton K, Shott S, Brubaker L. Outcome after rectovagi-nal fascia reattachment for rectocele repair. Am J ObstetGynecol 1999;181:1360–4.

58. Glavind K, Madsen H. A prospective study of the discretefascial defect rectocele repair. Acta Obstet Gynecol Scand2000;79:145–7.

59. Singh K, Cortes E, Reid WMN. Evaluation of the fascialtechnique for surgical repair of isolated posterior vaginalwall prolapse. Obstet Gynecol 2003;101:320–4.

60. Marks MM. The rectal side of the rectocele. Dis ColonRectum 1967;10:387–8.

61. Sullivan ES, Leaverton GH, Hardwick CE. Transrectalperineal repair: an adjunct to improved function afteranorectal surgery. Dis Colon Rectum 1968;11:106–14.

62. Block IR. Transrectal repair of rectoceles using obliterativesuture. Dis Colon Rectum 1986;29:707–11.

63. Goh JT, Tjandra JJ, Carey MP. How could managementof rectoceles be optimized? ANZ J Surg 2002;72:896–901.

64. Sehapayak S. Transrectal repair of rectocele: an extendedarmamentarium of colorectal surgeons. A report of 355cases. Dis Colon Rectum 1985;28:422–33.

65. Janssen LWM, vanDijke CF. Selection criteria for anteriorrectal wall repair in symptomatic rectocele and anteriorrectal wall prolapse. Dis Colon Rectum 1994;37:1100–7.

66. van Dam JH, Huisman WM, Hop WCJ, Schouten WR.Fecal continence after rectocele repair: a prospective study.Int J Colorectal Dis 2000;15:54–7.

67. Ayabaca SM, Zbar AP, Pescatori M. Anal Continenceafter rectocele repair. Dis Colon Rectum 2002;45:63–9.

68. Kohli N, Miklos JR. Dermal graft-augmented rectocelerepair. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:146–9.

69. Oster S, Astrup A. A new vaginal operation for recurrentand large rectocele using dermis transplant. Acta ObstetGynecol Scand 1981;60:493–5.

70. Goh JTW, Dwyer PL. Effectiveness and safety of polypro-pylene mesh in vaginal prolapse surgery. Int Urogynecol J2001;12:S90.

71. Watson SJ, Loder PB,Halligan S, BartramCI, KammMA,Phillips RKS. Transperineal repair of symptomatic recto-cele with Marlex mesh: a clinical, physiological and radio-logic assessment of treatment. J Am Coll Surg 1996;183:257–261.

72. Mercer-Jones MA, Sprowson A, Varma JS. Outcome aftertransperineal mesh repair of rectocele: a case series. DisColon Rectum 2004;47:864–8.

73. Cundiff GW, Harris RL, Coates K, LowVHS, Bump RC,AddisonWA. Abdominal sacral colpoperineopexy: a newapproach for correction of posterior compartment defectsand perineal descent associates with vaginal vault pro-lapse. Am J Obstet Gynecol 1997;177:1345–55.

74. Sullivan ES, Longaker CJ, Lee PY. Total pelvic meshrepair: a ten-year experience. Dis Colon Rectum 2001;44:857–63.

75. Addison WA, Cundiff GW, Bump RC, Harris RL. Sacralcolpopexy is the preferred treatment for vaginal vaultprolapse. J Gynecol Tech 1996;2:69–74.

76. Lyons TL, Winer WK. Laparoscopic rectocele repairusing polyglactin mesh. J Am Assoc Gynecol Laparosc1997;4:381–4.

77. Visco AG, Weidner AC, Barber MD, Myers ER, CundiffGW, Bump RC, et al. Vaginal mesh erosion after abdom-inal sacral colpopexy. Am J Obstet Gynecol 2001;184:297–302.

Address reprint requests to: Geoffrey Cundiff, MD, JohnsHopkins Medicine, Department of Obstetrics and Gynecol-ogy, 4940 Eastern Avenue, Room 125 A1C, Baltimore, MD21224; e-mail: [email protected].

Received May 24, 2004. Received in revised form September 13, 2004.Accepted September 16, 2004.


Documents

Rectocel Cundiff and Fenenr