Surgical management of posterior vaginal defects
- Amy J Park, MD
Amy J Park, MD
- Assistant Professor
- Departments of Obstetrics & Gynecology and Urology
- Georgetown University
- Tristi W Muir, MD
Tristi W Muir, MD
- Department of Obstetrics and Gynecology
- Houston Methodist Hospital
- Marie Fidela R Paraiso, MD, FACOG
Marie Fidela R Paraiso, MD, FACOG
- Professor of Surgery
- Director, Urogynecology and Reconstructive Pelvic Surgery
- Cleveland Clinic Lerner College of Medicine at Case Western University
The surgical approach to management of posterior vaginal wall defects (rectocele) will be discussed here. The clinical manifestations, diagnosis, and nonsurgical management of posterior vaginal defects are reviewed separately. (See "Clinical manifestations, diagnosis, and nonsurgical management of posterior vaginal defects".)
SURGICAL AND FUNCTIONAL ANATOMY
Histology — The apical portion of the posterior vaginal wall consists of mucosa (which includes the epithelium of the posterior wall and the lamina propria), a superficial and deep muscularis layer, and adventitia. This fibromuscularis layer has been called "rectovaginal fascia" and "perirectal fascia."
Histologic examination of the rectovaginal septum reveals that the distal portion near the perineal body contains dense connective tissue; the midportion has an adventitial layer containing fat, fibrous tissue, blood vessels, nerves, and elastic fibers; and the most proximal end is mostly adipose tissue . The adipose tissue between the vaginal tube and rectum allows these two structures to function independently of one another.
Comparisons of the histology of women with and without prolapse have shown that the smooth muscle content of the posterior vaginal wall of women with prolapse is disorganized and significantly reduced compared to women without prolapse .
Normal anatomic support — The upper fourth of the posterior vaginal wall is suspended by the cardinal-uterosacral ligament complex. The middle half is attached laterally to the arcus tendineus fascia pelvis proximally and the arcus tendineus rectovaginalis distally. The lower fourth fuses into the perineal body.
- Kleeman SD, Westermann C, Karram MM. Rectoceles and the anatomy of the posteriorvaginal wall: revisited. Am J Obstet Gynecol 2005; 193:2050.
- Boreham MK, Wai CY, Miller RT, et al. Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse. Am J Obstet Gynecol 2002; 187:1501.
- Delancey JO, Hurd WW. Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 1998; 91:364.
- Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976; 126:568.
- Biller DH, Guerette NL, Bena JF, Davila GW. A prospective, randomized controlled trial of the use of an anal purse-string suture to decrease contamination during pelvic reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:59.
- Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993; 36:976.
- Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2013; :CD004014.
- Jia X, Glazener C, Mowatt G, et al. Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis. BJOG 2008; 115:1350.
- Maher C, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2010; :CD004014.
- Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762.
- Sand PK, Koduri S, Lobel RW, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001; 184:1357.
- Altman D, Zetterström J, Mellgren A, et al. A three-year prospective assessment of rectocele repair using porcine xenograft. Obstet Gynecol 2006; 107:59.
- Altman D, Zetterström J, López A, et al. Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study. Dis Colon Rectum 2005; 48:1233.
- Dell JR, O'Kelley KR. PelviSoft BioMesh augmentation of rectocele repair: the initial clinical experience in 35 patients. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:44.
- Altman D, Mellgren A, Blomgren B, et al. Clinical and histological safety assessment of rectocele repair using collagen mesh. Acta Obstet Gynecol Scand 2004; 83:995.
- Novi JM, Bradley CS, Mahmoud NN, et al. Sexual function in women after rectocele repair with acellular porcine dermis graft vs site-specific rectovaginal fascia repair. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1163.
- Withagen MI, Milani AL, den Boon J, et al. Trocar-guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial. Obstet Gynecol 2011; 117:242.
- Elmér C, Altman D, Engh ME, et al. Trocar-guided transvaginal mesh repair of pelvic organ prolapse. Obstet Gynecol 2009; 113:117.
- Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004; 104:1403.
- Ayabaca SM, Zbar AP, Pescatori M. Anal continence after rectocele repair. Dis Colon Rectum 2002; 45:63.
- Arnold MW, Stewart WR, Aguilar PS. Rectocele repair. Four years' experience. Dis Colon Rectum 1990; 33:684.
- Boccasanta P, Venturi M, Stuto A, et al. Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum 2004; 47:1285.
- Komesu YM, Rogers RG, Kammerer-Doak DN, et al. Posterior repair and sexual function. Am J Obstet Gynecol 2007; 197:101.e1.
- Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol 1997; 104:82.
- FRANCIS WJ, JEFFCOATE TN. Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw 1961; 68:1.
- Kahn, MA, Stanton, SL , Kumar, D , Fox, SD. Posterior colporrhaphy is superior to the transanal repair for treatment of posterior vaginal wall prolapse. Neurourol Urodyn 1999; 18:70.
- Nieminen K, Hiltunen KM, Laitinen J, et al. Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study. Dis Colon Rectum 2004; 47:1636.
- Farid M, Madbouly KM, Hussein A, et al. Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation. World J Surg 2010; 34:822.
- Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, et al. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007; 197:76.e1.
- Mellgren A, Anzén B, Nilsson BY, et al. Results of rectocele repair. A prospective study. Dis Colon Rectum 1995; 38:7.
- Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000; 182:1610.
- Maher CF, Qatawneh AM, Baessler K, Schluter PJ. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Obstet Gynecol 2004; 104:685.
- Cundiff GW, Weidner AC, Visco AG, et al. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998; 179:1451.
- Kenton K, Shott S, Brubaker L. Outcome after rectovaginal fascia reattachment for rectocele repair. Am J Obstet Gynecol 1999; 181:1360.
- Porter WE, Steele A, Walsh P, et al. The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol 1999; 181:1353.
- Glavind K, Madsen H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand 2000; 79:145.
- Abramov Y, Gandhi S, Goldberg RP, et al. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 2005; 105:314.
- Sung VW, Rogers RG, Schaffer JI, et al. Graft use in transvaginal pelvic organ prolapse repair: a systematic review. Obstet Gynecol 2008; 112:1131.
- Murphy M, Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines on vaginal graft use from the society of gynecologic surgeons. Obstet Gynecol 2008; 112:1123.
- SURGICAL AND FUNCTIONAL ANATOMY
- Normal anatomic support
- Functional anatomy
- PREOPERATIVE PREPARATION
- SURGICAL APPROACHES
- Posterior colporrhaphy
- Site-specific defect repair
- Graft augmentation
- Endorectal repair
- Anal sphincteroplasty
- Abdominal sacral colpopexy (colpoperineopexy)
- Iliococcygeus fascia suspension
- POSTOPERATIVE INSTRUCTIONS
- CHOICE OF PROCEDURE
- Vaginal versus transanal approach
- Posterior colporrhaphy versus site-specific versus graft augmentation
- Posterior colporrhaphy
- Site-specific repair
- Graft augmentation
- SUMMARY AND RECOMMENDATIONS