Surgical management of posterior vaginal defects
- Amy J Park, MD
Amy J Park, MD
- Associate 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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- 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