Patients with pelvic organ prolapse present with a variety of symptoms and anatomical findings. In the case of posterior vaginal wall prolapse, one must first determine what part of the patient's support mechanism has failed. It is important to decide in the clinical examination whether her prolapse is related to a loss of apical support, a weakness in the distal vaginal wall, a separation or weakness in the perineal body, or some combination of these support failures.
Like anterior wall prolapse, loss of apical support can lead to prolapse of the upper and mid vagina. Elevating the top of the vagina with a ring forceps or Kelly clamp to a more physiologically normal position in the office or operating room can determine the role of apical failure in the posterior wall prolapse. Once that determination is made, the surgeon then can decide on the type of repair the patient requires.
Occasionally, if the clinical examination does not match the patient's symptoms, radiologic studies such as a defecography can help identify the support defects.
If the prolapse stems predominantly from a loss of apical support, treatment can be addressed through one of several procedures, from a sacral colpopexy to a uterosacral suspension or a sacrospinous vaginal vault suspension. If the prolapse involves a more traditional type of rectocele, where there is loss of support in the distal vaginal wall, one must decide what type of repair—site specific or standard posterior colporrhaphy—will result in the best anatomic and functional outcomes.
Finally, weakness in the perineal body or perineocele is determined by palpating the thickness and integrity of the perineal body on rectal exam.
Equally important to the anatomic considerations and prior to any surgery, the patient's symptoms as well as her current and future sexual function should be addressed. Women with posterior compartment prolapse frequently have symptoms related to bowel dysfunction, including straining, incomplete bowel emptying, painful bowel movements, and fecal incontinence. The extent or severity of symptoms is not necessarily related to the severity of prolapse, and frequently her bowel function is most dependent on upper GI function and the type and frequency of her stool.
Studies have generally shown that most bowel symptoms—particularly straining and incomplete emptying—are resolved or improved with posterior wall repair. In some cases, surgical treatment may not necessarily correct bowel dysfunction, and occasionally it may contribute to bowel dysfunction.
Before surgical therapy, it is critical to understand which symptoms are bothering the patient, if they are related to the physical findings, and if surgical correction of the anatomy will improve her symptoms. Each patient should be appropriately counseled about the possible impact of prolapse surgery on both bowel and sexual function. Depending on the aggressiveness of the repair, approximately 15% of patients may experience some discomfort with intercourse after a colpoperineorrhaphy. Not plicating the levators can decrease but not totally alleviate this risk (Obstet. Gynecol. 2004;104:1403-21).ht
Traditional Repair Yields Best Outcomes
The approach to rectocele repair has evolved over the years, but the literature still suggests that a more traditional type of repair, with side-to-side plication and the use of delayed absorbable suture yields the best results with the least morbidity.
This surgical technique generally involves a two-layer repair, with minimal trimming of some of the vaginal wall and closure of the vaginal mucosa with an interrupted or running polyglactin suture.
Authors of a 2007 Cochrane Review of the Surgical Management of Pelvic Organ Prolapse in Women reported that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele compared with the transanal approach (relative risk 0.24), a type of rectocele repair performed commonly performed by colorectal surgeons. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis. There also were no randomized trials using permanent mesh for rectocele repairs, either as an inlay or as a “suspension kit” (Cochrane Database Syst. Rev. 2007;3:CD004014).h
In one well-conducted, randomized controlled study, the traditional posterior colporrhaphy was found to have a lower failure rate compared with the site-specific repair alone, or a site-specific repair with the addition of a porcine small intestine submucosa graft for rectoceles. Symptomatically, if the anatomical repair was successful, there were no significant differences between the posterior colporrhaphy, site-specific repair, or site-specific repair augmented with porcine small intestine submucosa in terms of perioperative and postoperative morbidity, functional outcomes, quality of life, and bowel and sexual function (Am. J. Obstet. Gynecol. 2006;195:1762-71).