It is very important when taking a history preoperatively to assess if a patient is sexual active, plans on becoming active, and what her current sexual function is. Dyspareunia is reported as a presenting symptom in 29% of women undergoing rectocele repair [26]. Further, dyspareunia is a known potential complication of posterior compartment repair, so the above must be openly discussed preoperatively. There are numerous questionnaires that can be utilized to objectively classify a woman’s sexual function both pre- and postoperatively. For example, the Sexual History Form and the Female Sexual Function Index are validated measures [27, 28]. Some questionnaires are for general sexual function and others have been validated specifically in the pelvic organ prolapse population. This preoperative assessment is important to help counsel the patient on the appropriate repair. It is also useful so that there is a baseline to compare postoperative outcomes against if results are not satisfactory.

Women with rectoceles can present with other aspects of sexual dysfunction along with dyspareunia. Out of a selective group of 68 women with sexual dysfunction who were undergoing fascial suture rectocele repairs, 85% were noted to have dyspareunia as a presenting symptom [29]. After the repair at six-month follow-up, the patients showed significant improvement for desire (p > 0.001), satisfaction (p > 0.0001), and pain (p > 0.0001). There were no significant changes for arousal (p = 0.0897), lubrication (p = 1), or orgasm (p = 0.0893). Only one patient experienced de novo dyspareunia. This was attributed to a postoperative infection resulting in excessive scar tissue of the posterior wall of the vagina. A systematic review by Jha and colleagues of 14 articles that assessed sexual function and dyspareunia before and after anterior and/or posterior prolapse repair with native tissue found significant improvements postoperatively in sexual function and dyspareunia [30]. Unfortunately this analysis included all patients who had prolapse repair regardless of whether anterior, posterior, or combined, and no subanalysis limited to posterior repairs was performed. The authors did note that in studies by Colombo [31], Haase [32], and Dua and colleagues [33], higher rates of dyspareunia were reported in patients who underwent a colpoperineorrhaphy or posterior repair in addition to an anterior repair than in those patients who underwent an isolated anterior repair.

As noted earlier, after prolapse repair there is often an improvement in many of the sexual function domains; however, some studies suggest that posterior repair may have higher rates of postoperative dyspareunia than repair of other compartments of pelvic organ prolapse. One such study looked at a cohort of women who underwent anti-incontinence surgery and concomitant pelvic organ prolapse repair. They divide these women in two groups for comparison: those that had posterior repair and those who did not have a posterior repair. Although both groups had improvements postoperatively in their Pelvic Organ Prolapse-Urinary incontinence Sexual Function Questionnaire (PISQ) score, the women who did not have posterior repairs were noted to have a lower incidence of dyspareunia than those who had posterior repairs [34]. A systematic review of complications after vaginal prolapse repair found that reported rates of dyspareunia varied widely after prolapse repair surgery. Seventy studies were identified with reports of dyspareunia with an average rate of 9.1% and a range of 0–66.7%. These studies were not analyzed based on location of repair; however, five of the papers cited posterior repair as a risk factor for dyspareunia [35].

Dyspareunia rates following transvaginal posterior repair have not been found to vary by type of surgical repair. A meta-analysis showed similar dyspareunia outcome rates for posterior colporrhaphy and for site-specific posterior repairs. Traditional posterior colporrhaphy or midline plication had a reported mean postoperative dyspareunia rate of 18% (range 5–45%) based on analysis of seven studies with a total of 522 patients, and site-specific repair was found to have an identical mean postoperative dyspareunia rate of 18% (range 7–67%) based on analysis of eight studies with a total of 487 patients [6]. Another study compared traditional posterior colporrhaphy to site-specific repairs in a retrospective chart review and again found similar rates of dyspareunia and bowel symptoms, though the site-specific repair had a higher recurrence rate of a symptomatic bulge beyond the hymenal ring (11% vs. 4%, p = 0.02) [36].

The surgical approach, whether abdominal, vaginal, or transanal, may affect postoperative dyspareunia rates. In a randomized study comparing transanal and transvaginal rectocele repairs, none of the subjects reported de novo dyspareunia, while 27% reported improvement of sexual function, slightly in favor of the transanal repair [37]. Similar to prior studies, this study also found higher rates of prolapse recurrence with the transanal approach. Though less common, dyspareunia is also seen with the abdominal approach. Sergent and colleagues found that sacrocolpopexy with polyester mesh had a de novo dyschezia rate of 1.7% and dyspareunia rate of 0.8% [38]. Claerhout and coworkers utilized polypropylene mesh in abdominal repairs and found de novo constipation rates of 5% and de novo dyspareunia of 19% with mesh [39]. A comparison of these few small studies is not meant to replace a large randomized study (that would be more appropriately powered to show differences in these domains), but rather to illustrate that different mesh types (i.e. polyester vs. propylene) used abdominally may result in different dyspareunia rates.

Levator plication, another technique to correct posterior compartment defects, is associated with increased rates of dyspareunia. In a prospective study, 93 women who had undergone prolapse repair completed the validated International Consultation on Incontinence modular Questionnaire-Vaginal Symptoms (ICIQ-VS) at 6 and 12 months postoperatively. The study found that the subjective vaginal and sexual matters scores improved less in women who had levator plication sutures during posterior vaginal repair compared to those who did not. Furthermore, the women with levator plication showed a significant increase in postoperative dyspareunia (p ≤ 0.05) while women who underwent posterior repair only had no change in their incidence of dyspareunia [40]. It is believed that the de novo dyspareunia that occurs with levatorplasty results from pressure atrophy of the included muscle and the subsequent scarring that takes place [41, 42]. This may not be the complete cause, however, as dyspareunia can be associated with posterior colporrhaphy even if there is no concomitant levatorplasty or synthetic material used.

Surgical techniques to decrease risk of dyspareunia are mostly based on expert opinion, as there are no well-designed, randomized controlled trials to assess the impact of different methods of posterior prolapse repair on sexual function and dyspareunia. Sexual function and dyspareunia have not been found to correlate with anatomical success of prolapse repair. One study of sexually active women undergoing posterior repair looked at whether vaginal dimensions at the time of surgery predicted dyspareunia and did not find an effect [42]. However, expert opinion suggests avoiding excessive tightening of the posterior vagina during a rectocele repair. If a concomitant perineal body repair is needed it is also important to avoid excessive tightening of the introitus as this can contribute significantly to sexual dysfunction after surgery. The surgeon’s fingers can be used intraoperatively to calibrate the vagina to an appropriate size. Some advocate calibrating the vagina to 2–3 fingerbreadths, which should prevent anatomic difficulties with vaginal penetration in women who are interested in resuming this type of sexual activity [41].

The surgeon may choose to utilize an absorbable mesh, biologic graft, or permanent mesh. The use of mesh to augment posterior repairs is a potential contributor to postoperative dyspareunia. It is important to remember that the mesh may contract after it is placed intraoperatively. Mesh has been shown to contract or retract after placement with some showing up to a 66% decrease in size [43]. To date there is no clear evidence that this gradual decrease in mesh size is associated with dyspareunia, but it is a potential explanation for those who believe that mesh augmentation of the posterior compartment can worsen sexual outcomes. Mesh should be tailored or placed so as to avoid excessive tension to accommodate for such potential tightening. If vaginally placed mesh is anchored in structures such as muscle, the presence of a tight mesh band can lead to pulling on these muscles groups that may result in significant discomfort during intercourse. Mesh exposure and extrusion may also cause sexual complications and will be discussed later in the chapter .

Although mostly based on expert opinion, there are a few areas of surgical technique that should be considered when placing mesh posteriorly. Appropriate thickness of the vaginal flaps and meticulous closure of any vaginal incisions may reduce mesh-related complications. Care must be used to ensure appropriate placement of mesh so that it does not bunch or role in the vagina. This can form areas of inflammatory reactions that can be uncomfortable for women and may also be felt by male partners. Another potential cause of dyspareunia is vaginal narrowing. Vaginal narrowing can occur secondary to excessive trimming of the vaginal wall, which also result in tenuous coverage of any foreign material utilized. For abdominally placed mesh, differences in technique such as the extent of the posterior dissection or the width of the dissection with subsequent mesh fixation have also been proposed as potential factors that might lead to differences in painful intercourse post abdominal sacrocolpopexy.

Sexual function outcomes following vaginally placed biologic grafts have also been considered. Studies have been conflicted regarding whether graft augmentation of posterior repair improves anatomic or functional outcomes [44–46]. Therefore, the decision to utilize a graft or mesh should be weighed against the potential risks, including dyspareunia. Paraiso and colleagues compared posterior colporrhaphy, site-specific repair, and site-specific repair with porcine small intestine submucosa graft in a randomized trial [45]. They found no difference in postoperative sexual function (PISQ-12 and asking “Do you feel pain during intercourse?”). There were also no differences in quality of life measures or bowel function. Perioperative and postoperative morbidity did not show a difference, albeit the study was underpowered to discern differences in these events. Importantly, however, they reported a lower failure rate with traditional repair techniques compared to the site-specific repair with porcine small intestine submucosa graft for rectoceles. This study suggests that sexual complications do not differ significantly based on repair type, but biologic agents have higher failure rates. A prospective cohort study of 50 women undergoing posterior wall repair and prespinous colpopexy with a biological small intestinal submucosa graft reported statistically significant improvement in vaginal symptoms and sexual matters score at 6 month follow-up [47]. One weakness of this study was that it did not have a control arm, so only limited conclusions can be drawn concerning the use of graft. Of note, this study found that concomitant pelvic surgery did not affect the outcomes of posterior wall repair with prespinous colpopexy and biological graft.

Synthetic permanent mesh is also used in prolapse repair. If the surgeon and patient elect to use a permanent mesh, selecting the appropriate type of mesh is an intraoperative decision that can minimize morbidity. Macroporous, monofilament, polypropylene mesh (type 1) has been found to have the most favorable biocompatibility profile of the synthetic meshes that are currently available. The lack of interstices allows native collagen to grow into the material and the large pore size allow for entry of macrophages and the body’s other immune mediators [48]. One study that looked at posterior repair with permanent mesh (composite polyglactin 910-polypropylene) with 3-year follow-up found de novo dyspareunia in 27% of women [49]. The study’s long-term follow-up showed no improvement from baseline, preoperative dyspareunia. This was in contrast to previously published short-term results that showed an improvement. When patients with persistent dyspareunia and those with de novo dyspareunia were combined for analysis, the prevalence of dyspareunia was a staggering 60%. The “extrusion” rate was 30% and the recurrence rate was 22%. The repair described in the study avoided a rectovaginal plication and trimming of vaginal wall because these maneuvers (that they avoided) could presumably result in vaginal narrowing, and ultimately dyspareunia. A prospective study of monofilament polypropylene mesh use in posterior repairs reported a similarly high rate of postoperative dyspareunia [50]. At mean follow-up of 17 months a statistically significant increase of dyspareunia from 6% preoperatively to 69% postoperatively was found. In this study, the surgeon dissected laterally to the rectal pillars, performed a plication of the rectovaginal fascial tissues, and secured the mesh. Excess vaginal wall was also trimmed prior to closing the posterior vaginal wall.

Based on the available studies, if a vaginal approach is elected for posterior repair we would caution the use of biological agents or permanent mesh given the high incidence of recurrence and dyspareunia. The International Urogynecological Association Grafts Roundtable that convened in 2005 suggested the following patient factors as relative contraindications for the use of biomaterials in pelvic floor reconstructions: pelvic irradiation; severe urogenital atrophy; immunosuppression; active infection; and comorbidities such as poorly controlled diabetes, morbid obesity, and heavy smoking [51], and we would agree with these relative contraindication for the use of biomaterials in posterior repairs. Further, in 2008 and 2011 the FDA issued Public Health Notifications on the serious complications of transvaginal mesh and subsequently stated that it might reclassify vaginal mesh as a high-risk device requiring clinical study from its status as a moderate-risk device approved in the 510(k) process. It is our opinion that because the data on the use of mesh in the posterior compartment would not support its routine use, as studies have found no significant reduction in recurrence rate with a higher complication rate, we reserve it for the rare case when the rectovaginal septum is completely obliterated.

There are other intraoperative techniques to prevent dyspareunia that may not fit neatly into a category. For example, the use of copious irrigation and perioperative antibiotics is something that routinely happens. These are simple methods to reduce the risk of infection. These techniques are included in this section because of the potential complications that infection can carry. An abscess of a local surgical site infection, for example, may result in excessive scarring and inflammation that potentially lead to painful intercourse.

In order to identify postoperative dyspareunia, the surgeon should ask specific questions regarding the patient’s sexual function. As with preoperative evaluations, standardized questionnaires can be utilized to aid with evaluation. Patient’s bother and time from surgery must be considered when discussing potential treatments of this outcome. If a patient elects for therapy for dyspareunia, conservative treatment options exist. Topical lubricants, vaginal estrogen, and even topical local anesthetics have been described to help lessen or alleviate some of the more mild symptoms. Systemic or local anxiolytics such as benzodiazepines have also been utilized to help relax pelvic floor muscles (Fig. 6.3). When palpation on physical examination reveals pain at specific trigger points, injections with local anesthetics and/or steroids can be considered.

Physical therapy with the optional use of vaginal dilators is another method that can help address symptoms. Vaginal dilators are thought to improve dyspareunia by stretching the levator ani muscles and softening or preventing scar formation (Fig. 6.4). A randomized controlled trial of sexually active patients with no preoperative dyspareunia undergoing posterior colporrhaphy was done to determine when vaginal dilators could be safely used during the early postoperative period [52]. Patients were randomized to daily vaginal dilator use from postoperative weeks 4–8 or to no dilator use. No difference was found between those using dilators compared to controls with regard to de novo dyspareunia rates, Patient Global Impression of Improvement scores, or Pelvic Organ Prolapse/Urinary Incontinent Sexual Function Questionnaire-12 scores. Of note, in contrast to prior studies that reported improvement in dyspareunia with dilator use [16, 45], this study found no change in overall sexual function from baseline at 6 months. The authors attributed this difference to the relatively low dyspareunia rates at baseline and the lack of standardized definition of dyspareunia across studies .

Careful physical examination is also extremely useful to determine the specific cause of dyspareunia and to identify what will respond best to surgical intervention. Palpation for tight bands of tissue, extrusions, and tender pelvic muscles is an important aspect of the physical exam to identify potential causes of dyspareunia and to direct management of this complication. If a discrete band of tissue is identified on physical exam attached to the vaginal wall and incorporated into the levator ani muscles, operative release of this tissue can help to alleviate symptoms of pain during intercourse. Aside from the release of excessively tight tissue, graft material may be necessary if there is a paucity of local tissue to reconstruct an adequate vaginal lumen. Excessive narrowing of the vaginal introitus or canal may also require surgical intervention.

Other therapies have also been studied for the treatment of dyspareunia. There is level III evidence to support the use of botulinum toxin in the treatment of severe refractory vaginismus. This comes from a study of 24 women where the etiology of vaginismus was not specified in the inclusion criteria. After failing other therapies these women were injected with 150–400 units of onabotulinum toxin type A in three sites on each side of the puborectalis muscle. After a mean follow-up of 12 months none of the patients had recurrent vaginismus, and 75% were able to achieve satisfactory intercourse [53]. More specifically, there are case reports describing the use of botulinum toxin in a postoperative patient who experienced de novo dyspareunia and vaginismus [54, 55].

Preoperative imaging may be useful during surgical planning; however, there is no standardized method for radiographic rectocele evaluation. It has been reported that 80% of colorectal surgeons use defecography before a rectocele repair compared to only 6% of gynecologists [56]. This variance is due in part to a lack of evidence demonstrating superior outcomes associated with use of preoperative defecography. Defecography provides a two-dimensional view of rectal emptying and is useful to exclude patients with pelvic floor dyssynergia who will not benefit from an operation. The dynamic nature of the test and use of contrast allows for visualization and identification of the rectocele and any adjacent enterocele, sigmoidocele, or intussusception. Knowledge of associated defects theoretically may aid in avoidance of injury and surgical planning, for example, the addition of a sigmoid resection or sigmoidopexy. A benefit of defecation proctography to dynamic MRI is that it is performed in a position of gravity, which permits study of anatomy and function under conditions that better recreate daily life [57]. However, some studies have shown a lack of utility in obtaining preoperative defecography. In an older study , 74 patients with rectocele and symptoms of obstructed defecation were prospectively enrolled and underwent preoperative defecography in addition to a standardized questionnaire and physical exam [58]. Following a combined transvaginal/transanal rectocele repair they were again evaluated with defecography and, at median follow-up of 58 months, results of the rectocele repair were independently evaluated. Outcome analysis found that clinical success was not influenced by preoperative size of the rectocele, barium trapping, internal intussusception, rectal evacuation, perineal descent, or radiologic evidence of anismus, leading the authors to question the role of defecography in predicting clinical outcomes. Another study retrospectively looked at 170 patients who had undergone defecography and compared detection of prolapse on clinical and radiographic exam [3]. The authors concluded that most radiographic rectoceles and cystoceles are found on physical exam, while correlation is poor between defecography and physical exam in cases of enteroceles and sigmoidoceles.

Depending on surgeon preference, a bowel prep may be used preoperatively for abdominal and transanal posterior repairs. A bowel prep does not necessarily decrease the risk of rectal injury; however, it does decrease the risk of gross contamination if in fact a rectal injury occurs. Some laparoscopic/robotic surgeons have suggested that more complete bowel prep decreases distention secondary to bulky stool or excessive bowel gas that can make dissection more challenging and interfere with visualization. Women with symptomatic rectoceles can have a significant degree of constipation and trapping of stool at baseline. In cases where women have excessive amounts of stool in the rectal vault, intraoperative rectal exam or manipulation can be a more challenging proposition. Patients may benefit from a modified bowel prep. An enema given preoperatively can be an effective way of cleaning out the rectal vault if that is all that is needed preoperatively. Enemas are generally well tolerated and do not dehydrate patients the same way a full bowel prep would.