While most rectoceles are asymptomatic, others can have a plethora of symptoms, and an initial assessment, carefully teasing out these complaints, needs to be performed to discern how much of the symptoms can be attributed to the presence of the rectocele. This is beyond the scope of this chapter and includes incomplete evacuation, fragmentation of bowel movements, fecal incontinence, fecal leakage, or aided man evers for bowel evacuation such as pressing fingers on the perineum or against the posterior wall of the vagina, or significant repositioning techniques on the toilet, or frank digitation and disimpaction. The mechanical bulge can lead to complaints of vaginal fullness or dyspareunia.

Workup includes a minimum of physical exam and endoscopy. Further workup strategies including: transvaginal ultrasound (TVUS), defecography, anorectal manometry (ARM) and balloon expulsion, entero-defecography, dynamic perineal ultrasound, magnetic resonance imaging (MRI) defecography, pudendal nerve terminal motor latency (PNTML) and psychologic evaluation have all been described [42–48]. Workup is dependent on physician preferences, the available facilities, and other concomitant patient complaints.

The three main non-abdominal approaches for an isolated rectocele repair are: transvaginal, transperineal and transrectal. The aim of this chapter is to discuss the common complications that occur with each of these.

The transvaginal approach consists of an incision on the posterior vaginal wall and eventual plication of the rectovaginal fascia. Incorporating the underlying levator ani muscles with interrupted sutures from the levator plate to the perineal body, while reducing the anterior rectal wall, is the classic “posterior colporrhaphy”. The excess vaginal tissue is excised and repair is completed. This technique tends to be favored by the gynecologists given their natural comfort with a transvaginal operations. It also allows an avenue to address other gynecological concerns such as concomitant vaginal hysterectomy or cervical amputation. Since most of the reported studies describing transvaginal approaches are performed by gynecologists, the great majority of patients do not have the functional preoperative workup to assess the type of constipation (outlet obstruction vs. slow transit) or the imaging (defecography) that colon and rectal surgeons tend to employ. Much of this variability is due to differences in training, but this may also be by natural selection, as the gynecologists’ patients will have presenting symptoms typically more gynecologically focused: i.e., vaginal bulge and dyspareunia. Therefore, anal manometry, colonic transit studies and defecography are less utilized in gynecology preoperative workup and also the reported postoperative complications is also gynecologically focused. For example, in the gynecology literature frequently defines recurrence as the relapse of the vaginal bulge with a generalization of the postoperative defecatory complaints. Karram and Maher [49] as part of the Fifth International Collaboration on Incontinence summarized an extensive review of studies and outcomes (Table 9.1). The patients were followed a minimum of 12 months in most studies. Anatomic cure ranged from 76 to 96%, vaginal bulge persisted 4–31%, vaginal digitation continued 0–33%, defecatory dysfunction was seen in 8–36%, and dyspareunia in 8–45%. Many of the trials did not include rates of dyspareunia or defecatory disorders preoperatively to allow postoperative comparison. The postoperative dyspareunia incidence can be assumed to be underestimated as many of the subjects are elderly women and sexually inactive. While the Maher study [50] noted 37/38 women with dyspareunia preoperatively and only 2 postoperatively, the Abramov [51] study noted an increase from 8/183 to 31/183 respectively. Kahn [52] also reported worsening postoperative dyspareunia. Weber illustrate in her study that the resultant vaginal dimension did not correlate with sexual function [53].

Comparisons amongst these studies are difficult as there is a variable selection process that led to surgery. Other complications noted in these repairs as reported by Mellgren include 12% post-operative hematoma, 4% urinary retention and 4% urinary tract infection [54]. Arnold et al. noted: 10% urinary retention, 4% wound breakdown, 3% infection (not abscess) and 7% impaction in the initial post-operative period in their 29 patients [55]. Long-term follow-up noted 54% with constipation, 36% incontinence, 32% pain, 41% bleeding, 23% sexual dysfunction. Despite these findings, patients reported 77% rate of improvement and 77% satisfaction.

While still a trans vaginal approach, others favor a discrete identification of fascial defects and doing a localized repair with nonabsorbable suture. This is described as a “site-specific repair” in which only the area where the levator defect is seen is plicated. The theory is that minor levator ani plication will decrease incidence of dyspareunia [52, 56]. However, collection of many series (Table 9.2) by Karam [49] in comparison with posterior colporrhaphy to site-specific repair, showed no difference in regards to postoperative complications and success. The wide range of results may be attributed to the observation of Nichols that the anterior compartment repair is: “…the most misunderstood and poorly performed” gynecological surgery [57].

Other techniques described may or may not incorporate mesh (biologic: autologous/allograft/xenograft and synthetic) into the repair. Sand [58] reported on 132 women with polyglactin mesh to reinforce the repair and found no difference in comparison to those without mesh. Sung [59] compared tissue porcine sub intestinal submucosal tissue graft repair with native tissue repair in a double-blind multicenter randomized trial with 137 total women for grade 2 symptomatic rectoceles. At one year no difference was seen in objective and subjective success rates for defecatory symptoms. Dyspareunia rates were also not statistically different with 7% and 12.5% respectively. Paraiso [60] evaluated 3 techniques in a prospective randomized trial of posterior colporrhaphy, versus site-specific repair and site-specific repair augmented with porcine small intestine submucosa. While fairly small numbers in each (n = 37, 37, 32 respectively) the anatomic failure rate was statistically highest in the graft augmented group and no significant difference was seen in subjective symptoms or dyspareunia. These results do not support the use of mesh.

Transrectal approach, also described as transanal or endorectal repair, has long been reported by colon and rectal surgeons as their procedure of choice, presumably because the approach is within these surgeons’ technical area of expertise. This technique is characterized by the plication of rectovaginal septum after raising rectal mucosal flaps, removing excess tissue and obliterating the rectocele defect. Anterior levatorplasty is frequently incorporated if incontinence is an issue [61]. While one can also address other anorectal pathology, the transrectal approach is limited in that it can only access the rectocele defect without any opportunity for repairing any other concomitant pelvic pathology such as enterocele and/or cystocele, two known contraindications [62, 63].

While the transanal technique attempts to obliterate the anatomic defect, some studies suggest this specific approach may yield better functional outcomes than other techniques [64]. Hammond studied 88 women who underwent transanal rectocele repair, specifically focusing on bowel and urinary symptoms pre and postoperatively. When compared to a control group without rectocele, women had significant improvement in multiple aspects of defecation, including straining, sensation of incomplete emptying, and need for digital support or laxatives [61].

Despite good symptomatic results with transanal repairs, a retrospective study with long term outcomes (mean 74 months) in 71 patients who underwent transanal rectocele repair showed an overall 50% recurrence rate, with 41% rate of isolated rectocele recurrence and 8% rectocele recurrence with an associated enterocele [65]. Nieminen’s randomized control trial comparing transanal to transvaginal repair in 30 patients suggested that while both techniques offered reliable repairs with associated symptomatic relief, the transanal repair led to more frequent recurrence. Rectocele recurrence was statistically significantly higher in the transanal repair group (40%) versus transvaginal group (7%), after 12-month follow-up [66]. Furthermore, transanal repair also caused weakened anal sphincter tone postoperatively more so than transvaginal repair, a findings supported by other groups [67]. Despite Nieminen noting worse anatomic repair and weakened sphincter tone in the transanal repair group, patients in both groups had significantly decreased need to digitate themselves during defecation and decreased rectocele symptoms. The number of patients followed was too small to detect a superiority between the two approaches [66].

Careful selection may optimize success. A prospective review of transanal repair in 59 women with obstructed defecation over 19 months found especially superior evacuation (93%) if the patients were free of anismus [67]. Another study of 45 woman who underwent transanal repair only if they demonstrated greater than 15% contrast retention on defecography, noted improvement in complete emptying, reduction in manual maneuvers, reduction in dyspareunia (11–3%) and no new reports of sexual dysfunction [69]. A third study noted 80% improvement in pre-operative symptoms when surgery was offered only to those that had admitted to defecatory support and retention of barium on defecography. In this retrospective review of selective criteria for primarily transanal repair, 88% of 33 women reported complete resolution of vaginal bulge, with 92% reporting symptomatic improvement and operative satisfaction after a mean follow-up period of 31 months [68].

The transanal approach shares many of the same complications as the transvaginal approach. Nieminen’s small randomized trial of these two techniques failed to show significant differences with respect to complications, with only 1 out of 15 transanal repairs having a postoperative infection [66]. Commonly reported complications include: fecal impaction, urinary retention, bleeding, wound breakdown, sinus formation, and short longevity of the repair. Thornton [71] in his Posterior colporrhaphy: its effects on bowel and sexual function observed a 13% decline in anal continence and 36% dyspareunia in the transanal arm. Complications unique to the transanal approaches include rectovaginal fistula and stenosis [62, 68]. These unusual complications were reported rarely as a single incidence in most reported studies.

The transperineal approach for rectocele repair stems from the interest to avoid the complications from the other two techniques. By focusing on the failed rectovaginal septum itself, this approach attempts to avoid vaginal tightness and dyspareunia arising from the transvaginal approach or sphincter impairment and incontinence from the transanal approach [73]. The perineal entry allows direct access to the typically widened levator ani muscles, facilitating suture plication of the perineal tissue and rectal submucosa. A transperineal (anterior) levatorplasty, can also be added performed to buttress the rectovaginal septum simultaneously symptoms of dysfunctional defecation. On review of Medline Search, there was a scarcity of papers note in comparison to the other two techniques, One can only assume it is not as commonly performed as the other two approaches already discussed.

A 1998 prospective study of 35 women with rectocele with symptoms of outlet obstruction who underwent transperineal levatorplasty reported a 74% improvement in postoperative defecation, without need for digital maneuvers. Of the 20 women who reported pre-operative incontinence, 75% experienced an improvement in continence [73]. Lamah’s mean 3.2 year follow-up by patient questionnaire after transperineal levatorplasty for rectocele noted 88% had improvement in defecation without the need for digitation, with 74% reporting excellent/good satisfaction [74].

A small study of 15 women who had transperineal rectocele repair at St Mark’s Hospital with 27 months mean follow-up noted that both transanal and transperineal rectocele repair demonstrated a reduction in rectocele size, improvement in sensation of emptying, and less need for digitation. The transperineal repair, however, showed greater overall improvement overall in symptoms. Interestingly, the size of remaining rectocele, if any, did not correlate with symptom improvement in either group [75].

Because of concern for dyspareunia with the use of levatorplasty, a randomized control trial comparing transanal repair to transperineal repair with and without levatorplasty was conducted [76]. On 6-month follow-up, while a significant improvement in constipation was reported in both transperineal groups, it was greater within the transanal group. The transperineal levatorplasty group, however, had the best improvement with less need for digitation, better sensation of complete evacuation, without reporting major complications like hemorrhage, infection or perforation/fistulization. No significant improvement in sexual function was reported in any of the three groups, but the addition of levatorplasty to the transperineal approach was associated with 13% worsening dyspareunia, leading to their recommendation to avoid levatorplasty in sexually active women with rectocele [76].