You are in: eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence Relaxed Vaginal OutletArticle Last Updated: Aug 1, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: R Duane Cespedes, MD, Director of Female Urology and Urodynamics, Department of Urology, Wilford Hall Medical Center; Clinical Associate Professor, Department of Surgery, Division of Urology, University of Texas Health Science Center at San Antonio R Duane Cespedes is a member of the following medical societies: Alpha Omega Alpha and American Urological Association Coauthor(s): Gregory L Lacy, MD, Staff Physician, Department of Urology, San Antonio Uniformed Services Health Education Consortium, Wilford Hall Medical Center, Lackland Air Force Base Editors: Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern Memorial Hospital Author and Editor Disclosure Synonyms and related keywords: relaxed vaginal outlet, relaxed perineum, perineoplasty, vaginal prolapse, pelvic prolapse, uterine prolapse, urethral hypermobility, cystocele, rectocele, enterocele, perineal relaxation, pelvic floor relaxation, perineorrhaphy INTRODUCTIONSection 2 of 12
  The current generation of women is maintaining a more active lifestyle into an older age, resulting in an increase in the number of women who seek treatment for prolapse conditions. Consequently, an increased need for expertise in the diagnosis and treatment of these conditions is likely. An active lifestyle and improved quality of life can usually be preserved; however, this requires a thorough understanding of pelvic anatomy and pathophysiology and experience in selecting appropriate surgical procedures. ProblemA relaxed vaginal outlet can be defined as a weakening of the tissues of the distal rectovaginal septum and perineal body. A relaxed outlet is almost always associated with some degree of weakening of the more proximal rectovaginal fascias, which may result in a rectocele. Common symptoms include difficulty with defecation and, possibly, difficulty with sexual dysfunction. FrequencyIn the United States, the exact incidence of relaxed vaginal outlet is unknown because not all patients are symptomatic; however, it is thought to be quite common. EtiologyThe main support for the pelvic viscera is provided by a group of muscles collectively called the levator ani. An intact pelvic floor allows the pelvic and abdominal viscera to "rest" on the levator ani, significantly reducing the tension on the supporting fascia and ligaments. These pelvic ligaments are not true ligaments and are simply condensations of endopelvic fascia covering the pelvic structures. The pelvic floor musculature and the pelvic ligaments work together to provide support to the pelvic floor structures. Most of the weight of the pelvic viscera is supported by the levator ani, whereas the pelvic ligaments stabilize these structures in position, much as a ship's weight is supported by the water and the moorings simply keep the ship from straying from the dock. When the levator ani is damaged, excessive force is placed on the ligaments, creating a predisposition for pelvic prolapse. PathophysiologyConditions of vaginal prolapse, including urethral hypermobility, cystocele, rectocele, enterocele, perineal relaxation, and uterine prolapse, all result from weakness or damage to the normal pelvic support systems. Collectively, these conditions are called pelvic floor relaxation. The pathophysiology of this relaxation can often be linked to multiparity, advanced age, hormonal insufficiency, obesity, neurogenic dysfunction of the pelvic floor, connective tissue abnormalities, or strenuous physical activity. However, pelvic relaxation can occur in young, inactive, nulliparous patients; therefore, a single etiology can rarely be implicated. An association between collagen and connective tissue disorders and pelvic floor relaxation has been established. Some vaginal prolapse conditions may even be caused by prior pelvic surgery. For example, a hysterectomy may cause an enterocele or vault prolapse to form if the vault is not adequately resuspended and the cul-de-sac is not prophylactically obliterated. A bladder neck suspension can alter the vaginal axis, predisposing the patient to enterocele formation. A rectocele is a prolapse of the rectum into the vagina through a damaged rectovaginal septum. The most likely etiology for rectocele formation and perineal relaxation presumably is childbirth because these conditions are essentially confined to parous women. In some cases, a relaxed outlet may be caused by an inadequately or incompletely healed episiotomy performed at the time of childbirth. The most important fascia within the rectovaginal septum is Denonvilliers fascia, which is fused to the inner layer of the posterior vaginal wall and is believed to be disrupted at the caudal and lateral attachments at the perineal body during childbirth. In some cases, enterocele and rectocele formation occur simultaneously, especially if the patient had a hysterectomy. Although a high rectocele may be distinguished from an enterocele only at the time of surgery, a rectocele often forms a pocket just proximal to the anal sphincter. This pocket can trap stool and cause the typical symptoms of straining or the need for digital manipulation to facilitate bowel movements. Perineal body relaxation, a separate and distinct entity from a rectocele, usually manifests as a wide vaginal opening and is usually repaired at the same time as a rectocele. Because the levator ani is attached at the perineal body, strengthening of the perineal body by perineorrhaphy tightens the levator plate, improving the overall degree of pelvic relaxation. ClinicalRelaxed outlet/pelvic prolapse is associated with many symptoms, some of which are nonspecific to the underlying pelvic pathology. It is imperative for the physician to try to determine which symptoms are specifically related to the prolapse condition through meticulous patient interviewing and physical examination. The goal is that these symptoms will resolve or at least improve when the condition is treated. The most common symptoms of a rectocele and relaxed outlet are constipation, which is nonspecific, and splinting, which is the need to place fingers on the posterior wall of the vagina to effectively empty the rectum and complete defecation. Although uncommon, other presenting symptoms may include perineal pain or sexual dysfunction. In general, the larger the rectocele, the more severe the symptoms; however, approximately 10% of symptomatic patients have small rectoceles. Conversely, dyspareunia has been reported after surgical repair in as many as 30% of cases; however, the incidence today is less than 10% because the older method of repair is seldom used. For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Prolapsed Bladder. INDICATIONSSection 3 of 12
A weak perineal body and/or rectocele does not always require surgical repair unless the defect is significant or symptomatic. The potential for postoperative dyspareunia is rarely justified to repair a small asymptomatic rectocele or perineal body. Conversely, some investigators believe that not performing these repairs at the time of an incontinence procedure or hysterectomy may cause undue pressure on other areas of the pelvic floor, possibly necessitating additional surgery at a later date. This has not been the authors' experience, however. RELEVANT ANATOMYSection 4 of 12
The vagina can be anatomically divided into the proximal, middle, and distal regions. The proximal segment, called the vault or cuff, is stabilized by the parametrium, which includes the cardinal and uterosacral ligaments. Uterine and vault prolapse are both associated with damage to these supportive structures. The mid portion of the vagina is attached laterally to the pelvic sidewalls by the lower portion of the paracolpium to the arcus tendineus fascia pelvis (ATFP), which creates the superior lateral vaginal sulcus observed during a physical examination. The pubocervical fascia stretches between the ATFP to support the anterior vaginal wall and bladder. A cystocele can occur when damage to the pubocervical fascia in the central or lateral areas (or both) allows the bladder to prolapse into the vagina. In a similar fashion, the posterior vaginal wall in the mid vagina is supported centrally and laterally by the rectovaginal fascia, which is attached to the fascia of the levator ani musculature. These attachments prevent the rectum from prolapsing into the vagina and causing a rectocele. The distal vagina is firmly attached to the surrounding structures, including the urethra and symphysis pubis anteriorly, levator ani laterally, and perineal musculature posteriorly. Damage to the perineal musculature by childbirth or surgery are common causes of a relaxed outlet. CONTRAINDICATIONSSection 5 of 12
Although no absolute contraindications to performing these procedures exist, they are usually not performed unless the patient is symptomatic. In most cases, these procedures are performed in conjunction with other pelvic prolapse repairs. WORKUPSection 6 of 12
Imaging Studies
Diagnostic Procedures
TREATMENTSection 7 of 12
Surgical therapySurgical therapy, including rectocele and perineal body repair, are the mainstays of treatment. The choice of surgical treatment of a relaxed outlet or rectocele is based on the severity of symptoms and the presence of concomitant pathology. Repair is not always required unless the defect is large and/or symptomatic. It would be difficult to justify postoperative dyspareunia to address a small asymptomatic rectocele or perineal body. Conversely, some investigators believe that not performing these repairs at the time of an incontinence procedure or hysterectomy may cause undue pressure on other areas of the pelvic floor, possibly necessitating additional surgery at a later date. When treatment is indicated, management choices are both nonsurgical and surgical; however, surgery is the mainstay of treatment. With respect to surgical management, reconstructive repairs (eg, posterior colporrhaphy, perineorrhaphy) and obliterative repairs (eg, colpocleisis) have been performed depending on the age, level of sexual activity, and associated prolapse in other areas. For the management of relaxed outlet and rectocele, surgery is the mainstay of treatment. A successful surgical outcome is best facilitated by awareness of the various surgical approaches and techniques as well as adequate preoperative planning. Over the years, various surgical treatments for rectocele have been proposed and performed. The surgical approach for repair includes the following approaches: transabdominal, transvaginal, transperineal, combined transabdominal and transperineal, transanal, and laparoscopic. Multiple retrospective studies have shown transvaginal repair to be the superior approach in terms of recurrent prolapse and postoperative morbidity. Transvaginal repair provides better surgical exposure and the opportunity to perform additional pelvic and incontinence procedures. The traditional rectocele repair using sutures to reapproximate the separated fascia remains the most common and effective approach, especially in primary repairs. A relatively recent addition to the treatment of a relaxed outlet is the use of graft materials as a reinforcing material in pelvic prolapse surgery. Several authors have reported the use of various graft materials (synthetic and biologic) for interposition midline fascial repair of rectocele as well as re-enforcing primary rectocele repair. Materials that have been used include fascia lata, squamous intestinal submucosa (SIS), dermis, xenograft (porcine) and Prolene mesh. Long-term results using reinforcing materials in rectocele repair have not been adequately studied; however, 1 small series reported an 84% cure rate using polypropylene mesh. Several authors have reported their experience with site-specific rectocele repair. Site-specific repair, in which only the focal area of weakness is repaired, has recently been shown to have a lower cure rate than the traditional posterior repair. In most cases, the posterior fascial defect is continuous from the most proximal extent of the defect all the way down to the perineal body. In a large retrospective review, Ambramov et al demonstrated that site-specific rectocele repair was associated with a significantly higher anatomic recurrence rate with similar rates of dyspareunia and bowel symptoms compared with the standard repair. Preoperative detailsTypically, the patient is administered enemas the night before the procedure to cleanse the rectum, and preoperative intravenous antibiotics are also given. Generally, if other procedures are to be performed, the rectocele and perineal body repair are performed last because these repairs obscure proximal vaginal exposure. Intraoperative detailsSome investigators place Betadine-soaked rectal packing to assist in the identification of the rectum and to avoid injury; however, the authors prefer to manually push the rectum down and away. The ultimate size of the vaginal orifice is determined by placing Allis clamps on the inner aspect of the posterior labia and bringing the clamps together. Two fingers should be admitted easily. The skin between the Allis clamps is incised, followed by a triangular skin incision (with the apex pointing toward the anus) on the perineal body. The overlying skin is removed and a midline vaginal incision is made in the rectovaginal space, extending at least 1 cm proximal to the beginning of the rectocele. The underlying rectum is dissected off the posterior vaginal wall until the medial margins of the pubococcygeus muscle are observed. Starting near the vaginal apex, the pararectal fascia is closed over the rectal wall using absorbable or nonabsorbable 2-0 or 0 sutures in an interrupted fashion, all the way to the perineal body (see Images 1-6). An evaluation after the first few sutures are placed should allow 2 fingers to be admitted easily. If an inadequate vaginal caliber is created, dyspareunia or an inability to engage in sexual intercourse may occur. The sutures are placed sequentially all the way to the perineal body. The perineal body is repaired by placing multiple 0 absorbable sutures deeply into the bulbocavernosus and superficial transverse perineal muscles. The perineal body is then fixated to the distal end of the rectocele repair using a purse string type suture placement. This is an important consideration as the 2 structures will otherwise function as separate entities and the perineum can descend, making defecation difficult. If the patient has weak tissue or if additional strength is desired, a reinforcing material can be placed over the completed rectocele repair. The authors typically use preperforated porcine dermis and anchor it with 1-0 Vicryl sutures in at least 6 places using a Capio needle driver. Recheck that at least 2 fingers can be easily admitted into the vaginal opening. The vaginal mucosa is closed with absorbable suture in a running locking fashion, and the perineal skin is closed subcuticularly. A vaginal pack is placed. Postoperative detailsPatients should maintain a diet that keeps their stools soft, avoid any straining or heavy lifting, and refrain from sexual intercourse for approximately 4-6 weeks to allow complete tissue healing. COMPLICATIONSSection 8 of 12
Significant complications are uncommon with one study, reporting a 12.5% incidence of transient urinary retention but no rectal injuries, fecal incontinence, or hemorrhage. Postoperative dyspareunia rates are quite variable between series, and, in some cases, a rectocele repair can improve preoperative dyspareunia. Haase and Skivsted reported a 9% de novo dyspareunia rate; however, 24% of all patients had an improvement in their sexual satisfaction. Zimmern reported an 11% dyspareunia rate, yet 73% of patients stated their sexual function was improved. Scant data exist on the complications of using reinforcing materials for posterior repairs. A study by Porter using polypropylene mesh reported a 13% vaginal erosion rate; however, all responded to local debridement only. Another study using allograft dermis reported an 8% extrusion rate but none required operative treatment. The exact incidence of rectal injury is unknown and probably underreported since most can be easily repaired without long-term sequelae. A rectovaginal fistula is a dreaded and fortunately rare complication. OUTCOME AND PROGNOSISSection 9 of 12
The long-term results of traditional and site-specific rectocele repairs appears to be between 80% and 95% in various series. Long-term results using reinforcing materials in rectocele repairs have not been adequately studied; however, 1 small series reported an 84% cure rate using polypropylene mesh. Site-specific repairs in which only the focal areas of weakness are repaired have recently been shown to have a slightly lower cure rate than the traditional posterior repair as described above. In most cases, the posterior fascial defect is continuous from the most proximal extent of the defect all the way down to the perineal body. FUTURE AND CONTROVERSIESSection 10 of 12
The role of reinforcing materials is not yet clear; however, their use in selected patients with large rectoceles, poor tissue strength, or symptomatic recurrences appears indicated. The optimal material for reinforcing rectoceles has yet to be determined. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Relaxed Vaginal Outlet excerpt Article Last Updated: Aug 1, 2006 | ||||||||||||||||||||||||||||||||||||||||||
