You are in: eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence RectoceleArticle Last Updated: Sep 7, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Howard A Shaw, MD, Associate Professor of Obstetrics and Gynecology, University of Connecticut; Chairman/Director, Residency Program Director, Department of Obstetrics and Gynecology, St Francis Hospital and Medical Center Howard A Shaw is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American College of Physician Executives, Association of American Medical Colleges, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Connecticut State Medical Society, and Southern Medical Association Editors: Jordan G Pritzker, MD, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Gail F Whitman-Elia, MD, Professor, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine; 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: rectocele, prolapse of the genital organs, herniation or bulging of the posterior vaginal wall with the anterior wall of the rectum in direct apposition to the vaginal epithelium, pelvic organ prolapse, defect of the rectovaginal septum, weaknesses of the pelvic support system, pelvic support defects, occult enterocele, fascia of Denonvilliers, mass in the vagina, bulge in the vagina, levator ani muscles, anal sphincter, difficultywithintravaginalintercourse, recurrent vaginal ulcerations, fecal incontinence INTRODUCTIONSection 2 of 12
  Pelvic organ prolapse is a common condition whose incidence is increasing. Many cases of prolapse of the posterior vaginal wall occur along with other pelvic support defects. Pelvic surgeons who treat rectocele must have an excellent understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship between anatomy and function. These pelvic support defects may or may not cause symptoms. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been described in patients with rectoceles. Whether prolapse is the cause or result of these symptoms is uncertain. This article focuses on (1) current knowledge regarding the relationship of rectocele anatomy and function and (2) useful evaluations and treatments for women with rectoceles and defecation disorders. History of the ProcedureThe Egyptians were the first to describe prolapse of the genital organs. Hippocrates mentioned the introduction of half of a pomegranate into the vagina as a treatment for prolapse. The surgical treatment of rectocele has traditionally been the posterior colporrhaphy. This procedure was designed to repair perineal tears and included plication of the pubococcygeus muscles and the posterior vaginal wall and reconstruction of the perineal body. Recently, Richardson has advocated the site-specific repair of discrete breaks or tears in the rectovaginal septum. This approach aims for a more anatomic repair. Other considerations for treatment include the approach (transvaginal vs transanal) and the introduction of different types of grafts to attempt improvement of the longevity of the procedure. ProblemRectocele is defined as herniation or bulging of the posterior vaginal wall, with the anterior wall of the rectum in direct apposition to the vaginal epithelium (see Image 1). FrequencyPelvic organ prolapse is very common, and it is the indication for more than 300,000 surgeries in the United States annually. The number of women seeking care for pelvic organ prolapse is predicted to increase by 45% over the next few years. Ambulatory women have a reported prevalence rate of pelvic organ prolapse of 30-93%. One of the difficulties in reviewing studies of pelvic organ prolapse is that they include all support defects (eg, defects of the vaginal apex, anterior wall, and posterior wall), although most women have support defects at multiple locations. The other difficulty when reviewing the literature to determine the prevalence of pelvic organ prolapse is that in ambulatory women, most pelvic organ prolapse is mild, with prolapse beyond the vaginal introitus occurring in less than 5% of cases. Data on symptomatic women with prolapse are somewhat more robust. Olsen et al reviewed a cohort of 149,544 women and found an 11.1% lifetime risk of surgery for pelvic organ prolapse or urinary incontinence. Unfortunately, in this population, the reoperation rate was 29.9%, suggesting that surgical interventions are not always efficacious. Thus, pelvic organ prolapse and rectocele are relatively common, although the supporting data are limited. The incidence of pelvic organ prolapse and rectocele increases with age and parity, although even nulliparous women may present with a clinically significant rectocele, albeit relatively uncommon (see Image 1). EtiologyRectocele and other forms of pelvic organ prolapse are the result of women attaining an erect bipedal posture. Etiologically, most cases are the result of vaginal childbirth and chronic increases in intra-abdominal pressure. In some patients, rectocele is thought to develop as a result of congenital or inherited weaknesses within the pelvic support system. A number of iatrogenic factors may contribute to pelvic organ prolapse, including failure to adequately correct all pelvic support defects during pelvic reconstructive surgery. In some patients, the failure to reattach the endopelvic fascia to the perineal body at the time of vaginal delivery leads to a site-specific defect in the endopelvic fascia. Additionally, procedures that alter the direction of pelvic forces can cause areas to prolapse that previously had been adequately supported. Examples include (1) ventral suspensions of the urethra, uterus, or vagina that increase exposure of the cul-de-sac to increases in intra-abdominal pressure; (2) posterior fixation of the vaginal apex; (3) failure to detect and correct an occult enterocele; and (4) excessive shortening of the vagina. PathophysiologyRectocele is a defect of the rectovaginal septum, not the rectum. The pelvic surgeon must know the anatomy of the pelvic floor and the other supports of the vagina in order to diagnose and treat this disorder. The muscular support of the pelvis is from the pelvic diaphragm. The pelvic diaphragm is made up of a group of paired muscles that include the levator ani and coccygeus muscles. The levator ani are composed of the puborectalis, pubococcygeus, and ileococcygeus muscles. These muscles have their origin at the pubic rami on either side of the midline at the level of the arcus tendineus levator ani. The muscle fibers of the levator ani pass lateral to the vagina and rectum, creating a sling surrounding the genital hiatus. They also create the pelvic floor posteriorly and laterally. When a woman contracts the levator ani, the pelvic diaphragm provides a horizontal shelf where the pelvic viscera lie and the genital hiatus closes. The thin membranous connective tissue in the rectovaginal septum (and surrounding the entire vaginal tube) is called the Denonvilliers aponeurosis (fascia) or endopelvic fascia and is fused to the underside of the posterior vaginal wall. This rectovaginal fascia extends downward from the posterior aspect of the cervix and cardinal-uterosacral ligaments to its attachment on the upper margin of the perineal body; then, it laterally extends to the fascia over the levator ani muscles. The cardinal and uterosacral ligaments pull the vagina horizontally toward the sacrum, suspending it over the muscular levator plate. The perineal body is located between the vaginal introitus and anus. It is the attachment for the perineal membrane (bulbocavernosus muscles, superficial transverse perineal muscles, and investing fascia), a portion of the levator ani, the external anal sphincter, and the rectovaginal (endopelvic) fascia. Through its attachment to the cardinal and uterosacral ligaments, the rectovaginal septum stabilizes the perineal body, which is essentially suspended from the sacrum. The perineal body is further stabilized through the lateral attachments of the perineal membrane to the ischiopubic rami. Between the lateral and superior support, the downward mobility of the perineal body is limited. However, if this attachment is separated, as can occur during childbirth, the perineal body can become more mobile, leading to rectocele and perineal descent. ClinicalPatients with rectocele often present with feelings of pelvic pressure, a sensation of "bearing-down," or a perception that something is "falling out." Symptoms are often accentuated by standing and lifting and relieved by lying down. Symptoms directly related to the prolapse include the sensation of a mass or bulge in the vagina, pelvic pressure and pain, low back pain, and difficulty with intravaginal intercourse. Symptoms directly related to rectocele include defecatory dysfunction, inability to completely evacuate the distal rectum without straining, constipation, and dyspareunia. The pelvic examination findings should define the degree of prolapse and help determine the integrity of the connective tissue and muscular support of the pelvic organs. The pelvic examination is best performed with the patient in the dorsal lithotomy position, with her head elevated 45° (which allows for maximal Valsalva). Rectocele is suspected when posterior wall bulging is noted. The extent of prolapse must be documented. One method is to measure the degree of descent with respect to the hymenal ring. The Pelvic Organ Prolapse Quantitation examination is the most widely accepted at this time and has been adopted by the American Urogynecologic Society and the International Continence Society. The 9 measurements made are 6 topographical points on the vaginal walls, 2 topographical points on the perineum, and vaginal length. All portions of the vagina should be evaluated. This includes the vaginal apex, the anterior wall, and the posterior wall. The posterior wall is assessed while supporting the vaginal apex and anterior wall with a Sims speculum or with the posterior blade of a Grave speculum. This allows identification of the specific location of the defect in the rectovaginal fascia. The examiner may note that the rugae in the vaginal epithelium are lost overlying the defect in the endopelvic fascia. Generally, a pocket is observed just above the anal sphincter. Anterior displacement of the rectal wall observed upon rectovaginal examination is diagnostic of rectocele. A rectovaginal examination provides information regarding the integrity of the rectovaginal fascia, perineal body, and possible identification of an enterocele. In a healthy woman, the perineum should be located at the level of the ischial tuberosities or within 2 cm of them. Diagnosis of perineal descent is made if the perineum is noted to be below this level either at rest or with straining. In a patient with perineal decent, widening of the genital hiatus and perineal body and flattening of the intergluteal sulcus may be seen. The degree of perineal descent can be objectively measured with a thin ruler placed in the posterior introitus at the level of the ischial tuberosities. Descent is measured as the distance the perineal body moves when the patient strains. The bimanual examination is used to investigate the location, size, and tenderness of the cervix, uterus, bladder, and adnexa. The pelvic diaphragm should be assessed for integrity, as should the strength, duration, and anterior lift of the contraction. The firm muscular sling of the puborectalis should be palpable posteriorly because it creates a 90° angle between the anal and rectal canals. Voluntary contraction of this muscle pulls the examining finger anteriorly toward the muscle's insertion on the pubic rami. INDICATIONSSection 3 of 12
Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. Indications for surgery include the desire for definitive surgical correction of the mass or bulge in the vagina, pelvic pressure and pain, low back pain, difficulty with intravaginal intercourse, recurrent vaginal ulcerations due to pessary use, or fecal incontinence that the patient deems unacceptable. RELEVANT ANATOMYSection 4 of 12
The pelvic organs are maintained within the bony pelvis by levator ani muscles that are posteriorly fused (pelvic floor). The levator ani muscles are attached to the bony pelvis anteriorly and posteriorly; laterally, they are attached to the arcus tendineus musculi levatoris ani, which overlie the obturator internus muscles of the pelvic sidewalls. The anterior separation between the levator ani is called the levator hiatus. Inferiorly, the urogenital diaphragm covers the levator hiatus. The urethra, vagina, and rectum pass through the levator hiatus and urogenital diaphragm as they exit the pelvis. The posterior joining of the levator ani in the midline by the anococcygeal ligament forms the levator plate (see Images 2-4). The perineal body is a central point for the attachment of the perineal musculature. The perineal body lies beneath and supports the pelvic diaphragm. The distal posterior wall of the vagina is fused to the ventral surface of the perineal body. The perineal body is also important to the support of the rectum. The pelvic organs, their interrelationships, and their support systems must be thought of conceptually and functionally in 3 dimensions (see Images 2-4). Although the contents of the abdominal cavity bear down on the pelvic organs, they remain suspended in their relation to each other and to the underlying levator sling and perineal body. Each organ is capable of independent function because it is separated from other organs by connective-tissue spaces within the endopelvic connective-tissue support system. The normal tonic contraction of the levator ani muscles supports the pelvic organs from below and contributes to urinary and fecal continence. Relaxation of the levator ani muscles allows descent of the pelvic organs and aids urination and defecation. CONTRAINDICATIONSSection 5 of 12
Current anticoagulation and a medical risk profile that exceeds the benefits gained from surgical treatment of rectocele are contraindications for this somewhat elective procedure. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyPatients with rectoceles may present with an asymptomatic bulge found during the pelvic examination or with a myriad of symptoms. For patients without symptoms, expectant management is recommended. Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele. Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. One responsibility of the physician is to inform women of their treatment options and the potential benefits and risks of each option. Medical treatment options for women with symptoms primarily consist of management with pessaries. Prophylactic measures Prophylactic measures for preventing rectocele include diagnosis and treatment of chronic respiratory and metabolic disorders, correction of constipation and intra-abdominal disorders that may cause chronic increases in intra-abdominal pressure, and administration of estrogen to menopausal women who have no contraindication to its use. Counsel patients about the preventive effects of weight control, proper nutrition, smoking cessation, and avoidance of strenuous occupational and recreational stresses that could damage the pelvic support system. Teach and encourage women to perform pelvic muscle exercises as a method of strengthening their pelvic diaphragm and as prophylaxis against the development of rectocele. Failure to recognize and treat significant support defects at the time of concomitant gynecologic surgery can lead to progression of rectocele. Similarly, opening up the genital hiatus by performing a retropubic urethropexy (eg, Burch procedure) can predispose a patient to enterocele and rectocele. Disabilities that may occur include inability to defecate without manual replacement of the uterus, bladder, or rectum; sexual dysfunction; and vaginal ulceration. For mild degrees of relaxation, especially in younger women immediately following childbirth, levator muscle exercises, sometimes called Kegel exercises, are helpful in restoring the tone of the muscles of the pelvic floor. Instruct patients how to appropriately contract the puborectalis muscles. Patients should repeat this exercise approximately 75 times during the day. Like most forms of physical therapy, this is usually more effective in premenopausal women than in older women, in whom generalized skeletal muscle atrophy has occurred. With minor degrees of pelvic relaxation, estrogenic hormones may help improve the condition of the vaginal mucous membrane and relieve minor symptomatology. In addition to strengthening pelvic muscles and considering the administration of estrogen to menopausal women, nonsurgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. Numerous vaginal pessaries are available that are designed to support specific types of pelvic organ prolapse. Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet. On occasion, the vagina and its outlet may be so dilated that it does not hold a pessary. If no other reasonable therapeutic option is available for such a patient, a perineorrhaphy can be performed with the patient under local anesthesia, thus constricting the vaginal outlet to enable it to retain a pessary. Pessaries can cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized, making exogenous estrogen essential in the hypoestrogenic patient. Remove, clean, and reinsert vaginal pessaries periodically; failure to do so can result in serious consequences, including fistula formation. Patients can be treated successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations due to pessary use, or genuine stress incontinence that the patient deems unacceptable. Surgical therapyA variety of surgical techniques have been described, including posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal approaches. Historically, the primary surgical therapy for rectocele has been posterior colporrhaphy. The principal objective of the posterior repair is to repair perineal tears that occurred during vaginal delivery. The perineal closure is designed to narrow the caliber of the vaginal introitus, develop a perineal shelf, and partially close the genital hiatus. The original description described reduction of the rectocele, suturing of the levator ani muscles anterior to the rectum, repair of the perineal body, and correction of existing enterocele or prevention of potential enterocele. Approximating the levator muscles in the midline increases the length of the levator plate, shortens the longitudinal and transverse diameters of the genital hiatus, and improves the competence of the pelvic valve. This, however, is a nonanatomical approach to pelvic floor dysfunction and rectocele repair. Preoperative detailsSurgical repair of rectocele is indicated for a symptomatic patient with a rectocele caused by a rectovaginal fascial defect. The criteria necessary to perform a repair are in contrast to the outdated dictum that posterior colporrhaphy should always accompany anterior colporrhaphy. Rectoceles can be diagnosed based on physical examination and imaging study findings. A prudent plan is to consider performing preoperative radiologic evaluations of unusual rectoceles or those associated with rectal prolapse. Detachment of the posterior vaginal wall does not necessarily confirm the presence of a rectocele. Consider posterior colporrhaphy or other surgical management as a distinct and separate procedure when pelvic organ prolapse is repaired. Intraoperative detailsPosterior colporrhaphy Depending on the need for reconstruction of the perineum, the skin can be incised in a V-shaped fashion over the perineum or transversely along the external margin of the posterior fourchette. The vaginal wall of the posterior fourchette is sharply dissected from the underlying tissues of the perineal body. The rectovaginal space is entered and widely dissected to the vaginal apex, beyond the top of the rectocele (see Images 5-6). At this point, looking for an enterocele and repairing it as necessary is extremely important. The pararectal fascia is plicated over the rectum with interrupted, delayed, absorbable or permanent sutures from the vaginal apex to the introitus (see Image 7). As each suture is placed, the diameter of the vagina is assessed to ensure no transverse constriction is occurring that might result in dyspareunia. Linear, lateral, relaxing incisions relieve any constrictions that occur. If necessary, redundancy of the posterior vaginal wall flaps is trimmed and care is taken to preserve the vaginal caliber. The cut edges of the upper posterior vaginal wall are approximated in the midline. If a defective perineal body is present, its connective tissue is plicated in the midline. Plicating the muscle itself is not necessary; rather, plicate the capsule of the muscle. Plicating the capsule of the muscle most commonly involves the pubis rectalis muscle. The remaining cut edges of the posterior vaginal wall and perineum are approximated (see Images 8-9). Perineorrhaphy If a deficient perineal body is present after vaginal repair, consider performing a perineorrhaphy. The perineal deficit might be due to attenuation, laceration, or hypermobility of the perineal body. Whether levator ani plication adds to the success of the operation remains controversial. If any muscles are approximated in the midline, do not strangulate or destroy them. Take care to not constrict the posterior fourchette because this may result in dyspareunia. Defect-directed or site-specific repair A more anatomical approach has recently been described. Some authors advocate repairing the discrete fascial defects responsible for rectoceles. Discrete tears or breaks have been described in the rectovaginal septum, most commonly transverse separation of the rectovaginal septum from the perineal body. The defect-directed repair, or site-specific fascial repair, aims to provide an anatomical repair to close these fascial tears or defects. Begin with a midline epithelial incision and separate the epithelium from the rectovaginal fascia. The edges of the fascial defects or tears are identified; then, the defect is repaired with interrupted, delayed, absorbable sutures. Unlike the traditional posterior colporrhaphy, the sutures are placed from cephalad to caudad. The best plan is probably to repair the muscles of the perineal body, if separated, and then reconstruct the perineal body. The vaginal epithelium is then reapproximated; however, it is not intentionally narrowed, as with a posterior colporrhaphy. All studies using the site-specific defect repair report very low rates of dyspareunia with good functional and anatomical outcomes, but the long-term cure rates are unknown. Transanal repair In the colorectal literature, the transanal repair has been advocated via the rectal side of the rectocele. This repair has several variations, but the purpose of the procedure is to remove or plicate the redundant rectal mucosa, thus decreasing the size of the rectal vault, and to plicate or repair the anterior rectal wall musculature. Generally, the procedure is performed with the patient in the prone jackknife position. A U- or T-shaped incision is made transanally just above the dentate line. A mucosal flap is developed, separated from the rectovaginal septum, and excised. Then, the rectovaginal septum is plicated from the rectal side with absorbable sutures. The plication includes the anterior rectal musculature. The rectal mucosa and submucosa are closed in a separate layer. Advantages of this procedure include the excision of redundant rectal mucosa and the ability to deal with coincident anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse. Disadvantages include an inability to reconstruct the perineal body unless a second incision is made, an inability to correct an anal sphincter defect if present, and difficulty accessing a high rectocele. Complications of transanal repair include infection and rectovaginal fistula. One major concern after transanal rectocele repair is postoperative anal incontinence. This significant problem has been described in up to 38% of patients after transanal repair. Fecal incontinence may occur because of an occult sphincter laceration that causes symptoms with aging, or it may develop as a result of the anal dilation and stretching during the rectocele repair. One area that deserves attention is the recurrent rate of prolapses. Two separate randomized trials have shown that the transanal approach has a significantly higher failure rate when compared with the transvaginal approach (Maher, 2006). Posterior fascial displacement To prevent or reduce the risk of rectocele recurrence, a variety of graft materials and meshes have been used. These materials have been used in the traditional method of posterior colporrhaphy and in the defect-directed repair. Some surgeons have used graft material after a defect-directed repair. Placing a dermal allograft over the repair and securing it to the rectovaginal fascia cephalad, to the arcus tendineus fascia rectovaginalis laterally, and to the perineal body distally creates a second layer of support. Although the graft may strengthen the repair, remember that graft materials may shrink. Importantly, this can create a repair that is too tight and can decrease the flexibility of the posterior wall and cause restriction of the rectum, such that it cannot expand during accommodation or during coitus. This loss of flexibility in the posterior wall can lead to fecal urgency and dyspareunia. If the use of graft material is considered, the surgeon must choose the ideal material. It should have a very low rejection rate, be relatively inexpensive, decrease recurrence rates, and cause no harm with respect to bowel and sexual function. Currently, no good data support the use of one type of graft material over another. Many different materials have been used without clinical trials or long-term data to support their use. Abdominal approach This approach is most commonly used when correction of an accompanying enterocele or vault prolapse is indicated. Patients with rectocele often present with apical prolapse or defecatory problems, including chronic constipation or fecal incontinence. One advantage to using an abdominal approach, such as a sacral colpopexy for the repair of an apical support defect, is that the surgery can be completed with a single surgical approach. If the defect in the rectovaginal fascia is in the superior portion of the posterior vaginal wall, it can be repaired through the cul-de-sac during the sacral colpopexy. Some surgeons advocate extending the posterior graft of the sacral colpopexy down the posterior wall to correct these defects. Another modification of sacral colpopexy is the sacral colpoperineopexy. This procedure is used to treat perineal descent with posterior and apical pelvic organ prolapse. The aim of this procedure is to replace the normal support of the vagina and the continuous endopelvic fascia that runs from the sacrum to the perineal body. This procedure may be performed totally abdominally or as a combined abdominal and vaginal procedure. From the abdominal approach, the peritoneum overlying the apex and posterior wall of the vagina is incised to open the rectovaginal space. Sutures are placed over the length of the posterior wall, from the apex to the perineal body. The perineal body is elevated by the surgeon's nondominant hand. Stitches are placed abdominally into, or as close to, the perineal body as possible. The permanent graft is placed abdominally between the posterior vaginal wall and the rectum. The sacrocolpopexy is completed with attachment of the anterior wall graft and posterior wall graft to the previously placed sacral sutures. In the combined abdominal/vaginal approach, the sacral colpoperineopexy is performed as described above, except the perineal body sutures are placed transvaginally. Postoperative detailsPostoperative care usually consists of control of minor pain either with oral narcotics or with nonsteroidal anti-inflammatory drugs. For vaginal procedures, most patients are able return home the same day. Of course, abdominal procedures mandate stronger analgesia such as patient-controlled analgesia, and the patient stays in the hospital for 2-3 days. COMPLICATIONSSection 8 of 12
Immediate complications include adverse anesthesia reactions; hemorrhage; infection of the operative site or lower urinary tract; and injury of contiguous organs, blood vessels, or nerves. Infectious complications are rare (3-6%). Patients in whom graft material has been used have a graft erosion rate of up to 10%. Long-term complications include recurrent pelvic organ prolapse and dyspareunia in 20-30% of women. OUTCOME AND PROGNOSISSection 9 of 12
Failure and/or recurrence rates are highly variable. Important factors in prognosis are teaching patients to decrease intra-abdominal pressure through adequate control of respiratory illnesses and to decrease straining. Identifying and treating all pelvic floor defects at the time of the original surgery and Pelvic Organ Prolapse-Quantified system (POP-Q) stage are the greatest predictors of long-term success. FUTURE AND CONTROVERSIESSection 10 of 12
Individualize management of rectocele and pelvic organ prolapse. Patients who are candidates for surgical correction should undergo a careful preoperative assessment that includes treatment of contributing medical problems, identification of all support defects, and evaluation of pelvic floor function. Surgeons who perform reconstructive procedures for rectocele and pelvic organ prolapse should be familiar with multiple surgical procedures because intraoperative modification of the preoperative plan may be required. Thorough knowledge of the anatomy and physiology of these disorders allows selection of a surgical approach that is usually successful in relieving symptoms and restoring and preserving anatomic relationships, visceral function, and coital function long term. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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