The Forgotten Posterior Pelvic Floor; Rectocele Repair, Perineoplasty, & Defecatory Dysfunction

Mickey Karram M.D.

Director of Urogynecology

The Christ Hospital

Professor of Ob/Gyn & Urology

University of Cincinnati

ANATOMY OF THE POSTERIOR VAGINAL WALL RECTOVAGINAL SEPTUM??? WHAT IS FASCIA??? DOES IT TRULY EXTEND FROM

SACRUM TO PERINEUM??? IS RICHARDSON’S CLASSIFICATION

OF DEFECTS CLINICALLY APPLICABLE???

Anatomy of Posterior Wall

GOALS OF RECTOCELE REPAIR PROVIDE DURABLE SUPPORT FROM

POSTERIOR FOURCHETTE TO POSTERIOR VAGINAL FORNIX

Identfy and correct enterocele if present Rebuild Perineum and correct Anal

Sphincter if appropriate Narrow vaginal calibar if needed

POSTERIOR VAGINAL COMPARTMENT DEFECTSKEYS TO SURGICAL SUCCESS* Avoid Distortion Of Vaginal Access* Avoid Vaginal Constriction* Appropriate Use Of Levatoroplasty* Appropriate Use Of Perineorraphy* Defect Specific Repairs* Tight Repairs In Sexually Inactive

Women

POSTERIOR VAGINAL COMPARTMENT

SURGICAL CHALLENGES High Recurrent Rectocele Large Symptomatic Rectocele With A

Foreshortened Vagina The Entercele That You Can’t find Recurrent Cystocele And Rectocele

PROLAPSE SYMPTOMS THAT MAY COEXIST WITH RECTOCELES

Pelvic Pressure and Tissue Protrusion Feeling of a Gaping Introitus Sexual Dysfunction

DEFECATORY DYSFUNCTION THAT MAY COEXIST WITH RECTOCELES

Fecal Incontinence Paradoxical Sphincter Reaction Fecal Urgency Stool Clustering OUTLET OBSTRUCTION

EVALUATION OF RECTOCELES

CLINICAL Imaging Radiographic Electrophysiologic Endoscopic Transit Studies

SURGICAL APPROACHES TO RECTOCELE

Gynecologist

Traditional

Defect-Specific

Colorectal Surgeon

Transrectal Repair

SEXUAL DYSFUNCTION AFTER TRADITIONAL POSTERIOR COLPORRAPHY

Francis + Jeffcoate (1961) 50% Kahn + Stanton (1997) 18% To

27% Paraiso et al. (2001) Worsening

Dysparaenia

POSTERIOR COLPORRHAPHY: ITS EFFECTS ON BOWEL AND SEXUAL FUNCTION

Kahn & Stanton: Br J Obstet Gynecol 1997, 104: 82-86

Levatorplasty Performed On 231 Patients Vaginal Defects Corrected In 76% Worsening Of Bowel And Sexual Function

Posterior; Sutton

Clip 3

POSTERIOR COMPARTMENT DEFECTSCASE A.S. is a 51 yr old nulliparous female

with 5 yr hx of difficulty evacuating bowels; symptom’s onset with abd hyst for severe endometriosis. O/E small rectocele and cystocele. Defcography showed rectocele 2.5 cm on straining to 3.7 cm on evacuation, also enterocele seen. All other colorectal evaluation normal

Posterior/enterocele; andrea

POSTERIOR COMPARTMENT DEFECTS

CASE

77 yr old with complete procidentia and vaginal eversion Has significant bowel dysfunction with difficulty evacuating her stools as well as mild fecal incontinence. Desires to maintain a functional vagina

Complete Procidentia (1)

TREATMENT OF RECTOCELE

CONCLUSIONS Correlation between anatomic defect

and functional derangement is poor to non-existent

Enteroceles need to be routinely looked for when correcting rectoceles

Unsure of clinical utility of colorectal testing prior to rectocele repair