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PubMed1993

Dyschezia and rectocele--a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation.

UNLABELLED: Herniation of the anterior rectal wall into the lumen of the vagina (so called rectocele) may be encountered in patients who complain of constipation and emptying difficulties but it is difficult to ascertain whether this anatomic abnormality is an etiologic factor or a consequence of the dyschezia. PURPOSE: The aim of our study was to assess symptomatic, anatomic, and physiologic features encountered in women with a clearly defined rectocele in order to determine the predisposing factors, symptoms, functional associations, and effects on quantified rectal emptying. METHODS: Clinical, physiologic (manometry), and anatomic (evacuation proctography) assessments were carried out in 26 consecutive women (mean age, 47.6 +/- 12 years) with dyschezia and a large rectocele as evidenced by radiography and compared with a group of 26 consecutive women complaining of dyschezia without a significant rectocele (mean age, 42.6 +/- 14 years). Both groups were similar with respect to mean age, parity, laxative abuse, manual anal evacuation, fecal incontinence, urgency, and weekly stool frequency. RESULTS: Patients having a rectocele differed significantly from those without a rectocele in having frequent endovaginal digitation during defecation (7 vs. 1, P < 0.05), more frequent symptoms of urinary incontinence (14 vs. 3, P < 0.001), and a surgical history of hysterectomy (9 vs. 2, P < 0.05). The rectocele group differed in having a delayed rectal emptying (55.5 +/- 38 vs. 30.3 +/- 23 seconds, P < 0.005), a more frequent incomplete rectal emptying (23 vs. 11, P < 0.0005), and was more often associated with a manometric anismus (16 vs. 6, P < 0.01). During the straining effort, there was a correlation between the depth of the rectocele and the duration of rectal emptying (rs = 0.3, P < 0.05). In the group without manometric anismus, women with a rectocele (n = 10) had a more incomplete rectal emptying than those without rectocele (8/10 vs. 8/19, P = 0.05). CONCLUSION: Some of our results indicate that the rectocele itself could be a contributory factor in difficult evacuation. These results also exhibit the importance of other disorders, such as anismus, in the occurrence of dyschezia. Physiologic examination therefore should be made before considering surgical repair in any patient with rectocele and dyschezia.

Adult↗
PubMed1993

The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair.

Using the descriptions of Uhlenhuth, and Milley and Nichols, we have been able to identify a sheet of strong connective-type tissue between the rectum and vagina. This layer has been named the rectovaginal septum, referred to, by some, as the rectovaginal fascia. As it is considered to be analogous to the rectovesical septum in men, first described by Denovilliers, some refer to it as Denonvilliers' fascia in the female. This layer is immediately beneath the vaginal mucosa and clearly is what many would consider part of the vaginal wall. Its principal attachments are peripheral--it merges superiorly with the cardinal/uterosacral complex, fuses laterally with the fascia over the levator muscle, and merges distally into the perineal body. Histologically, it contains collagen that is quite dense in places, some strands of smooth muscle, and a very dense network of heavy elastin fibers. It is this layer that acts as a supporting structure for the perineal body and prevents the rectum from bulging into the vagina. Rectoceles represent a defect in this layer that allows the rectum to bulge inward. The defects are usually isolated breaks that can be repaired directly with excellent and predictable results.

Fascia↗
PubMed1994

Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination.

PURPOSE: The aim of this study was to devise a measuring method for an anterior rectocele on standardized defecographies and magnetic resonance images (MRI) to quantify anterior rectocele and to test whether this could substantiate clinical decision making for operative treatment for anterior rectocele. METHODS: Quantitative analysis by the measuring method as proposed was compared with qualitative scores on defecographies and MRI from the same patients. Thirty-eight patients with symptoms compatible with an anterior rectocele were subjected to physical examination in the left decubitis position and supine position and to defecography. Findings on defecography were compared with findings on physical examination. Thirteen patients were examined before and after surgical correction of the anterior rectocele for a total of 51 qualitative and quantitative examinations. The group of operated patients was analyzed for treatment results. Nineteen controls were included. RESULTS: Sixty-six radiographs of 33 defecographies were qualified in three grading classes and quantified with the proposed method by two observers. The mean measured value of the anterior rectocele in the three subjective grading classes is significantly different (P < 0.001). Anterior rectoceles qualified as severe had a measured value of 20 mm or more in 96 percent of the radiographs. Lower gradings were never > 20 mm. On MRI severe anterior rectoceles were not scored and measured values did not correlate with qualitative scores. When findings on physical examination were compared with defecographic measurement, the coefficient of correlation (r) between the radiologic assessment and clinical examination in the left decubitis position is r = 0.87, for the examination in the supine position, r = 0.77. All 15 cases scored as severe anterior rectocele in the left decubitis position had a measured anterior rectocele of > or = 20 mm. In the 13 cases that received surgery, there was a significant reduction of the anterior rectocele (P < 0.001) and clinical improvement. Patients with small or moderate anterior rectocele on physical examination with a size > or = 20 mm on defecography were cured by surgical correction. None of the controls had an anterior rectocele on physical examination or an anterior rectocele > or = 20 mm on defecography. CONCLUSIONS: An anterior rectocele with a size of 20 mm or more corresponds with a qualitative score of "severe" on radiographic defecography. Physical examination for anterior rectocele in the left decubitis position corresponds best with quantitative radiographic assessment and anterior rectocele with a size > or = 20 mm on defecography is pathologic. Patients with complaints compatible with anterior rectocele can be assessed in objective and quantitative terms by radiography and can be successfully surgically treated, even if at physical examination the anterior rectocele is not classified as large, provided that dynamic defecography shows an anterior rectocele of > or = 20 mm. The potential of dynamic MRI with regard to anterior rectoceles presently seems absent.

Adult↗
PubMed1998

Rectocele is associated with paradoxical anal sphincter reaction.

Rectocele is a frequent finding in constipated patients. However, constipation is not always relieved by rectocele repair, which may be due to other overlooked reasons for constipation. The study was designed to investigate patients with rectocele, in order to elucidate concomitant colorectal disorders and their association with rectocele. One hundred and twelve female patients suffering from severe constipation and rectal emptying difficulties were investigated using defecography, electrophysiology, anorectal manometry and colon transit time. Fifty-six patients with rectocele demonstrated by defecography were compared with 56 patients without rectocele, but with other abnormal findings at defecography. The frequency of paradoxical anal sphincter reaction (PSR) was higher in patients with rectocele (60%) than in patients without rectocele (24%). The present study supports an association between rectocele and PSR. We suggest that constipated patients with a rectocele should be investigated thoroughly before rectocele repair is considered. Further studies on the effect of biofeedback training in patients with rectocele and PSR are indicated.

Adult↗
PubMed1997

Role of defecography in predicting clinical outcome of rectocele repair.

PURPOSE: The aim of this study was to evaluate the role of defecography in predicting clinical outcome of rectocele repair. METHODS: Between January 1988 and July 1994, 74 consecutive patients (median age, 54 (range, 35-81) years) with a rectocele and symptoms of obstructed defecation were studied prospectively. After preoperative evaluation by a standardized questionnaire, physical examination, and defecography, a combined transvaginal/transanal rectocele repair was performed. At follow-up, all patients had defecography. Long-term results were qualified by an independent observer after a median follow-up of 58 (range, 14-89) months as "excellent," "good," or "poor." RESULTS: Rectocele repair was considered excellent in 37 patients and good in 13 patients. Defecography six months after surgery did not show persistent or recurrent rectocele in any of the patients. Size of the rectocele, barium-trapping in the rectocele, internal intussusception, rectal evacuation, and perineal descent did not appear to influence clinical outcome. Radiologic evidence of anismus did not correlate with long-term results of rectocele repair. CONCLUSIONS: Combined transanal/transvaginal repair of rectocele is an efficient therapy in patients with obstructed defecation. Various defecographic parameters (size of rectocele, internal intussusception, rectal evacuation, perineal descent, radiologic signs of anismus) do not appear to influence clinical outcome of surgery. The main value of defecography is the objective demonstration of rectocele and any associated abnormalities such as an enterocele preoperatively and again in objective assessment of the postoperative results.

Defecation↗
PubMed2000

Analysis of patients with poor outcome of rectocele repair.

PURPOSE: The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation. METHODS: Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35-81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12-92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome. RESULTS: Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal. CONCLUSIONS: Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.

Adult↗
PubMed2001

Rectoanal inhibition and rectocele: physiology versus categorization.

Some authors divide rectoceles into those with chronic evacuatory difficulty and normal genital position (type 1) and those with associated pelvic organ prolapse (type 2). This study assessed whether there are physiological differences between these two clinical rectocele types. Female patients were assessed by conventional anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex (RAIR), and defecography. Subjects included 33 volunteer controls without anorectal disease, 14 patients with type I rectocele, and 26 patients with type II rectocele. Significant differences were noted for resting pressure measurements (maximal resting anal pressure and vector volume) between rectocele types and between type I patients and controls. Significant differences were noted for squeeze parameters (maximal squeeze pressure and vector volume) only between rectocele types. There were minimal differences in parameters of the RAIR, with a reduced slope of inhibition in the proximal sphincter for both rectocele groups and a reduced maximal inhibitory pressure in the intermediate and distal sphincter of type 1 rectocele patients. There were no differences in transient excitation of the pressure wave during the RAIR reflex to account for pressure variations with no measured differences in rectocele depth (type 1, 2.87 +/- 0.7 cm; type 2, 2.84 +/- 1.4 cm) There are few physiological differences between the different clinical categories of rectocele patients based on the presence or absence of associated genital prolapse.

Adult↗
PubMed1995

Is barium trapping in rectoceles significant?

PURPOSE: This study was designed to determine whether rectocele size and contrast retention are significant. METHODS: Evacuation proctography and simultaneous intrarectal pressure measurements from a small, noncompliant balloon catheter were performed in three matched groups of 11 constipated female patients with rectoceles, rectoceles and contrast trapping of > 10 percent, and no rectocele. Computerized image analysis was used to measure rectocele area and evacuation. RESULTS: In the two groups with rectoceles, there was no significant difference in rectocele area or width pre-evacuation. The anorectal angle, pelvic floor descent, maximum anal canal width, evacuation time or completeness, maximum and distal intrarectal pressure, or need to digitate did not differ significantly between the groups. In seven patients with barium trapping (64 percent) the intrarectal pressure dropped abruptly as the balloon entered the rectocele, suggesting that trapping results from sequestration into the vagina, closing part of the rectocele from the normal intrarectal pressure zone. CONCLUSION: Because no impairment of evacuation appears to be associated with either a large rectocele or trapping, these evacuation problems should not be directly attributed to these proctographic findings.

Barium Sulfate↗
PubMed1996

Excellent outcome using selective criteria for rectocele repair.

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16-78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1-8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5-64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test, P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Constipation↗
PubMed1999

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation.

PURPOSE: The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation. METHODS: All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5-54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair. RESULTS: Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19 vs. 10, preoperative vs. postoperative; P = 0.02) and the need to use digital assistance vaginally (13 vs. 6; P = 0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22 vs. 18 percent; P = 0.95), the percentage reduction in rectocele area (65 vs. 62 percent; P = 0.95), or a rectocele width of more than 2 cm (44 vs. 50 percent; P = 0.80), did vs. did not feel improved, respectively. CONCLUSION: Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.

Adult↗
PubMed1999

The anatomic and functional variability of rectoceles in women.

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

Adult↗
PubMedDate not supplied

Barium trapping in rectoceles: are we trapped by the wrong definition?

BACKGROUND: Barium trapping within a rectocele is a criterion used by surgeons to select which patients with rectoceles should undergo operative repair. This proctographic study compared the presence and depth of barium trapping within a rectocele on postevacuation radiography with those seen on posttoilet radiography after further evacuation in the privacy of the bathroom. METHODS: Eighty-two consecutive patients with evidence of barium trapping on postevacuation radiographs of a fluoroscopic dynamic cystoproctographic examination were reviewed retrospectively. The size of the rectoceles and the depth of barium trapping on the postevacuation and subsequent posttoilet radiographs were measured. RESULTS: The posttoilet radiographs showed resolution of the barium trapping in 47 (57%) of the 82 patients. Resolution of the trapping was directly related to rectocele size. The mean differences in the depth of barium trapping between the postevacuation and posttoilet radiographs were significant for all sizes of rectocele. CONCLUSION: Barium trapping in rectoceles changes with the degree of rectal evacuation. More complete evacuation was shown on the posttoilet radiograph than on the postevacuation radiograph. Consequently, the posttoilet radiograph may be more appropriate for the preoperative assessment of barium trapping within rectoceles.

Barium Sulfate↗
PubMed2001

Associations of defecography and physiologic findings in male patients with rectocele.

This study evaluated the incidence and physiological findings in male patients with rectoceles. All defecographic studies were evaluated by a single colorectal surgeon. After diagnosis of rectocele in male patients, the patient's history, symptoms, and physiologic tests (anal manometry, pudendal nerve terminal motor latency [PNTML], assessment and electromyography [EMG]) were studied. A prominent rectocele was defined as one that did not empty during defecography and was associated with outlet obstructive syndrome. Forty (17%) rectoceles were diagnosed in 234 male patients with evacuatory disorders who underwent defecography. Rectoceles were anterior in 19 (48%) and posterior in 21 (52%) patients. The main complaint was constipation with difficult defecation in 33 (83%), followed by rectal pain in 5 (13%), rectal prolapse in 1 (3%), and incontinence in 1 (3%). Previous prostatic surgery had been performed in 16 (40%) patients. The mean age and duration of symptoms were 72.4 years (range, 30-88) and 10.3 years (range, 0.5-70), respectively. Excessive straining during evacuation was noted in 73%, unilateral or bilateral pudendal neuropathy in 24.5%, paradoxical puborectalis contraction in 49% and abnormal EMG in 11% of patients. Higher resting pressures with a mean 3.9 cm high pressure zone were noted in 29% of patients. The accompanying findings in defecography were, non-relaxing or partially relaxing puborectalis muscle (66%), perineal descent (65%), intussusception (23%), and sigmoidocele (15%). None of the patients underwent surgery for rectocele alone. In conclusion, rectocele is uncommon in males; it rarely appears as an isolated dysfunction as it is often associated with functional disorders of the pelvic floor. There is a frequent association between rectocele and prostatectomy. Clinical significance and therapeutic strategy remain unknown.

Adult↗
PubMed2002

Anal continence after rectocele repair.

INTRODUCTION: Rectocele may be associated with both chronic constipation and anal incontinence. Several different surgical procedures have been advocated for rectocele repair. The aim of the present study was to evaluate anorectal function and clinical outcome in a consecutive series of patients who underwent selected endorectal or transperineal surgery for rectocele for whom operative treatment was determined by clinical and proctographic features. Attention was paid to the cohort of rectocele patients presenting with incontinence as a leading symptom. METHODS: Sixty consecutive patients with symptomatic rectocele underwent surgical treatment at our institution. Fifty-eight of the patients were female (mean age 56; range, 21-70 years). Incontinence was graded according to a previously reported scoring system that accounts for the type and frequency of incontinence episodes. Preoperative anorectal manometry was performed using an open perfused polyethylene probe. Rectal sensation was recorded by balloon distention. Endoanal ultrasonography was performed with a 7.5-MHz probe. Preoperative defecography was performed at rest and on maximal squeeze and straining. Patients with obstructed defecation as their principal symptom, with associated mucosal rectal prolapse, underwent an endorectal procedure. For patients with associated anal incontinence (Grade B2 or greater), and without a rectal mucosal prolapse, a transperineal approach was performed with either an anterior external overlapping sphincteroplasty or levatorplasty. The median follow-up was 48 (range, 9-122) months. RESULTS: There was no operative mortality. Postoperative complications occurred in 18 patients (30 percent). Of 43 patients with incontinence, 34 (79 percent) were available for postoperative evaluation. None were fully continent. However, in 25 patients (73.5 percent), continence improved after surgery; half had only mucus soiling or loss of gas. Incontinence scores decreased (i.e., improved) from 4.8 +/- 0.9 to 3.9 +/- 0.9 (P = 0.002). A significant improvement was found both after transanal and perineal procedures. Only ten initially continent patients were available for postoperative assessment. All patients stated that they had clinical improvement in constipation. Their preoperative mean anal resting pressure was 62.5 +/- 3.9 (standard error of the mean) mmHg, with a postoperative mean of 75.5 +/- 7 mmHg. The preoperative mean squeeze pressure was 83.1 +/- 8.5 mmHg, with a mean postoperative squeeze pressure of 88.5 +/- 7.9 mmHg (P = not significant). The maximal tolerable volumes were all within normal limits, confirming the proctographic evidence that there were no cases of megarectum in our patient series. The pudendal nerve terminal motor latency was abnormal in all but two patients with incontinence (mean pudendal nerve terminal motor latency = 3.1; range, 1.2-4 milliseconds). Rectoceles recurred in six patients (10 percent): five after a Block procedure and one after a Sarles-type operation. The postoperative endosonographic appearance varied according to the nature of the procedure performed. CONCLUSION: There are few data concerning patients with rectocele who have associated anal incontinence, however, surgical decision analysis resulted in improvement in both constipation and incontinence in the majority of our patients with rectocele. Nevertheless, because none of the patients gained full continence postoperatively, pelvic floor rehabilitation might be also needed to achieve better sphincter function in patients with incontinence.

Adult↗
PubMed2001

Anterior rectocele due to obstructed defecation relieved by botulinum toxin.

Background. Surgical repair of rectocele does not always alleviate symptoms related to difficulty in defecation, and some patients have impaired fecal continence after surgical treatment. To avoid complications of surgical repair, we investigated the efficacy of botulinum toxin in treating patients with symptomatic rectocele. Methods. Fourteen female patients with anterior rectocele were included in the study. The patients were studied by using anorectal manometry and defecography, and then treated with a total of 30 units of type A botulinum toxin, injected into 3 sites, 2 on either side of the puborectalis muscle and the third anteriorly in the external anal sphincter, under ultrasonographic guidance. Results. After 2 months, symptomatic improvement was noted in 9 patients (P =.0003). At the same time, rectocele depth (mean +/- SD) was reduced from 4.3 +/- 0.6 cm to 1.8 +/- 0.5 cm (P =.0000001) and rectocele area from 9.2 +/- 1.3 cm(2) to 2.8 +/- 1.6 cm(2) (P =.0000001). Anorectal manometry demonstrated decreased tone during straining from 70 +/- 28 mm Hg at baseline to 41 +/- 19 mm Hg at 1 month (P =.003) and to 41 +/- 22 mm Hg at 2 months (P =.005). No permanent complications were observed in any patient for a mean follow-up period of 18 +/- 4 months. At 1 year evaluation, incomplete or digitally assisted rectal voiding was not reported by any patient, and a rectocele was not found at physical examination. Four recurrent, asymptomatic rectoceles were noted at defecography. Conclusions. Botulinum toxin injections should be considered as a simple therapeutic approach in patients with anterior rectocele. The treatment is safe and less expensive than surgical repair. A more precise method of toxin injections under transrectal ultrasonography accounts for the high success rate. Repeated injections may be necessary to maintain the clinical improvement.

Adult↗
PubMed1996

Anterior rectocele and anorectal dysfunction.

The two types of anterior rectocele, "distension" of Type 1 rectocele (T1R) and "displacement" or Type 2 rectocele (T2R), have different anatomical, clinical and therapeutic profiles. The aim of this study was to assess anorectal function in patients with distension or displacement rectocele. Three groups of female patients and one group of healthy female subjects were studied. Both the 10 Group 1 subjects, who had been diagnosed as having T1R, and 10 Group 2 women who had been diagnosed as having T2R, were symptomatic for digital evacuation of the rectum. The 10 Group 3 females had complained of sever idiopathic constipation but had no defecatory disorders. The control group was made up to 10 healthy volunteers. All patients and controls underwent clinical evaluation, colonic transit time (CTT), computerized anorectal manometry (CAM), and defecography. Bowel movements and clinical evaluation were similar for both rectocele groups. In Group 1, CAM detected significantly higher anal pressure (P < 0.05) and more impaired rectoanal inhibitory reflex (RAIR) (P < 0.01) in comparison to the other patients and controls. In Group 2, the lowest anal pressure (P < 0.001) was noted but RAIR was normal. Defecographic results, at rest and during evacuation, showed a significantly (P < 0.001) higher anorectal angle and a more abnormal pelvic floor descent in Group 2 than in the other study groups and controls. Therefore, peculiar anorectal function was present in patients with anterior rectocele. A pelvic floor dyssynergia was noted in the distension rectocele group, while a fall of the pelvic floor was noted in the displacement rectocele group.

Adult↗
PubMed1986

Transrectal repair of rectocele using obliterative suture.

Rectocele is a condition that can be repaired transrectally with an obliterative suture technique. The obliterative suture is essentially a tightly drawn continuous lock-stitch suture that strangulates the tissues contained in the suture line, and causes them to slough, yet approximates the tissues at the base of the suture line, the submucosa, and muscularis layers and allows them to heal rapidly. This technique is bloodless, easy to perform, and effective as far as cure and relief of symptoms. The time required for repair of the rectocele is approximately 6 minutes. The presence of a rectocele should be sought for routinely in every proctologic examination in the female. If anorectal surgery is to be performed, the rectocele should be repaired coincidentally, even if the rectocele is asymptomatic. If the rectocele is symptomatic, it should be repaired even if no other anorectal procedure is contemplated. The transrectal obliterative suture technique appears to have advantages over the vaginal or other transrectal techniques and is the method of choice for the repair of rectocele.

Female↗
PubMed1996

Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment.

BACKGROUND: The aim of this study was to evaluate the operative repair of rectoceles in a defined group of women by a technique designed to deal with the cause (failure of the rectovaginal septum) rather than the effect (rectal and vaginal wall bulging). STUDY DESIGN: Only women whose defecation was aided by vaginal digitation and who had large rectoceles on proctography were included. Any other clinical symptoms in the absence of vaginal digitation, even when proctography demonstrated a rectocele, were not taken as indicators for surgery in this study. There were nine women, median age 50 years (range, 32 to 61). The rectovaginal septum was repaired with Marlex mesh through a perineal approach by one surgeon. The median follow-up period was 29 months. RESULTS: Eight of the nine women achieved successful evacuation after surgery without the need for vaginal digitation. Rectocele size, depth, and the percent of barium trapped in the rectocele on proctography were all improved. Anorectal physiology measurements were unchanged by surgery. CONCLUSIONS: Operative repair of the rectovaginal septum removes the need for vaginal digitation in most women with large rectoceles on proctography. Further studies in well-defined groups of women are needed to establish how well rectocele repair aids women with a variety of other pelvic and perineal symtoms.

Adult↗