Colorectal CancerRectocele

Mr D.Kumar PhD FRCS

Consultant Colorectal SurgeonSt George’s NHS Trust

Rectocele

Prolapse of the anterior rectal and posterior vaginal wall into the lumen

of the vagina

RectoceleAnatomy

• Female equivalent of Denonvillier’s fascia - rectovaginal septum

• Separates the rectal(dorsal) compartment

from the urogenital (ventral) compartment• Rectovaginal septum and uterosacral ligaments

provide suspensory support to the perineal body• Further supported by the levator muscles

RectoceleAetiology

• Obstetric trauma – due to alteration in the functional and anatomical position of muscles

• Pathological stretching of pudendal nerves during descent of the foetal head – denervation of the pelvic floor muscles

• Persistent straining at stool

RectoceleClinical presentation

• Constipation (incomplete emptying) –75% of patients

• Vaginal bulge• Sense of rectal pressure• Rectal/low back pain• Bleeding• Dyspareunia• Vaginal digitation/perineal support• Majority totally asymptomatic

RectoceleClassification

• Low

• Middle

• High

Middle and high rectoceles often associated with cystoceles and enteroceles

RectoceleEvaluation

• History

• Examination

• Defaecography Barium

Isotope

• Endoanal U/S

• Pudendal nerve motor latency/manometry

RectoceleManagement

• Conservative

• Operative

RectoceleConservative management

• Bowel training

• Oestrogen replacement therapy – post menopausal

• Vaginal pessary

RectoceleSurgery

• Vaginal - Posterior Colporrhaphy (levatorplasty)

- Defect specific

RectoceleSurgery

• Transanal

ResultsVaginal Arnold et al 1990 – 50% still sympotomatic

Watson et al 1996 – removed the need to digitate in most patients

Murthy et al 1996 – excellent results (strict criteria)

TransanalSullivan et al 1968 – 97.5% success

Shapayak 1985 – 98% improvement

Jarsen’s et al 1994 – 92% success

Mellgren et al 1995 – 88% - complete resolution 52%

RectoceleTransanal

138 patients – symptomatic rectocele

58 had significant rectocele

45 decided to have surgery

• Mean age -57 years • Duration of symptoms -52 months• Median follow-up -24 months

RectoceleFunctional Outcome

Symptom Presurgery Post surgery p*

Straining 40/45 16/45 p< 0.001Incomplete evacuation 40/45 27/45 p< 0.001Vaginal digitation 28/45 6/45 p< 0.001Perineal digitation 22/45 10/45 p= 0.004Incontinence (Grades 3/4) 9/45 7/45 p= 0.688Dyspareunia 11/45 3/45 p= 0.020Vaginal bulging 43/45 10/45 p< 0.001

* McNemar testGrade 1 normal incontinence, 2 incontinent to flatus, 3 incontinent toliquid stool, 4 incontinent to solid stool

Heriot et al 2004

RectoceleAnorectal physiology assessment

Symptom Presurgery Post surgery p**mean (SD) mean (SD)

Resting anal 80(23) 76(29) 0.0370

pressure (cm H20)

Squeeze anal 136(42) 141( 40) 0.911

pressure (cm H20)

Anorectal reflex present 5/17 7/17 0.050*

Threshold volume (cc) 51(23) 41(19) 0.025

Max. volume (cc) 204(87) 201(78) 0.619

** Wilcoxons signed rank test * McNemar test

Heriot et al 2004

RectoceleComparison of PC vs TA

70 patients RCT- 40TA, 30PC• Matched for age, symptoms, % retention• Bowel Sx significantly better in the TA (p<0.01)• Bleeding significantly less in TA (p<0.01) • Analgesic requirement less in TA (p<0.02)• Dyspareunia worse in PC (p<0.001)

(Kahn et al 2001,unpublished)

RectoceleComplications

• Infection

• Bleeding

• Dyspareunia

• Recto –vaginal fistula

Summary

• Rectoceles are common• Only a small % symptomatic• Even a smaller percentage clinically significant• Proper evaluation essential• Patients with a vaginal bulge as the main symptom

should have post. Colporrhaphy• Those with bowel symptoms-transanal repair