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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