Anatomy

Rectoceles result from defects in the integrity of the posterior vaginal wall and rectovaginal septum, and subsequent herniation of the posterior vaginal wall and anterior rectal wall into the vaginal lumen through these defects. The normal posterior vagina is lined by squamous epithelium that overlies the lamina propria, a layer of loose connective tissue.A fibromuscular layer of tissue composed of smooth muscle, collagen, and elastin underlies this lamina propria, and is referred to as the rectovaginal fascia. This is an extension of the endopelvic fascia that surrounds and supports the pelvic organs, and contains blood vessels, lymphatics, and nerves that supply and innervate the pelvic organs.

The layer of tissue between the vagina and the rectum, or rectovaginal fascia, was believed to be analogous to the rectovesical septum and became known as Denonvilliers' fascia in the female, or the rectovaginal septum. Others described the rectovaginal septum as a support mechanism of the pelvic organs, and they were successful in identifying this layer during surgical and autopsy dissections.5-7 It is unclear whether this fascial layer extends from the vaginal cuff to the perineum or is only present along the distal vaginal wall from the levator reflection to perineum.

The normal vagina is stabilized and supported on three levels. Superiorly, the vaginal apical endopelvic fascia is attached to the cardinal-uterosacral ligament complex. Laterally, the endopelvic fascia is connected to the arcus tendineus fasciae pelvis, with the lateral posterior vagina attaching to the fascia overlying the levator ani muscles. Inferiorly, the lower posterior vagina connects to the per-ineal body, composed of the anterior external anal sphincter, transverse perineum, and bulbocavernosus muscles. The cervix (or vaginal cuff in the hysterectomized woman) is considered to be the superior attachment site or "superior tendon," and the perineal body the inferior attachment site or "inferior tendon." The endopelvic fascia extends between these two sites comprising the rectovaginal septum (Figure 8-5.1). A rectocele results from a stretching or actual separation or tear of the rectovaginal fascia, leading to a bulging of the posterior vaginal wall noted on examination during a Valsalva maneuver. Trauma from vaginal childbirth often leads to transverse defects above

Figure 8-5.1. Diagrammatic representation of the rectovaginal septum including its attachment from vaginal apex to perineal body. (Reprinted with the permission of The Cleveland Clinic Foundation.)
Figure 8-5.2. Fascial tears of the rectovaginal septum can occur superiorly or inferiorly at sites of attachment to a central tendon. (Reprinted with the permission of The Cleveland Clinic Foundation.)

the usual location of the connection to the perineal body (Figure 8-5.2). In addition, patients may present with lateral, midline, or high transverse fascial defects. Separation of the rectovaginal septum fascia from the vaginal cuff results in the development of an enterocele as a hernia sac without fascial lining and filled with intraperitoneal contents (Figure 8-5.2). This can present clinically as a rectocele bulge.

The levator musculature extends from the pubic bone to the coccyx and provides support for the change in vaginal axis from vertical to horizontal along the mid vagina. A rec-tocele typically develops at, or below, the levator plate, along the vertical vagina, weakening the fascial condensation of the attachments of the perineal musculature (Figure 8-5.3).

Figure 8-5.3. Rectoceles develop at or below the levator muscles,splaying the perineal musculature attachments.(Reprinted with the permission of The Cleveland Clinic Foundation.)
Pregnancy And Childbirth

Pregnancy And Childbirth

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