The typical finding in a woman with a symptomatic rectocele is a lower posterior vaginal wall bulge noted on physical examination. It may extend superiorly to weaken the support of the upper, posterior vaginal wall, leading to an enterocele, or to the vaginal apex, leading to vaginal vault prolapse. In an isolated rectocele, the bulge extends from the edge of the levator plate to the perineal body. As a rectocele enlarges, the perineal body may further distend and become thinner leading to an evident perineocele. Entero-celes and rectoceles frequently coexist. The physical examination should include not only a vaginal examination but also a rectal examination, because a perineocele may not be evident on vaginal examination. At times, it can be identified only upon digital rectal examination where an absence of fibromuscular tissue in the perineal body is confirmed.
The gynecologic preoperative evaluation of a symptomatic posterior vaginal bulge typically includes only a history and physical examination. Gynecologists have not adopted the performance of defecography or other evaluation techniques to assess rectoceles. Whereas 80% of colorectal surgeons use defecography, only 6% of gynecologists use it.1-3 In addition, differentiation between enterocele and rectocele components of posterior vaginal wall prolapse is typically performed on a clinical and intraoperative basis. It is unclear at this time whether surgical therapy outcomes are negatively impacted by the lack of a preoperative evaluation beyond a history and physical examination.
Typically, gynecologists consider repair of the rec-tocele indicated for obstructive defecation symptoms, lower pelvic pressure and heaviness, prolapse of posterior vaginal wall, and pelvic relaxation with enlarged vaginal hiatus. However, one should be cautioned that although repair of rectoceles may correct abnormal anatomy and alleviate these symptoms,colorectal dysfunction, including constipation, may persist.
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