Management of the posterior compartment

A rectocele is a herniation of the rectum through the recto vaginal septum causing a protrusion of the posterior vaginal wall. The prevalence of rectocele ranges from 20% to 80% of the general population. Hendrix et al. performed a cross-sectional analysis of women who enrolled in the women’s health initiative of a hormone replacement therapy clinical trial. The total populationwas 27,342women. At baseline pelvic examination the prevalence of rectocele was approximately 18%, whether or not the women had undergone a prior hysterectomy. African/American women in this particular study demonstrated the lowest predisposition for prolapse. Parity and obesity were strongly associated with the increased risk for rectocele. However, whether or not black women are protected from prolapse remains a contentious issue as a Nigerian study has shown rectocele may be present in up to 11.4% of women over the age of 40. The natural history of prolapse has been very poorly studied, Handa et al. performed annual pelvic examinations on women over a 2–8-year period. The annual incidence of rectocele was 5.7 cases per 100 women years. While the progression rate for stage 1 rectocele was 13.5 per 100 women years there was a regression rate of 22 per 100 women years. This shows spontaneous regression is common in stage 1 prolapse. It is therefore very important that stage 1 prolapse be managed conservatively in the first instance as many will resolve. Rectocele was once thought to be a condition affecting only multiparous females and resulting from obstetric damage or increased tissue laxity with ageing and menopausal atrophy. However, rectocele has been observed in asymptomatic volunteers during defaecography. Obstetric events are usually the major predisposing factor. Traumatic delivery and damage to nerve, muscle and connective tissue will result in altered function and anatomical position of the pelvic tissues. The rectal fascia may separate from the perineal body causing a low transverse defect, although higher isolated defects in various parts of the recto vaginal tissue are also described. Chronic constipation and straining may also cause damage to the recto-vaginal septum over time and result in a rectocele. Finally, posterior vaginal prolapse is extremely common after colposuspension, which is likely to change the vaginal axis and cause a strain on the posterior vaginal wall detaching it from its fascial attachments. Table 1 shows aetiological factors in the development of a rectocele.