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Management of Large Rectoceles in Geriatric Patients

3/1/2016 - Anne Garrison, MD

Mentor:  Tiffany Moore-Simas, MD

Editor: Julie Decesare, MD and Eduardo Lara-Torre, MD

Approved:  1/5/16, Revised (updated Reference) 7/17

Patients with rectoceles may be asymptomatic or have symptoms such as splinting, pelvic pressure, dyspareunia, constipation, fecal incontinence, and defecatory dysfunction. Rectocele extent does not necessarily correlate with the severity of symptoms.

No treatment is required for asymptomatic or mildly symptomatic elderly patients. Effective management of constipation is important.  Treatment is necessary if hydronephrosis, non-resolving vaginal erosions, or obstruction develop.

Nonsurgical treatment options should be discussed. Pelvic examination should assess the extent of prolapse in all compartments and include rectovaginal exam, assessment of the anal sphincter, and neurologic evaluation of the area.  A pessary can be offered regardless of prolapse stage. Numerous vaginal pessaries are available and data do not support one type of pessary over another for women with rectoceles.

Pelvic floor muscle rehabilitation and symptom-directed therapy may be offered. Pelvic floor physical therapy is typically performed once or twice weekly over a 2 to 3 month period, supervised by an experienced therapist or practitioner.  

Indications for surgical management include desire for definitive correction, difficulty with intercourse, recurrent ulcerations from pessary use, or unacceptable incontinence. Decision to perform surgery must balance the surgical risks against the potential benefits. Perioperative risk is increased in older patients with concomitant medical problems and careful preoperative assessment and management of identified conditions should be performed. Pre-operative defect assessment including evaluation for presence of co-existing enterocele, sigmoidocele, and apical defects can inform the surgical approach. Dyspareunia should be assessed in sexually active patients.

There is no consensus regarding the optimal surgical approach. Historically, the primary surgical therapy is posterior colporrhaph, often including a perineorrhaphy. The surgeon should maintain adequate vaginal caliber for sexually active patients. Plication of the levator ani muscles may also be performed. Other techniques include defect-directed repair and posterior fascial replacement via transanal, laparoscopic, and abdominal approaches. Obliterative procedures (colpocleisis) can be offered to women at high risk for complications with reconstructive procedures who do not desire vaginal intercourse.

Caution should be exercised using mesh for prolapse repair. A variety of graft materials and meshes have been studied in clinical trials, and it is not clear that any material is superior, or that repair with mesh provides added benefit compared to surgery without mesh. Complications reported to the FDA for mesh prolapse repairs include mesh erosion and contraction, pain, infection, bleeding, dyspareunia, fistula, and vascular and organ injury.  Many complications require additional interventions including hospitalization and medical or surgical treatment. 

Further Reading:

Pelvic organ prolapse. Practice Bulletin No. 176. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e56–72.

Food and Drug Administration. FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse. www.fda.gov. Available at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm.

 

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