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3/1/2016

Management of Large Rectoceles in Geriatric Patients

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 develops.

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 does not support one type of pessary over another for patients 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 two to three 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 colporrhaphy, 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.

The use of mesh is reserved for complicated rectocele repairs. The general use of placement of mesh devices does not demonstrate an acceptable risk-benefit profile compared with repairs performed using native tissue. Complications for mesh prolapse repairs included mesh erosion and contraction, pain, infection, bleeding, dyspareunia, fistula, and vascular and organ injury.  Many complications required additional interventions including hospitalization and recurrent medical or surgical treatments.

Further Reading:

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519. (Reaffirmed 2021)

Bharucha, A. E., & Knowles, C. H. (2022). Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. Neurogastroenterology and motility, 34(11), e14453. https://doi.org/10.1111/nmo.14453

 

Initial Approval:  January 16, Revised July 2017; Reaffirmed January 2019; Revised September 2020, Revised March 2022, Revised January 2024.

 

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