Anatomy

Defects in the integrity and attachments of the posterior vaginal wall and rectovaginal septum may result in herniation of the posterior 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 all of the pelvic organs, and contains blood vessels, lymphatics, and nerves that supply and innervate the pelvic organs.

Denonvilliers originally described a dense tissue layer in men between the bladder and the rectum and named it the rectovesical septum.4 Many clinicians refer to this layer as Denonvil-liers' fascia. The layer of tissue between the vagina and the rectum was felt to be analogous to the rectovesical septum and became known as Denonvilliers' fascia in the female, or the recto-vaginal septum.4 Others described the rectovagi-nal fascia as a support mechanism of the pelvic organs, and were successful in identifying this layer during surgical and autopsy dissections.4-6

The normal vagina is stabilized and supported on three levels. Superiorly, the vaginal apical endopelvic fascia is attached to the cardinal-uterosacral ligament complex (level I). Laterally, the endopelvic fascia is connected to the arcus tendineus fasciae pelvis (level II). Inferiorly, the lower posterior vagina connects to the perineal body (level III).7 The endopelvic fascia extends between the vaginal apex and the perineal body, comprising the rectovaginal septum (Fig. 19.3). An enterocele or rectocele results from a stretching or actual separation or tear of the rectovagi-nal fascia, leading to a bulging of the posterior vaginal wall noted on examination during a Valsalva maneuver. Trauma from vaginal childbirth

Rectovaginal Septum Anatomy
Figure 19.3 Schematic representation of the rectovaginal septum including its attachment to the vaginal apex superiorly and perineal body inferiorly. Reprinted with permission of the Cleveland Clinic Foundation.

commonly leads to transverse defects above the usual location of the connection to the perineal body (Fig. 19.4).4,8 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 intraperi-toneal contents. The levator plate extends from the pubic bone to the sacrum/coccyx and provides support for the change in vaginal axis from vertical to horizontal along the midvagina. A rectocele typically develops at, or below, the levator plate, along the vertical vagina.

Figure 19.4 Fascial tears of the rectovaginal septum can occur superiorly or inferiorly at sites of attachment to a central tendon. Reprinted with permission of the Cleveland Clinic Foundation.

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