A rectocele is defined as greater than 2 cm of rectal wall outpouching or bowing while straining, and can precede or accompany rectal intussusception, as demonstrated in Figure 9.3. The rectocele can prevent passage of stool both by obstructing the anal orifice and by acting as a diverticulum to sequester stool. Patients with rectoceles commonly complain of the need for frequent sequential episodes of defecation, and even for manual compression or splinting of the anterior perineum or posterior vagina in order to completely evacuate. Additionally, with relaxation, patients may experience reduction of the rectocele and return of the sequestered stool to the lower rectum, potentially resulting in incontinence. Rectoceles are found in 25% to 50% of women, and are often asymptomatic.23'27
Van Dam and associates28 investigated the utility of defecography in predicting the outcome of rectocele repair. Rectocele size, barium trapping, intussusception, evacuation, and perineal descent were measured during defecography exams of 74 consecutive patients with symptomatic rectoceles. The patients then underwent a transanal/transvaginal repair, followed by a 6-month-postoperative defecography and reassessment of the five most common presenting symptoms (excessive straining, incomplete evacuation, manual assistance required, sense of fullness, bowel movement less than three times per week). No postoperative defecograms demonstrated a persistent or recurrent rectocele; however, one third of patients had a poor result based on persistent symptoms. There was no association between defecography measurements and outcome of the repair. Still, the authors concluded that defecography serves three major purposes in the evaluation of a rectocele: preoperative evidence of its presence and size, documentation of additional pelvic floor abnormalities, and an objective assessment of postoperative changes.
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