Rectocele Repair- Risk and Complications

Introduction

A rectocele is characterized by bulging the rectal wall into the neighboring territory of the vaginal canal, potentially leading to various distressing symptoms. Rectocele repair, a surgical procedure, offers a viable solution to alleviate the associated symptoms. This surgical intervention is the most prevalent and effective means of addressing rectocele. However, it is crucial to understand the risks and potential complications associated with this surgery, as elaborated below.

What Is Rectocele?

A rectocele manifests pelvic organ prolapse, where the rectal tissue protrudes into the neighboring vaginal canal by breaching the rectovaginal septum. To grasp the anatomy, picture the bladder in the front of the vagina while the rectum occupies the rear position. The rectovaginal septum serves as a vital barrier, restricting the vagina from the lower part of the large intestine, the rectum. This septum's structural integrity is closely tied to the endopelvic fascia. When this septum weakens, it paves the way for rectal tissue to bulge, ultimately giving rise to the condition known as a rectocele. The symptoms include:

• A distinct sensation of fullness or a noticeable bulge in the vaginal area.

• Struggles with bowel movements, including difficulties with complete emptying, persistent straining, or the sensation of an obstruction.

• Persistent, nagging issues with chronic constipation.

• A lingering feeling of pressure within the pelvic region.

• Discomfort and pain during sexual intimacy.

• Unpleasant sensations of pain, irritation, or dryness in the vaginal region.

What Is Rectocele Repair?

Rectocele repair is a surgical endeavor to restore the rectovaginal septum's natural anatomical configuration. The approach to management varies depending on the severity of the condition. In milder cases, conservative measures come into play, encompassing dietary adjustments, including a high-fiber regimen, increased hydration, and the incorporation of pelvic floor exercises. When these conservative strategies prove insufficient, vaginal pessaries become a viable option. These devices, available in different sizes and shapes, offer support to the vaginal wall, with the ring support pessary being the most commonly utilized variant. As a final recourse, surgical intervention becomes a consideration when conservative treatments fall short, and symptoms remain bothersome. The core tenet of surgical repair is restoring the posterior wall's normal structure and function, including its integral fibromuscular support. The different approaches include:

• Transperineal: This surgical approach targets the perineum region between the vaginal orifice and the perineum itself. Within this category are two distinct procedures: Delorme's surgical technique and Alteimer's recto sigmoidectomy.

• Transvaginal: The approach here involves working through the vaginal wall, employing a method known as posterior colporrhaphy. In this procedure, an incision is carefully made in the vaginal tissue, extending from the region between the vagina and anus up to the upper part of the vagina. Subsequently, the vaginal wall is gently separated from the rectum, and the fibromuscular tissue is skillfully folded and sutured to reinforce its strength. Any excess tissues are meticulously removed, and the incisions are securely closed. A mesh material may be introduced to support the folded tissue in select cases. There are two primary techniques utilized for this purpose: the traditional Denonvilliers' transversal suture (TDTS) and perineal body anchorage (PBA).

• Transanal: Rectocele repair through the anal canal involves several specialized techniques, including the stapled transanal rectal resection (STARR), the Sullivan-Khubchandani technique, and the trans-STARR technique.

• Abdominal: The surgical entry is made through the lower abdominal region. Within this approach, two key surgical techniques are employed: rectopexis, which may involve the use of a mesh or be performed without it, and colo-rectum resection.

What Are the Risks and Complications of Rectocele Repair?

The risks and complications of using vaginal pessary for rectocele repair include:

• Discomfort and Pain: Some individuals may experience discomfort or pain while wearing the device due to the pressure it exerts on the vaginal walls.

• Irritation: Pessaries can irritate the vaginal mucosa, leading to uncomfortable symptoms like itching and vaginal discharge. This irritation often results from the friction caused by the pessary.

• Challenges in Removal: Removing the pessary can be challenging, potentially causing it to become lodged and leading to feelings of anxiety and discomfort.

• Slippage: Occasionally, the pessary can slip out of the vagina, which may occur during physical activities or bowel movements.

• Allergic Reactions: Some individuals may experience allergic reactions to the materials used in the pessary.

• Infection Risk: There is a slightly increased risk of infection, including urinary tract infections, although this risk is relatively uncommon when proper hygiene is maintained.

• Erosion or Ulceration: Prolonged use of a pessary, especially if not correctly fitted, can lead to erosion or ulceration of the vaginal tissues.

• Sexual Interference: The presence of the pessary can interfere with sexual activities, affecting intimacy and comfort.

The risks and complications of surgical rectocele repair include:

• Postoperative Pain and Discomfort: Discomfort around the vaginal area is joint following surgery, but this can typically be managed with pain-relieving medication and adequate rest.

• Infection Risk: There is a risk of infection at the surgical site, so precautions should be taken, and antibiotics may be prescribed to treat any infections that arise.

• Bleeding: Surgical procedures inherently carry a risk of bleeding. If not effectively controlled, it could result in blood loss significant enough to necessitate a blood transfusion.

• Anesthesia Risks: Anesthesia can lead to complications such as allergic reactions or issues in the blood and circulatory system during surgery.

• Urinary Symptoms: After surgery, urinary symptoms like difficulty urinating, urinary tract infections, and urinary retention may occur, but these typically resolve with time.

• Fecal Incontinence: There may be temporary issues with bowel control post-surgery.

• Constipation: Temporary constipation is possible but can often be managed with medication and dietary adjustments.

• Risk of Recurrence: Rectocele recurrence is possible, particularly in chronic straining issues or other factors.

• Allergic Reactions: In procedures involving mesh, allergic reactions to the material used can occur.

• Incision Issues: In some cases, incisions may open up, interfering with the healing process; this is known as wound dehiscence and may require additional surgical intervention.

• Scar Formation: Although rare, hypertrophic or keloid scars may develop due to surgery.

Conclusion

Rectocele, while not life-threatening, can significantly impact a patient's quality of life. The utilization of pessaries, though generally well-tolerated, may come with minor complications like ulcerations, discomfort, pain, irritation, and the occasional challenge in removing the device. On the other hand, surgical rectocele repair carries a higher risk profile for complications. To achieve a favorable outcome, it becomes paramount to thoroughly comprehend the patient's risk factors, carefully select the appropriate surgical technique, and implement diligent postoperative care.