Female Pelvic and Reconstructive Surgery (FPRS) is a multidisciplinary subspecialty
that combines the efforts of different professionals to benefit women with pelvic
floor disorders.[1] Gynecologists, urologists and colorectal surgeons are working simultaneously and
trying to offer the best treatment to their patients. However, each medical specialty
presents different backgrounds, and this leads to different points of view for approaching
a disease whose treatment could (or should) be carried out in a collaborative fashion.
This is particularly important when surgical treatment is indicated.
The posterior compartment of the female pelvic floor is an interesting and scarcely
explored area, with divergent opinions about the best way to manage it. These differences
are so present that the International Urogynecological Association (IUGA) and the
International Continence Society (ICS) recently decided to make a joint report about
Female Anorectal Dysfunction.[2]
Rectocele is a bulging of the rectum that protrudes to the posterior vaginal wall
and corresponds to half of all prolapse surgeries performed in the US.[3] Annually, 160,000 Pelvic Organ Prolapse (POP) surgeries are made in the US, and
due to the aging population, there is a trend in the increase of number of procedures.[4] Considering that rectocele is part of the posterior compartment, the reconstruction
of this area is still one of the most difficult aspects of pelvic floor surgery,[5] and its repair involves from simple plication to site-specific repair, as well as
the use of synthetic and biological meshes.
The contribution of different specialties to the treatment of rectocele may have its
peculiarities. However, these differences never have been investigated in depth. In
a quick search on PubMed we were able to retrieve almost 1,200 abstracts using rectocele as keyword. However, only a single study addressing these differences was found.
Surgeons and gynecologists have not reached a consensus regarding the nomenclature,
diagnosis and treatment of rectocele.[6]
Colorectal surgeons refer to rectocele as the most prevalent clinical finding of the
obstructive defecation syndrome (ODS), and it presents constipation, straining for
defecation, fecal urgency (sense of incomplete evacuation), tenesmus, pelvic heaviness
and self-digitation.[7]
[8] Although rectocele may be associated to ODS, most studies point out that it is rather
a consequence than a cause of ODS.[9]
Moreover, most studies frequently investigate the association of rectocele with adjuvant
anatomical abnormalities. One classic example is the link between rectocele and intussusception.
About 67.5% of patients with clinical diagnosis of rectocele present an intussusception
on magnetic resonance defecography.[10] A study with postoperative proctograms indicated that the anterior rectal wall intussusception
would have the same etiology as a rectocele, that is, a deficient recto-vaginal ligamentous
support.[11]
Regarding diagnosis, colorectal surgeons usually classify rectocele by defecography,
magnetic resonance imaging defecography, and endoanal ultrasonography, and the intensity
of the symptoms may be scored by constipation degree or other anorectal symptoms.
On the other hand, these professionals seldom or never use the Pelvic Organ Prolapse
Quantification (POP-Q) classification.
Differently, gynecologists recognize rectocele as a clinical finding of pelvic organ
prolapse (POP). No special importance is given to rectal examination and to the necessity
for differential diagnosis with other anorectal disorders.[5] It seems to us that gynecologists investigate these patients in a more superficial
fashion. Women generally present to gynecologists with other symptoms that are more
relevant to them, such as urinary incontinence, and gynecologists in general apparently
underestimate the clinical manifestations of rectocele in comparison to colorectal
surgeons. There are two important questions that rise from this issue: is the training
in ob-gyn residency programs adequate enough for approaching FPRS? Is there an adequate
academic formation in colorectal surgery in ob-gyn residency programs? Efforts must
be done to improve these possible flaws in the ob-gyn resident training program.
However, there are points of convergence between specialists when the patient presents
symptoms of the rectocele. Expectant management should be employed even though differences
can be observed according to symptoms. Colorectal surgeons are more prone to prescribe
treatment with fibers and biofeedback training for rectoceles with ODS.[12] On the other hand, gynecologists tend to add the use of pessaries for some severe
associated prolapses.[13]
Divergences begin when surgical treatment is taken into consideration. Colorectal
surgeons prefer the transanal approach, such as stapled transanal rectal resection
(STARR) and laparoscopic ventral rectopexy. These are the most common choices for
rectoceles that coexist with intussusception.[7]
[14] A robotic approach has also been utilized with favorable short-term results when
compared with the laparoscopic rectopexy.[15] Rectoceles associated with internal rectal mucosal prolapse can be corrected by
rectal prolapsectomy.[16] A recent meta-analysis showed that STARR may reduce ODS symptoms; however, it seems
that its effect is overestimated.[17] Moreover, proctalgia, fecal urgency, and rectal bleeding are complications that
can occur in patients who undergo to this procedure.
Gynecologists are more focused on the transvaginal approaches for simple rectoceles.
A Cochrane review found that the posterior vaginal repair presents fewer current prolapse
symptoms when compared with the transanal repair.[18] The other advantages would be the broader exposure when compared with the transanal
repair and the possibility of correcting other concomitant pelvic prolapses (such
as cystocele or uterine prolapse), or other posterior defects (posterior colporrhaphy,
perineorrhaphy and site-specific defect repair).[5]
Finally, the use of meshes lacks consensus. Most of the authors use it as a combined
transanal-transperineal and abdominal approach. Synthetic meshes in the posterior
compartment are not recommended by the specialized societies (International Urogynecological
Association, Society of Gynecological Surgeons, American Urogynecological Association)
and the US Food and Drug Administration (FDA) released a public health notification
warning surgeons about possible complications.[19]
Despite FPRS being a multidisciplinary specialty, differences regarding the diagnosis
and treatment of rectocele are seen between gynecologists and colorectal surgeons.
Medical societies that diagnose and treat rectocele should come together in a joint
effort to stablish guidelines to standardize the approach of these patients, aiming
to improve the diagnosis and treatment of rectocele. Both gynecologists and colorectal
surgeons should gain more knowledge about anorectal disorders and transvaginal approaches
for the surgical procedures. Multidisciplinary groups will enhance this proximity
and improve patient care.
