Rectocele surgery corrects a type of pelvic organ prolapse that occurs when the supportive tissue separating the rectum and the vagina weakens, allowing the rectum to bulge into the back wall of the vagina. This procedure, often called a rectocele repair or posterior colporrhaphy, aims to push the rectum back into its proper position and reinforce the damaged wall between the two organs. The decision to proceed with surgery depends on the severity of the patient’s symptoms and their impact on daily life.
Deciding on Surgical Intervention
Surgery is typically not the initial approach for a rectocele, as many patients can manage mild symptoms with non-surgical methods like dietary changes, stool softeners, or strengthening pelvic floor exercises. Surgery is necessary when symptoms are severe or when conservative treatments have failed to provide relief. Indications for surgical repair include significant discomfort, a feeling of pressure or a bulge in the vagina, or pain during intercourse.
A major factor prompting surgical intervention is obstructed defecation, which is difficulty having a bowel movement. Some patients must manually press on the back wall of the vagina or the surrounding perineum to empty their bowels, a symptom known as manual splinting. Surgery is reserved for advanced stages, especially when functional issues compromise a person’s quality of life. The goal of the procedure is to restore normal anatomy and function, rather than simply fixing a physical bulge that is not causing symptoms.
Overview of Rectocele Repair Techniques
The primary objective of rectocele repair is to strengthen the rectovaginal septum, the wall of tissue between the rectum and vagina, preventing the rectum from bulging forward. The most common approach is the transvaginal repair, also known as posterior colporrhaphy, where an incision is made in the back wall of the vagina. The surgeon dissects the tissue layers, pushes the rectum back, and uses sutures to tighten the supportive layers. This technique involves suturing the patient’s own tissues together, which is called native tissue repair.
Another, less common approach is the transanal repair, performed through an incision near the anus. This method, sometimes used by colorectal surgeons, focuses directly on the rectal wall defect. Transvaginal repair generally shows better long-term anatomical results and symptom improvement compared to the transanal approach. Both procedures are typically performed under general or spinal anesthesia and may involve a short hospital stay of one to three days.
In some cases, particularly for recurrent prolapse or when the native tissue is weak, a synthetic mesh or biological graft may be used to reinforce the repair, known as an augmented repair. While mesh can offer a lower rate of anatomical recurrence, its use in primary rectocele repair is limited due to concerns about complications, such as mesh exposure or erosion. For most isolated rectoceles, native tissue repair remains the preferred method.
Immediate Post-Operative Recovery
Following the procedure, patients are monitored in the recovery area and may wake up with a catheter draining the bladder and possibly a temporary gauze pack in the vagina. These devices are usually removed the day after the operation, and the care team ensures the patient can empty their bladder without difficulty. Pain management is a priority, and physicians prescribe a combination of anti-inflammatory and narcotic pain medications to manage discomfort, which is most noticeable during the first three to seven days.
A major focus during the initial recovery is preventing constipation and straining, as this pressure can endanger the delicate repair. Patients are immediately started on stool softeners and a high-fiber regimen, sometimes with a liquid or simple diet at first, until the first bowel movement occurs. Activity restrictions are strict in the first few weeks, prohibiting heavy lifting (typically over 5 to 10 pounds) and any strenuous activity. Walking is encouraged to promote circulation, but patients should rest frequently.
Managing Expectations and Long-Term Results
The timeline for resuming normal activities varies, but most patients are advised to avoid heavy lifting and sexual intercourse for at least six weeks, with full healing taking up to 12 weeks. Success rates for rectocele repair are high, with 80% to 90% of patients reporting significant improvement in their symptoms. Most patients experience sustained relief from obstructive defecation and pelvic pressure.
Recurrence is possible, where the prolapse returns over time. The recurrence rate after a native tissue rectocele repair is estimated to be between 10% and 20%. A repair in one area does not prevent the development of prolapse in another compartment, such as the bladder or uterus, which may require future intervention. Long-term follow-up with the surgeon is important, and patients are encouraged to maintain pelvic floor exercises and avoid activities that place excessive strain on the pelvic floor to help preserve the surgical outcome.