The surgical anatomy of rectocele and anterior rectal wall intussusception

Abstract

The aim of the study was to analyse the dynamic anatomical supports of the posterior vaginal wall from the perspective of rectocele and rectal intussusception repair. Two groups of patients were studied. Group 1 (n = 24) with genuine stress incontinence but no major vault prolapse had vagino/proctomyograms and transperineal ultrasound examinations. Group 2 with vaginal vault prolapse, clinical rectoceles and obstructive defecation symptoms (n = 19 had single-contrast defecating proctography before and after posterior-sling surgery. The posterior vaginal wall is suspended between perineal body, which underlies half its length, and uterosacral ligaments, which also support the anterior wall of rectum. Muscle forces stretch the vagina and rectum against the perineal body and uterosacral ligaments, creating shape and strength, like a suspension bridge. Postoperative proctogram studies indicated that anterior rectal wall intussusception has the same etiology as rectocele, deficient recto-vaginal ligamentous support. Repair to uterosacral ligaments and perineal body should be considered with large rectoceles, anterior rectal wall intussusception and obstructive defecation disorders.

Live anatomy of the perineal body in patients with third‐degree rectocele

“…Our surgical measurement included the STP and DTP muscles, whereas Zetterstrom et al [2] measured the PB by ultrasonography as the distance between the inner surface of the internal anal sphincter and the reflection of a finger held gently against the posterior vaginal wall. Using radiological methods, Abendstein et al [1] reported that the PB formed more than 50% of the support of the posterior vaginal wall; however, they did not specify the actual length of the PB.…”

“…The supportive role of the perineal body (PB) is well documented. Using X-ray and evacuating proctogram studies, Abendstein et al [1] demonstrated that the PB structures support at least 50% of the posterior vaginal wall. Using an ultrasound technique limited to the axial plane, Zetterstr€ om et al [2] found that the PB measured only 12 AE 3 mm in asymptomatic subjects.…”

Posterior vaginal compartment prolapse and defecatory dysfunction: are they related?

“…When uterosacral/cardinal ligaments stretch or levator muscles weaken through direct injury, avulsion, or neuromuscular damage from obstetrical trauma, excessive force may be placed on the rectovaginal septum leading to attenuation and/or discrete breaks and posterior vaginal compartment prolapse [22][23][24].…”

Incontinence in full‐thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

“…A self‐administered questionnaire is less intimidating for the patient and is more sensitive [9]. Finally, the postoperative benefit for continence may be overestimated in studies offering a follow‐up that is too short [5].…”