Mickey Karram M.D. Director of Urogynecology The Christ Hospital Professor of Ob/Gyn & Urology

1. The Forgotten Posterior Pelvic Floor; Rectocele Repair, Perineoplasty, & Defecatory Dysfunction Mickey Karram M.D. Director of Urogynecology The Christ Hospital Professor of Ob/Gyn & Urology University of Cincinnati

2. ANATOMY OF THE POSTERIOR VAGINAL WALL • RECTOVAGINAL SEPTUM??? • WHAT IS FASCIA??? • DOES IT TRULY EXTEND FROM SACRUM TO PERINEUM??? • IS RICHARDSON’S CLASSIFICATION OF DEFECTS CLINICALLY APPLICABLE???

4. Anatomy of Posterior Wall

5. GOALS OF RECTOCELE REPAIR • PROVIDE DURABLE SUPPORT FROM POSTERIOR FOURCHETTE TO POSTERIOR VAGINAL FORNIX • Identfy and correct enterocele if present • Rebuild Perineum and correct Anal Sphincter if appropriate • Narrow vaginal calibar if needed

6. POSTERIOR VAGINAL COMPARTMENT DEFECTS KEYS TO SURGICAL SUCCESS • Avoid Distortion Of Vaginal Access • Avoid Vaginal Constriction • Appropriate Use Of Levatoroplasty • Appropriate Use Of Perineorraphy • Defect Specific Repairs • Tight Repairs In Sexually Inactive Women

7. POSTERIOR VAGINAL COMPARTMENT SURGICAL CHALLENGES • High Recurrent Rectocele • Large Symptomatic Rectocele With A Foreshortened Vagina • The Entercele That You Can’t find • Recurrent Cystocele And Rectocele

8. PROLAPSE SYMPTOMS THAT MAY COEXIST WITH RECTOCELES • Pelvic Pressure and Tissue Protrusion • Feeling of a Gaping Introitus • Sexual Dysfunction

9. DEFECATORY DYSFUNCTION THAT MAY COEXIST WITH RECTOCELES • Fecal Incontinence • Paradoxical Sphincter Reaction • Fecal Urgency • Stool Clustering • OUTLET OBSTRUCTION

10. EVALUATION OF RECTOCELES • CLINICAL • Imaging • Radiographic • Electrophysiologic • Endoscopic • Transit Studies

12. SURGICAL APPROACHES TO RECTOCELE • Gynecologist Traditional Defect-Specific • Colorectal Surgeon Transrectal Repair

13. SEXUAL DYSFUNCTION AFTER TRADITIONAL POSTERIOR COLPORRAPHY • Francis + Jeffcoate (1961) 50% • Kahn + Stanton (1997) 18% To 27% • Paraiso et al. (2001) Worsening Dysparaenia

14. POSTERIOR COLPORRHAPHY: ITS EFFECTS ON BOWEL AND SEXUAL FUNCTION Kahn & Stanton: Br J Obstet Gynecol 1997, 104: 82-86 • Levatorplasty Performed On 231 Patients • Vaginal Defects Corrected In 76% • Worsening Of Bowel And Sexual Function

22. KSutt

23. POSTERIOR COMPARTMENT DEFECTS CASE • S.J. Is A 43 Year Old P-3; S/P Vaginal Hysterectomy A/P Repair For Mild Uterovaginal Prolapse 1 Year Ago, Presents With Severe Dysparaenia 2 Degrees To Tight Introitus And Recurrent Prolapse Of Upper Post Vaginal Wall. Probably High Rectocele And Enterocele. Also C/O Of Splinting And Pressure

24. Jump

25. POSTERIOR COMPARTMENT DEFECTS CASE • A.S. is a 51 yr old nulliparous female with 5 yr hx of difficulty evacuating bowels; symptom’s onset with abd hyst for severe endometriosis. O/E small rectocele and cystocele. Defcography showed rectocele 2.5 cm on straining to 3.7 cm on evacuation, also enterocele seen. All other colorectal evaluation normal

26. Andreastoher

27. POSTERIOR COMPARTMENT DEFECTS CASE 77 yr old with complete procidentia andvaginal eversion Has significant bowel dysfunction with difficulty evacuating her stools as well as mild fecal incontinence. Desires to maintain a functional vagina

28. Complete Procidentia (1)

29. TREATMENT OF RECTOCELE CONCLUSIONS • Correlation between anatomic defect and functional derangement is poor to non-existent • Enteroceles need to be routinely looked for when correcting rectoceles • Unsure of clinical utility of colorectal testing prior to rectocele repair