Pelvic Floor Reconstruction

Center for Intestinal Continence
St. Anthony's Hospital, Professional Office Building
1201 Fifth Ave. N., Suite 408
St. Petersburg, FL 33705
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Rectocele

A rectocele is a bulge of the front wall of the rectum into the vagina.  The rectal wall may become thinned and weak, and it may balloon out into the vagina when you push down to have a bowel movement.  This area is called the "rectovaginal septum" and may be a weak area in the female anatomy

Other structures may also push into the vagina.  The bladder bulging into the vagina is a cystocele, the small intestines pushing down on the vagina from above is an enterocele.

Although uncommon, men may also develop a rectocele.

Symptoms:  Many women have rectocelses but only a small percentage of women have symptoms related to rectocele.  They would include vaginal bulging, the sensation of a mass in the vagina, pain with intercourse, or something prolapsing from the vagina.  Occasionally, vaginal bleeding.

Constipation, particularly difficult evacuation with straining.

A general feeling of pelvic pressure or discomfort is often present.

Diagnosis:  Most rectoceles may be identified with the examination of the vagina and rectum.  Further investigation may require an x-ray called a defecagram.  This study show how large the rectocele is and if it empties with evacuation.

Treatment:  Rectoceles that are not causing symptoms do not need to be treated.  In general, avoid constipation.

Medical therapy would include a high fiber diet with 6 to 8 glasses of fluid each day.  You may wish to add a fiber supplement and/or a stool softener.

Surgical therapy available is the minimally invasive "Apogee" procedure which uses a soft synthetic mesh or biomaterial.

The material is placed between the vaginal wall and the wall of the rectum to provide reinforcement and correct the bulging of the wall of the rectum into the vaginal wall.  This is performed laparoscopic with small incisions at the vaginia, and in the thigh/buttock crease on both sides.

If you have a cystocele, vaginal prolapse and/or entrocele, these can be repaired at the same time.

Post Operative

Hospital stay will depend on your recovery, 2-5 days.  Incisions will be small and should heal quickly.  Depending on the nature of your work one to two weeks postop, depending on the nature of your job.  You will have to refrain from sexual intercourse, heavy lifting and rigorous exercise for six to eight weeks.

Rectal Prolapse

Rectal Prolapse is a condition in which the rectum (lower end of the colon, located just above the anus) turns itself inside out.  In the earliest phases of this condition, the rectum does not stick out of the body, but as the condition worsens, it may protrude.  Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage and may result in leakage of stool or mucus.  The condition occurs in both sexes, although it is more common in women then men.

Several factors may contribute to the development of rectal prolapse.  It may come from a lifelong habit of straining to have a bowel movement or as a delayed result of stresses involved in childbirth. 

            Diagnosis can be made by taking a careful history and performing a complete anorectal examination.  To demonstrate the prolapse, patients may be asked to "strain" as if having a bowel movement or to sit on the commode and "strain" prior to examination.

At times, however, a rectal prolapse may be "hidden" or internal.  In this situation, an x-ray examination called videodefogram may be helpful.  This is an x-ray taken while the patient is having a bowel movement, and assist the surgeon to determine if surgery would be beneficial and which operation may be appropriate.

Anorectal manometry may also be used.  This test measures whether or not the muscles around the rectum are functioning normally.

            Treatment of rectal prolapse depends on several factors, age, physical condition, extent of prolapse and test result. Once the prolapse has occurred, medical therapy is not helpful.

The surgical options would be: Anterior resection.  Removing the S-shaped sigmoid colon (the portion of the large intestine just before the rectum) the two cut ends are reattached.  This straightens the lower portion of the colon and makes it easier for stool to pass.

Rectopexy , The rectum is isolated from surrounding tissues, and the sides of the rectum lifted and fixed to the sacrum (lower backbone) with stitches or with a nonabsorbable mesh.

These procedures may be performed laparoscopic or require open incision on the abdomen.

The minimally invasive Delorme procedure involves the resection of only the mucosa (inner lining) of the prolapsed rectum.  The exposed muscular layer is then folded and stitched up and the cut edges of mucosa stitched together.

Obstructed Defecation (Severe constipation)

Obstructed defecation syndrome is characterized by chronic constipation.  There often is a sense of not having emptied the rectum along with heaviness in the perianal area.  There might also be a need for straining and/or manual manipulation during defecation.

            Symptoms include multiple trips to the bathroom, prolonged straining, incomplete elimination and/or prolonged time to have a bowel movement, routine use of laxatives or enema, and the need the press around your genitals or anus to have a bowel movement.

            Diagnosis is the key to successful treatment of defecation disorders.  In addition to a physical exam, some diagnostic tests that may be performed are colonoscopy: the doctor looks at the interior lining of the large intestines through a thin, flexible viewing called a colonoscope.    

Colonic marker studies:  The patient swallows small tablets.  During a period of seven days, the patient is x-rayed to track the progress of the markers to see how quickly they are moving through the GI tract.

Electromyography (EMG):  Test for weakness in the pelvic floor muscles surrounding the anus to determine.

Anal Manometry: Tests how well the muscles surrounding the anus are working.

Dynamic defecography:  The patient sits on a special toilet and strains while being viewed under x-ray Images are taken and this allows the doctor to access bowel function.

Treatment: Conservative medical treatment would include diet change, high fiber foods, increase fluid intake. Fiber supplements, which are neither harmful or habit forming, as some stimulant laxative may become.  Exercise would also be added to this regime.

If unresponsive the medical therapy, a surgical procedure can be performed call STARR (Stapled Trananal Rectal Resection) that is performed through the anus, and requires no external incisions, and leaves no visible scars.

Using a surgical stapler, the surgeon removes excess tissue in the rectum and reduces the deformities that cause obstructive defecation syndrome.

Patients typically in the hospital for one to three days.