World Journal of Surgery

, Volume 34, Issue 4, pp 822–829 | Cite as

Randomized Controlled Trial between Perineal and Anal Repairs of Rectocele in Obstructed Defecation

  • Mohamed Farid
  • Khaled M. MadboulyEmail author
  • Ahmed Hussein
  • Tarik Mahdy
  • Hesham A. Moneim
  • Waleed Omar



The present study was designed to evaluate functional outcome of perineal repair with and without levatorplasty versus transanal repair of rectocele in obstructed defecation.

Methods and patients

A total of 48 multiparous women with obstructed defecation caused by a rectocele were randomly allocated to three groups: transperineal repair with levatorplasty (TPR-LP; n = 16); transperineal repair without levatorplasty (TPR; n = 16); and transanal repair (TAR; n = 16). The study included defecographic assessment, anal manometry, symptom improvement, sexual function, and score on a function questionnaire. Assessments were done preoperatively and 6 months postoperatively.


Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in both groups with transperineal repair but not in the group with transanal repair. Significant reductions in mean anal resting pressure, maximum reflex volume, and urge-to-defecate volume were observed only with the transperineal approach (with and without levatorplasty). Functional score improved significantly in the transperineal groups (with levatorplasty, P < 0.001; without levatorplasty, P < 0.01), but not in the transanal group (P = 0.142). Levatorplasty added to transperineal repair significantly improved the overall functional score compared with transperineal repair alone (P < 0.01) and transanal repair TAR (P < 0.001).


Rectocele repair appears to improve anorectal function by improving rectal urge sensitivity. Transperineal repair of rectocele is superior to transanal repair in both structural and functional outcome. Levatorplasty improves functional outcome, but potential effects on dyspareunia should be discussed with the patient.


Transanal Approach Incomplete Evacuation Rectovaginal Septum Anterior Rectal Wall Obstruct Defecation Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors appreciate the great help of Dr. Anthony Senagore, Professor of Surgery, Department of Surgery, Michigan State University, Grand Rapids, Michigan, and Dr. Conor Delaney, Professor and Chief, Division of Colorectal Surgery, Case Western Reserve University, Cleveland, Ohio.


  1. 1.
    Heriot AG, Skull A, Kumar D (2004) Functional and physiological outcome following transanal repair of rectocele. Br J Surg 91:1340–1344CrossRefPubMedGoogle Scholar
  2. 2.
    Deitz HP, Steensma AB (2006) The role of childbirth in the aetiology of rectocele. Br J Obstet Gynecol 113:264–267Google Scholar
  3. 3.
    Lehur PA, Mirallie E (2003) Against anterior levator plasty in the treatment of rectoceles in women. Gynecol Obstet Fertil 31:969–971PubMedGoogle Scholar
  4. 4.
    Harewood GC, Coulie B, Camilleri M et al (1999) Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol 94:126–130CrossRefPubMedGoogle Scholar
  5. 5.
    Sloots CE, Meulen AJ, Felt-Bersma RJ (2003) Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time. Int J Colorectal Dis 18:342–348PubMedGoogle Scholar
  6. 6.
    Van Laarhoven CJ, Kamm MA, Bartram CI et al (1999) Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation. Dis Colon Rectum 42:204–210 discussion 210–211CrossRefPubMedGoogle Scholar
  7. 7.
    Raz S, Nitti VW, Bregg KJ (1993) Transvaginal repair of enterocele. J Urol 149:724–730PubMedGoogle Scholar
  8. 8.
    Lopez A, Anzen B, Bremmer S et al (2001) Durability of success after rectocele repair. Int Urogynecol J Pelvic Floor Dysfunct 12:97–103CrossRefPubMedGoogle Scholar
  9. 9.
    Roman H, Michot F (2005) Long-term outcomes of transanal rectocele repair. Dis Colon Rectum 48:510–517CrossRefPubMedGoogle Scholar
  10. 10.
    Arnold MW, Stewart WR, Aguilar PS (1990) Rectocele repair. Four years’ experience. Dis Colon Rectum 33:684–687CrossRefPubMedGoogle Scholar
  11. 11.
    Mellgren A, Lopez A, Schultz I et al (1998) Rectocele is associated with paradoxical anal sphincter reaction. Int J Colorectal Dis 13:13–16CrossRefPubMedGoogle Scholar
  12. 12.
    De Tayrac R, Picone O, Chauveaud-Lambling A et al (2006) A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh. Int Urogynecol J Pelvic Floor Dysfunct 17:100–105CrossRefPubMedGoogle Scholar
  13. 13.
    Ellis CN (2007) Stapled transanal rectal resection (STARR) for rectocele. J Gastrointest Surg 11:153–154CrossRefPubMedGoogle Scholar
  14. 14.
    Murthy VK, Orkin BA, Smith LE et al (1996) Excellent outcome using selective criteria for rectocele repair. Dis Colon Rectum 39:374–378CrossRefPubMedGoogle Scholar
  15. 15.
    Lehur PA, Kahn X, Hamy A (2000) Surgical treatment of anterior rectoceles in women. The perioneal-vaginal approach. Ann Chir 125:782–786CrossRefPubMedGoogle Scholar
  16. 16.
    Fabiani P, Benizri E, Gugenheim J et al (2000) Surgical treatment of anterior rectoceles in women. The transanal approach. Ann Chir 125:779–781CrossRefPubMedGoogle Scholar
  17. 17.
    Regadas FS, Regadas SM, Rodrigues LV et al (2005) Transanal repair of rectocele and full rectal mucosectomy with one circular stapler: a novel surgical technique. Tech Coloproctol 9:63–66 discussion 66CrossRefPubMedGoogle Scholar
  18. 18.
    Tjandra JJ, Ooi BS, Tang CL et al (1999) Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus. Dis Colon Rectum 42:1544–1550CrossRefPubMedGoogle Scholar
  19. 19.
    Altman D, Mellgren A, Blomgren B et al (2004) Clinical and histological safety assessment of rectocele repair using collagen mesh. Acta Obstet Gynecol Scand 83:995–1000PubMedGoogle Scholar
  20. 20.
    Lechaux JP, Lechaux D, Bataille P, Bars I (2004) Transperineal repair of rectocele with prosthetic mesh. A prospective study. Fr Ann Chir 129:211–217CrossRefGoogle Scholar
  21. 21.
    Watson SJ, Loder PB, Halligan S et al (1996) Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. J Am Coll Surg 183:257–261PubMedGoogle Scholar
  22. 22.
    Albo M, Dupont MC, Raz S (1996) Transvaginal correction of pelvic prolapse. J Endourol 10:231–239CrossRefPubMedGoogle Scholar
  23. 23.
    Abramov Y, Gandhi S, Goldberg RP et al (2005) Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 105:314–318PubMedGoogle Scholar
  24. 24.
    Altman D, Zetterstrom J, Mellgren A et al (2006) A three-year prospective assessment of rectocele repair using porcine xenograft. Obstet Gynecol 107:59–65PubMedGoogle Scholar
  25. 25.
    Nieminen K, Hiltunen KM, Laitinen J et al (2004) Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study. Dis Colon Rectum 47:1636–1642CrossRefPubMedGoogle Scholar
  26. 26.
    Ternent CA, Bastawrous AL, Morin NA et al (2007) Practice parameters for the evaluation and management of constipation. Dis Colon Rectum 50:2013–2022CrossRefPubMedGoogle Scholar
  27. 27.
    Ellis CN (2005) Treatment of obstructed defecation. Clin Colon Rectal Surg 18:85–95CrossRefPubMedGoogle Scholar
  28. 28.
    Maeda K, Maruta M, Hanai T et al (2003) Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. Tech Coloproctol 7:181–185CrossRefPubMedGoogle Scholar
  29. 29.
    Lehur PA, Stuto A, Fantoli M et al (2008) Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum 51:1611–1618CrossRefPubMedGoogle Scholar
  30. 30.
    Amin AI, Hallbook O, Lee AJ et al (2003) A 5-cm colonic J pouch colo-anal reconstruction following anterior resection for low rectal cancer results in acceptable evacuation and continence in the long term. Colorectal Dis 5:33–37CrossRefPubMedGoogle Scholar
  31. 31.
    Kelvin FM, Maglinte DD, Benson JT (1994) Evacuation proctography (defecography): an aid to the investigation of pelvic floor disorders. Obstet Gynecol 83:307–314PubMedGoogle Scholar
  32. 32.
    Williams N, Barlow J, Hobson A et al (1995) Manometric asymmetry in the anal canal in controls and patients with fecal incontinence. Dis Colon Rectum 38:1275–1280CrossRefPubMedGoogle Scholar
  33. 33.
    Samalavicius NE (2002) Endorectal repair of rectocele. Acta medica Lituanica 9:226–229Google Scholar
  34. 34.
    Boccasanta P, Venturi M, Calabro G et al (2001) Which surgical approach for rectocele? A multicentric report from Italian coloproctologists. Tech Coloproctol 5:149–156CrossRefPubMedGoogle Scholar
  35. 35.
    D’Avolio M, Ferrara A, Chimenti C (2005) Transanal rectocele repair using EndoGIA: short-term results of a prospective study. Tech Coloproctol 9:108–114CrossRefPubMedGoogle Scholar
  36. 36.
    Frascio M, Stabilini C, Ricci B et al (2008) Stapled transanal rectal resection for outlet obstruction syndrome: results and follow-up. World J Surg 32:1110–1115CrossRefPubMedGoogle Scholar
  37. 37.
    Sarles JC, Arnaud A, Selezneff I et al (1989) Endo-rectal repair of rectocele. Int J Colorectal Dis 4:167–171CrossRefPubMedGoogle Scholar
  38. 38.
    Ho YH, Ang M, Nyam D et al (1998) Transanal approach to rectocele repair may compromise anal sphincter pressures. Dis Colon Rectum 41:354–358CrossRefPubMedGoogle Scholar
  39. 39.
    van Dam JH, Huisman WM, Hop WC et al (2000) Fecal continence after rectocele repair: a prospective study. Int J Colorectal Dis 15:54–57CrossRefPubMedGoogle Scholar
  40. 40.
    Cundiff GW, Fenner D (2004) Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 104:1403–1421PubMedGoogle Scholar
  41. 41.
    Ayabaca SM, Zbar AP, Pescatori M (2004) Anal continence after rectocele repair. Dis Colon Rectum 45:63–69CrossRefGoogle Scholar
  42. 42.
    Janssen LW, van Dijke CF (1994) Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse. Dis Colon Rectum 37:1100–1107CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • Mohamed Farid
    • 1
  • Khaled M. Madbouly
    • 2
    Email author
  • Ahmed Hussein
    • 2
  • Tarik Mahdy
    • 1
  • Hesham A. Moneim
    • 1
  • Waleed Omar
    • 1
  1. 1.Department of SurgeryUniversity of MansouraMansouraEgypt
  2. 2.Department of SurgeryUniversity of AlexandriaAlexandriaEgypt

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