Rectocele and anal sphincter defect - surgical anatomy and combined repair

This study reports on the surgical anatomy and technique of perineal repair in a selected group of parous women with faecal incontinence and/or difficulty in evacuation. Anal sphincter muscle damage is usually attributed to childbirth, although most of these women present for the first time years later. Consecutive patients with the above symptoms were examined clinically and then investigated with a perineal ultrasound scan. During the perineal operation for repair, further investigation by transillumination and measurements with calipers were done in 50 patients. All patients received routine postoperative care, and were followed up for at least 6 months. From 1995 to 2009 a total of 117 patients, all female, underwent perineal repair by a single surgeon. The age range was 24 - 82 years. In the last 50 consecutive patients, transillumination was positive prior to repair in all, and negative after. The average thickness of the rectocele wall was 2.4 mm prior to repair and 4.8 mm after. In all patients a rectocele was found in conjunction with the anal sphincter defect. The results of combined repair were satisfactory in 109 of 117 patients (93%). A rectocele consists of rectal mucosa, and represents a pulsion diverticulum of the lower anterior rectum. The mucosa herniates through a defect in the midline in the lower anterior rectal muscle wall. This defect then extends into the internal and external anal sphincters. It is a consistent finding in women with faecal incontinence due to anal sphincter disruption. If the anterior rectal muscle wall is repaired first, anal sphincter repair is facilitated.