Transanal approach to rectocele repair may compromise anal sphincter pressures

This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation.

Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later.

All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n = 19; after, n = 3; P = 0.001), need to digitate per vagina (before, n = 16; after, n = 0; P = 0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2); P = 0.004), and laxative requirements (before, n = 7; after, n = 0; P = 0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P < 0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P < 0.05) after operations. There was no other morbidity.

Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.