Successful surgical repair of anterior rectocele in patient with constipation.

A 56-year-old female visited our department because of the constipation over 30 years. In addition, intermittent cramping abdominal pain was combined in recent 6 months. Despite of the combination of prokinetics, bulking agents and osmotic laxatives, the frequency of defecation was about once every 4 to 7 days, and she performed digital vaginal pressure to defecate. Laboratory findings, plain abdominal radiography, colonoscopy and abdominal computed tomography were unremarkable. Colon transit time was within the normal range.

Eventually, about 5 cm sized anterior rectocele was detected on fluoroscopic defecography (Figure A and D). We treated with medication and biofeedback therapy. However, constipation was not improved for 6 months and even the size of rectocele was increased to 5.5 cm on the follow-up defecography (Figure B and E). Therefore, she underwent rectocele repair with colporrhaphy. About 6 months after surgery, the size of rectocele was decreased to 2 cm on follow-up defecography (Figure C and F). When we evaluated symptom response before and after the surgery using Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22),1,2 the score of constipation and evacuation was decreased. And, she could defecate daily without abdominal pain.

Figure

Fluoroscopic defecography. The measured size of rectocele (white arrow) is perpendicular to the axis of the anal canal (white line). (A) Initial image of the resting phase. (B) The resting phase image after 6 months. (C) The resting phase image after surgery. (D) About 5 cm sized large anterior rectocele was observed at initial pushing phase. (E) The size of anterior rectocele was increased in 6 months (about 5.5 cm). (F) The size of rectocele was decreased after surgery (about 2 cm).

Rectocele is a herniation of the rectal wall that often becomes apparent during defecation. Rectocele is common in adult women (20%), and most of it is small (< 2 cm), asymptomatic, therefore treatment is not necessary. However, surgery is suitable for patients in whom large rectocele (> 3 or 4 cm) or those with coexisting vaginal prolapse is present in spite of adequate medication.3 Thus, surgical treatment could be considered in some patients with rectocele.