Pelvic organ prolapse (POP) is extremely common and prevalence rates have been reported as high as 50%. Of the women who have POP, approximately 10% will have surgical correction for their condition and 1 in 3 women will have multiple surgeries.¹ Women with POP often present with multi-compartmental defects and associated urinary and bowel symptoms. A rectocele can cause symptoms of vaginal bulge with subsequent need for a woman to perform vaginal splinting in order to evacuate her rectum; however, significant defecatory dysfunction and symptoms of obstructed defecation are usually not due to rectocele alone. Development of obstructed defecation following hysterectomy can be indicative of enterocele or rectal prolapse, and it has been reported that between 21% and 34% of women who present with rectal prolapse have concurrent POP.² Fortunately there is increasing awareness that women presenting with POP and defecatory dysfunction should have a multidisciplinary evaluation for possible concomitant urogynecologic and colorectal surgical repair. A study based on the American College of Surgeons National Surgical Quality of Improvement Program (ACS NSQIP) database reported that the number of concomitant POP and rectal prolapse surgeries increased from 2.6% to 7% over an almost 10-year period.³

At a minimum, evaluation for women with POP includes history and physical examination. While physical examination can assess for vault prolapse, the degree of associated enterocele or rectal prolapse and/or intussusception can be underappreciated. Dynamic MRI of the pelvis should be considered for women with significant defecatory dysfunction or obstructed defecation complaints as it provides both anatomical and functional information. Images are obtained at rest and with Valsalva to visualize prolapse of the small and large bowel. Women with complaints such as feeling their bowel movements are blocked at a certain point, pelvic pressure alleviated with bowel movements, and pushing on the perineum to evacuate their bowels may have an enterocele, rectal kinking from redundant sigmoid colon, and/or rectal prolapse (Figures 1 and 2). Crane et al reported that at 1 year following robotic sacrocolpopexy with and without rectocele repair, 44% of women had persistent outlet constipation regardless of whether rectocele repair was performed.⁴ A subsequent study reports no change in the Colorectal-Anal Distress Inventory (CRADI-8) or Colorectal Anal Impact Questionnaire (CRAIQ-7) for obstructed defecatory symptoms after sacrocolpopexy with posterior repair, and the authors state that they cannot recommend posterior compartment surgery as providing any patient benefit.⁵ On the contrary, when sacrocolpopexy and rectopexy are performed together both bowel function and quality of life are improved.⁶ These studies are thought-provoking as to whether preoperative dynamic MRI for the women who only had rectocele repair would have been useful in identifying an anatomical abnormality such as sigmoid intussusception or rectal kinking such that correction would have resolved the constipation and obstructed defecation symptoms.

Figure 1. Sagittal T2 MRI image at rest of woman with vault prolapse and symptoms of obstructive defecation.

Women with both urogynecologic and colorectal anatomical abnormalities should be considered for a multidisciplinary surgical approach that may include concomitant ventral mesh rectopexy with or without sigmoid resection, sacrocolpopexy, transvaginal rectocele repair, and a procedure to correct stress incontinence. Due to concerns for possible bowel anastomotic leak if sigmoid resection is performed and/or unrecognized intraoperative bowel injury, these procedures can be performed with a biologic graft; however, the theoretical increased risk with synthetic mesh is tempered by a relatively high recurrence rate (unpublished data). Furthermore, although the data are limited regarding complications of ventral mesh rectopexy with mesh, complication rates are low and have been reported between 0% and 2.4%.⁷ Considering the recurrence rate exceeds reported complication rates with mesh, synthetic mesh should be considered unless there is significant concern for bowel contamination or there is another contraindication.

Figure 2. Sagittal T2 “dynamic” MRI image with Valsalva showing large enterocele.

There is increasing evidence supporting the safety and feasibility of performing simultaneous sacrocolpopexy and rectopexy with low complication rates.⁸ Prior studies have shown that no added morbidity has been demonstrated with addition of sacrocolpopexy to rectopexy, although the surgical time required to perform these 2 procedures certainly takes longer than when only 1 is performed.³ In our practice, we work closely with our colorectal colleagues and frequently perform concomitant robotic sacrocolpopexy with ventral rectopexy. When performing the combined procedure, the surgical dissection starts at the sacral promontory to ensure adequate exposure of the anterior longitudinal ligament. If a hysterectomy is performed, the supracervical approach is preferred assuming no contraindication to reduce the risk of a mesh complication.⁹ Following exposure of the anterior longitudinal ligament and hysterectomy (if performed), the colorectal surgeon mobilizes the sigmoid colon and rectum, then sutures mesh to the anterior rectum. Mobilization of the colon and rectum facilitates creation of peritoneal flaps that will eventually cover the rectopexy and colpopexy grafts. Next, a Y-shaped mesh is sutured to the cervix and anterior and posterior vagina in standard fashion for the colpopexy. Finally, the tails of the Y-mesh and the rectopexy mesh are both sutured to the anterior longitudinal ligament.

In conclusion, it is important to carefully evaluate a female patient who presents with POP and defecatory dysfunction as there may be an underlying colorectal disorder that also requires surgical correction. Close collaboration between vaginal reconstructive surgeons, colorectal surgeons, and radiologists can provide the best outcomes for these women.