Rectocoeles result from weakness in the rectovaginal septum, which causes a herniation of the anterior rectal wall into the posterior wall of the vagina. Rectocoeles can be asymptomatic and incidental findings during pelvic floor assessment or might prevent complete evacuation with trapping of faeces causing obstructive defaecation symptoms (ODS). First line treatment for rectocoele causing ODS are conservative measures with the aim to improve rectocoele emptying, while surgery is reserved for patients not achieving satisfactory improvements. Different surgical techniques have been described to repair symptomatic rectocoeles, with the aim of these techniques is to reinforce the rectovaginal septum.
The standard repair offered in our trust in women with rectocoele leading to obstructive defaecation symptoms, refractory to extensive conservative treatment, is a native tissue transvaginal rectocoele repair (TVRR) performed by colorectal surgeons with a specific interest in pelvic floor disorders. Primary aim of the study is to assess the efficacy of the procedure, while secondary aim is to establish specific symptom improvement after the surgical repair.

This retrospective study was approved by the institutional review board and had also favourable ethical approval 18/SC/0147.  Patients who underwent transvaginal rectocoele repair between 2007 and 2018 under three pelvic floor surgeons were included. All patients underwent a complete evaluation performed by an experienced colorectal surgeon with special interest in pelvic floor disorders. Patients had pelvic floor tests in the form of anoretal manometry, rectal balloon sensation, endoanal ultrasound and evacuation proctography. 
Conservative treatment in our Pelvic Floor Unit consists of a variety of strategies to improve pelvic floor muscle strength and relaxation, stool consistency and rectal emptying, which is offered by either a colorectal nurse specialists or pelvic floor physiotherapists. These strategies include education and counselling, pelvic floor exercise with an escalation to use suppositories and rectal irrigation if needed.
All surgical procedures were conducted using a transvaginal access by three colorectal surgeons specialised in pelvic floor disorders. Inverse T-incision and full mobilization of the rectocoele from the posterior wall of the vagina and levatorplasty was done as well. For patients’ present stress urinary incontinence and middle compartment symptoms a combined surgery was associated.

From 2006-2018, 236 patients had a transvaginal rectocoele repair in our centre were identified. The data was not available for twenty-one patients and so these were excluded leaving 215 patients included in the analysis.  The mean age for these was 55 years (range 30-81). 206 (95.8%) had previous vaginal deliveries, mean 2.4 (range 1-8).  86 (40%) patients had a hysterectomy, 61 (28.4%) had pelvic floor surgery and 35 (16.3%) had anal surgery.
The main complaint of this cohort of patients was ODS in 209 patients (97.2%) and feeling of vaginal prolapse/bulge in 175 patients (81.4%). Other symptoms present were various degree of anal incontinence (AI) in 119 patients (55.3%), faecal urgency in 104 (48.4%), need for vaginal splinting in 99 (46%) and anal digitation in 56 (26%), associated constipation in 39 (18.1%) and dyspareunia in 17 patients (7.9%). Concomitant urinary symptoms were present in 139 patients (67.9%). 
In total, 86.5% of patients (186/215) underwent pre-operative conservative management and biofeedback, with a mean of sessions of 2.7 (SD 1.5, range 1-9). Of those, 82.8% (154/186) used suppositories, 49.5% (92/186) polyethylene glycol, 34.9% (65/186) used transanal irrigation, 17.7% (33/186) loperamide, 12.9% (24/182) ispaghula husk, 7% (13/186) prokinetic laxatives.

Regards surgical procedures, 98.1% (211/215) of patients had a levatorplasty at the time of the rectocoele repair and 19.5% (42/215) had an enterocoele repair. 27.4% (59/215) had a joint procedure with the urogynaecologists for urinary stress incontinence (tension-free vaginal tape TVTO), anterior or middle compartment prolapse. The mean length of hospital stay was 3.2 days (SD 1.2, range 2-10). 

In terms of postoperative complications, 24 patients (11.2%) suffered from in-hospital complications. Of those, 18 (8.4%) with urinary retention and 2 (0.9%) with ileus, and 4 (1.9%) urinary tract infections. During follow up 14 patients (6.5%) had complications. Of those, 2 (0.9%) had urinary retention, 11 (5.1%) had vaginal infection and 1(0.5%) patient had to be re-admitted for a recto-vaginal fistula. Seven patients suffered from chronic pelvic pain (3.3%) and 17 (7.9%) with dyspareunia. 23 patients (10.7%) needed further pelvic floor surgery and 4 (1.9%) had a third pelvic floor procedure.
The mean length of follow up was 12.7 months (SD 13.9, range 1.4-71.5). Global improvement was reported in 189 (87.9%), 18 (8.4%) found that the procedure didn’t change their symptoms, while 8 (3.7%) have been lost on follow-up. 
Furthermore, 67% of patients (144/215) agreed to continue conservative management after surgery, while 29.3% didn’t feel the need for further interventions (3.7% patients were lost on F/U) with a mean of 2.8 clinic sessions (SD 2.1, range 0-12), and 23.3% (50/215) needed to use transanal irrigation. Overall, 115 patients (53.5%) had residual symptoms, of which 50 (23.3%) were ODS, 32 (14.9%) were anal incontinence and 33 (15.3%) were mixed ODS/AI. Table 1 summarises the variations of the different types of symptoms after surgery. Excluding patients that had previous surgery or a combined procedure in the anterior pelvic floor compartment at the time of the transvaginal rectocoele repair, 46.3% (62/134) improved their initial urinary symptoms, 6.7% (9/134) developed de novo symptoms, 5.2% (7/134) had symptom deterioration and 1 patient (0.7%) didn’t change the initial symptomatology.

Overall in-hospital complication rate was low at 12.1%, and 6.5% at follow-up. The high rate of satisfaction might be explained by the combination of conservative and surgical treatment. The importance of conservative management in our institution is demonstrated by the fact that 86.5% of patients had conservative treatment before and 67% after surgery, with a median of 2.7 sessions pre and 2.8 post-surgery. This might be a potential strategy to reduce recurrence in the future due to inadequate defaecatory technique and also a constructive solution to treat residual symptoms. Global improvement was reported in 189 (87.9%), which is higher to the previously reported to be 72.8% (95% CI: 66.8-78.3%), and this can be explained by the detailed selection of suitable patients and the optimisation of function prior to surgery. 
The absolute dyspareunia rate in our group of patients did not change before and after treatment (6.5% patients had improvement in dyspareunia vs 6.5% of patients developed new dyspareunia) showing that surgery not only can cause this problem but may also correct pain by strengthening the rectovaginal septum and reducing a vaginal sensation of lump. The rate of pre-operative dyspareunia might be explained by the presence of vaginal prolapse symptoms, while improvement after might be associated by the vaginoplasty performed at the end of the transvaginal repair, which might correct tissue laxity and improve sexual function.

Transvaginal rectocoele repair is an effective procedure in patients with significant rectocoeles leading to difficult defaecation symptoms, when conservative treatment has failed to achieve satisfactory improvement. Transvaginal rectocoele repair in our institution is a safe and effective treatment with few complications and can be associated with other procedures to correct urinary incontinence of middle compartment symptoms with high patients’ satisfaction. The addition of levatoplasty in our institution does no lead to unacceptable dyspareunia rates.

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