Currently there is little evidence to support the use of absorbable or permanent mesh in the posterior wall. Case series of mesh inlays or mesh kits without native tissue controls are still needed to determine the risks and benefits of these procedures. The caution is to not consider the posterior vaginal wall as a mirror image of the anterior vaginal wall. While one type of graft may improve the surgical cure for cystoceles, it may not add any benefit for rectocele repairs.
Additionally, stiffness in the posterior vaginal wall can lead to dyspareunia and defecation disorders, primarily fecal urgency and fecal incontinence. If the rectum is not expandable because the posterior vaginal wall is stiff and nonpliable, the patient feels a constant urge to defecate, and if she has poor anal sphincter function, a noncompliant rectal reservoir can lead to fecal or flatal loss.
In my practice, when a patient complains of splinting or incomplete evacuation, I suspect a distal rectocele and a deficient perineal body. Perineal body defects are often found in patients who have an enlarged vaginal introitus or a history of straining or prior episiotomy, for instance, and addressing these defects is a key part of posterior wall repair that is too often neglected.
When a perineorrhaphy is performed, the bulbocavernosus muscles must be identified and plicated in the midline with care so as not to narrow the introitus so significantly that coital activity would be impaired. Caudad to the bulbocavernosus muscles, mobilization of the lateral tissues will enable plication of the medial portions of the puboperineus muscles. This compensatory repair will help bulk and strengthen the perineal body.
I use 3-0 prolonged, delayed, absorbable sutures, in one or two layers. This step increases the length and thickness of the perineal body and can also increase the functional length of the posterior vaginal wall.
Technique for Traditional Colporrhaphy
As described by Dr. B.H. Goff and later Dr. David Nichols, the traditional posterior colporrhaphy involves opening the posterior vaginal wall epithelium in the midline and dissecting laterally and superiorly, then plicating the posterior vaginal wall muscularis—or rectovaginal septum, as the endopelvic fascia is termed—in the midline. The excess of the epithelium is then trimmed and brought back together in the midline.
With the Goff method, the rectovaginal septum is not dissected “off” the posterior vaginal wall. In contrast, with the Bullard modification, the rectovaginal septum is dissected off the posterior vaginal wall. This mobilizes the connective tissue layer to the lateral sidewalls and allows a separate layer to be plicated between the vagina and rectum.
I prefer this technique for two reasons. First, it allows one to decrease the size of a dilated rectal ampulla by inverting the dilated rectal wall into the rectal lumen similar to a transrectal rectocele repair. Also with this method, any “ridge” created is directed posterior for less dyspareunia. The levator muscles should never be plicated, unless an obliterative procedure is being performed, because of the impact on sexual function.
To begin, two Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. The position of these clamps should be modified, however, depending on the size of the genital hiatus, so that three finger breaths can be easily admitted to ensure enough room for sexual intercourse. As patients age, this becomes increasingly important as the incidence of erectile dysfunction in male partners precludes penetration in a very narrow genital hiatus.
Since rectocele repair is usually done after other apical or anterior wall compartment defects are corrected (rectoceles are rarely isolated problems, and high rectoceles are usually associated with apical defects or enteroceles), it is important to appreciate that the introitus may tighten during the healing process.
Once the Allis clamps are placed on the hymenal ring, with a finger placed in the rectum, the surgeon must identify the extent of the weakness in the vaginal wall. This is accomplished by a thorough examination of the vagina with palpation between the finger and thumb. For example, with a finger in the rectum, palpate transrectally the thickness of the perineal body. This will enable you to determine if the bulbocavernosus muscles are separated or retracted, generally from childbirth or chronic straining or constipation, and will give you an assessment of the perineal body integrity.
Further, by elevating the vaginal wall rectally, the point of weakness and placement of the apical limit of the repair can be determined. At that point, another Allis clamp is then placed accordingly in the vagina to mark the top of the repair.