Posterior ColporrhaphyEdit

Posterior Colporrhaphy is a surgical repair aimed at restoring support to the back wall of the vagina in women with posterior vaginal wall prolapse, commonly called a rectocele. The procedure is typically offered to patients who have persistent symptoms such as a bulge, vaginal fullness, or defecatory difficulties despite conservative measures like pelvic floor exercises. It is most often performed through a vaginal approach and can be done alone or in combination with repair of the anterior compartment or perineal reinforcement. Over the years, native-tissue repair has been the mainstay, with augmentation using implants reserved for select cases and subject to heightened scrutiny.

Pelvic organ prolapse is a heterogeneous condition influenced by aging, childbirth history, connective tissue integrity, and overall pelvic floor function. In the posterior compartment, weakness of the rectovaginal fascia and surrounding support structures allows the rectum to bulge into the vagina. Decisions about surgery weigh symptom relief and quality of life improvements against risks of complications and the chance of recurrence. A patient-centered approach often involves discussing nonoperative options, the durability of repair, and the surgeon’s experience with different techniques. See also Rectocele and Pelvic organ prolapse for broader context, and Vaginal surgery for related procedures.

Indications and patient selection

Symptomatic rectocele with bulge or defecatory complaints that affect daily activities or intercourse.
Prolapse confined to the posterior vaginal wall, particularly when conservative measures have not yielded durable relief.
Concomitant defects in the anterior compartment that may benefit from combined repair.
Adequate health status to tolerate anesthesia and surgery; clear expectations regarding outcomes and recovery.

Techniques

Native tissue posterior colporrhaphy

Access is gained through a vaginal incision along the posterior wall.
The surgeon identifies the rectovaginal fascia and any defects.
A midline plication of the fascia tightens the posterior compartment, aiming to restore apical support and reduce bulging.
The mucosa is re-approximated, and if indicated, the perineal body may be reinforced.

Perineorrhaphy and levator ani plication

Perinealai reinforcement (perineorrhaphy) can be added to tighten the vaginal opening and support the pelvic floor.
Some surgeons perform targeted plication of the levator ani muscles to bolster pelvic floor support, especially in cases of broader levator defunction.

Site-specific repair

In selected cases, attention is paid to specific defects within the posterior wall rather than a single midline plication, aiming to restore the functional anatomy of the rectovaginal fascia.

Mesh-augmented repair (controversial)

Some clinicians have used vaginal mesh to reinforce the posterior wall, with the goal of reducing recurrence.
This approach is controversial due to higher risks of mesh erosion, infection, pain, and dyspareunia.
Regulatory guidance in many regions has tightened or restricted mesh use for prolapse, and many guidelines now favor native-tissue repair as the default approach for the posterior compartment. See Transvaginal mesh and FDA for related regulatory discussions.

Abdominal or laparoscopic/robotic approaches

Rarely used for isolated posterior prolapse, but some complex cases may involve abdominal or minimally invasive routes when extensive uterosacral or pararectal support structures require reconstruction or when concomitant procedures are planned.

Outcomes and controversies

Native-tissue posterior colporrhaphy typically provides durable anatomic correction for many patients, with symptom relief reported in a majority of cases in the short to medium term.
Recurrence or new symptoms can occur over time, with reported rates varying by study and technique.
The main controversy centers on the use of implants or mesh in pelvic floor repair. Proponents of mesh augmentation argue for lower recurrence and greater long-term durability, while critics emphasize higher complication rates and patient morbidity.
In practice, most right-leaning guidelines emphasize evidence-based practice, patient choice, and preserving access to effective, affordable treatments. They argue for restraint in adopting devices with mixed safety signals and for ensuring that regulatory actions do not unduly restrict access to proven native-tissue repairs.
It is important to consider the patient’s goals, sexual function, and overall health when weighing options such as native-tissue repair versus augmentation. See Transvaginal mesh and Rectocele for related discussions.

Risks and postoperative considerations

Potential complications include infection, bleeding, injury to surrounding organs, dyspareunia (painful intercourse), persistent or new constipation or fecal urgency, and recurrence of prolapse.
Recovery typically involves a period of activity modification, stool softeners, pelvic floor rehabilitation, and follow-up with the surgeon to monitor healing and symptom resolution.
Outcomes depend on the patient’s tissue quality, the surgeon’s experience, and whether additional pelvic floor support structures are addressed during the operation.

Postoperative care and prognosis

Patients are usually advised to avoid heavy lifting and straining for several weeks and to maintain bowel regularity.
Follow-up appointments assess healing, continence, and sexual function, and address any persistent symptoms.
Long-term prognosis varies; some patients maintain relief of prolapse symptoms for years, while others may require additional procedures if recurrence occurs.