Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse

PURPOSE: This study was undertaken to determine the outcome and changes produced by an endorectal anterior wall repair in objective functional parameters using anorectal manometry and defecography and to asses their usefulness in the selection of patients for the operation. METHODS: Between 1986 and 1990, we performed a prospective study of 76 consecutive patients with symptomatic rectocele and/or an anterior rectal wall prolapse. All patients were studied prospectively according to a fixed protocol. Standard questionnaire, defecation diary, clinical examination, defecography, and anal manometry were performed preoperatively and three to four months postoperatively. RESULTS: Three months postoperatively, 38 patients (50 percent) had no complaints at all (excellent result), 32 (42 percent) had only a minor complaint (good result), and in 6 patients (8 percent) the complaints were essentially unchanged (unsatisfactory result). After one year, similar figures were obtained. The postoperative mean stool frequency in all patients after three months was significantly increased (P < 0.05) but not after one year. Postoperative defecographies showed a complete absence or significant diminution of the rectocele at three months and were significantly correlated with relief of symptoms. An inverse correlation was found between improvement in incontinence grade after operation and (larger) preoperative volume at which urge to defecate was elicited, making it a good predictor of improvement in incontinence by the operation. CONCLUSIONS: The anterior rectal wall repair positively influences rectal sensation in patients with incontinence and/or obstructed defecation caused by a rectocele and/or an anterior rectal wall prolapse. Anorectal manometry was useful in studying the beneficial physiologic effects of the endorectal repair. In patients with no previous pelvic surgery, a large urge to defecate volume is a good predictor of a good clinical outcome.