Posterior Vaginal Repair and Perineoplasty

Aim

Correct defects in the rectovaginal fascia separating rectum and vagina while allowing bowel function to be maintained or corrected without interfering with sexual function

Indications

Treatment of rectocele (rectum bulges or herniates forward into the vagina) and defects of the perinium (area seperating entrance of the vagina and anus)

Surgical Techniques

• An incision is made on the posterior wall of the vagina starting at the entrance and finishing at the top of the vagina. (figure 1)
• Dissecting the vagina and rectovaginal fascia from the vagina until the pelvic floor muscles (Puborectalis) are located
• Defects in the fascia are corrected by centrally plicating the fascia using delayed absorption sutures (figure 2)
• The perineal defects are repaired by placing deep sutures into the perineal muscles to build up the perineal body
• The overlying vaginal and vulval skin is then closed (figure 3)
• A pack is usually placed into the vagina and a catheter into the bladder at the end of surgery.

Diagrammatic representation of the surgery is shown:

Complications

• Return of the prolapse in 10%
• Failure to correct symptoms like incomplete bowel evacuation or constipation
• Painful intercourse in 1-5%.
• Blood loss requiring transfusion <1%
• Inadvertent damage to the rectum is very uncommon

Surgery will be covered with antibiotics to decrease the risk of infection and blood thinning agents (Clexan self injected for 5 days) will be used to decrease the risk of clots forming in the postoperative phase.

For the first 24 hours postoperatively a vaginal pack is often inserted into the vagina to decrease the risk of bleeding and a catheter is used to drain the bladder.

In hospital and recovery

After the operation you will have an IV drip in your arm for fluids and pain relief. You can expect to stay in hospital between 3-4 days. The vaginal pack, if used, is removed on the first day and the bladder catheter after the first few days or when your bladder empties appropriately. In the early postoperative period you should avoid situations where excessive pressure is placed on the repair ie lifting, straining, coughing and constipation. Maximal fibrosis around the repair occurs at 3 months and care needs to be taken during this time. If you develop urinary burning, frequency or urgency you should see your local doctor. Vaginal spotting or discharge is not uncommon in the first 10 but should be reported to your doctor if heavy or persistent. You will be reviewed at 6 weeks by Dr Maher. Sexual activity can usually be safely resumed at this time. You can return to work at approximately 4-6 weeks depending on the amount of strain that will be placed on the repair at your work and on how you feel.

Avoiding heavy lifting (>15kg), weight gain and smoking can minimize failure of the procedure in the long term. If you have any questions about this information, you should speak to Associate Professor Maher or a doctor of his team before your operation