Full-thickness rectal prolapse following posterior vaginal repair: something to worry about?

Rectocoele is a common condition, which often leads to the need for surgical repair [1–3]. Common risks and complications of surgical repair discussed and documented on consent forms include: need for repeat repair; failure to improve symptoms; painful intercourse; unmasking of urinary incontinence and urinary retention; the usual surgical risks—thromboembolic events, bleeding, infection [4]. Following an interesting case, namely, a full-thickness rectal prolapse after a posterior trocar-inserted vaginal polypropylene mesh repair of a fourth-degree rectoenterocoele, we looked at the literature on this issue. A literature search using the terms rectocoele, posterior repair, mesh repair of rectocoele, rectal prolapse, pelvic floor repair and concurrent rectal prolapse and rectocoele was undertaken. There were no reported cases that demonstrated a full-thickness rectal prolapse following mesh repair for rectocoele. There was a case reported by South and Amundsen in 2007 of an overt rectal prolapse following repair of a fourth-degree vault prolapse with colpocleisis and levator ani plication [5]. Our case would appear to be the first experienced postoperatively after performing an Avaulta mesh procedure. However, the aetiology of both is likely to be similar and is likely to be underreported. Risk factors for rectocoele include high parity (especially large birth weights delivered vaginally), chronic raised intraabdominal pressure (chronic cough, persistent heavy lifting, constipation), age and increased body mass index (BMI) [2, 6]. Previous vaginal-wall repair also increases the risk of developing vaginal wall prolapse; it is often quoted that one in three women who undergo vaginal-wall repair will need further surgery, with some studies showing reoperation rates of 43 % with standard repair techniques [7] and others objective failure rates at 1 year of 43 %, and objective failure rates of 40 % and subjective failure of 24 % at 5 years of follow-up [8, 9]. Surgical treatment of a rectoenterocoele includes posterior colporrhaphy with or without mesh or an abdominal procedure such as a sacrocolpopexy. Our unit has had success with mesh repair [10], as measured using the International Consultation on Incontinence Modular Questionnaire-Vaginal Symptoms (ICIQ-VS) questionnaire, and hence vaginal mesh was used in the case that we were involved in. A full-thickness rectal prolapse occurs when all layers of the rectal wall protrude through the anus [11]. This most commonly affects elderly women with a history of obstetric trauma causing weakening of the pelvic floor and damage to the pudendal nerve [11]. This then leads to weakness of the anal sphincters, predisposing to rectal prolapse. Other risk factors for rectal prolapse include obesity, increasing age and chronically raised intra-abdominal pressure—a significant overlap with the risk factors for pelvic organ prolapse (POP) [12]. It is therefore not surprising that the two defects commonly coexist [12]. It is accepted that connective tissue damage and disorders predispose to POP. The more significant the prolapse, the more likely it is that the damage is not confined to one area but distributed throughout the pelvis and that repairing or supporting one defect may shift the balance in the pelvis and thus expose or provoke a defect in another area. South and Amundsen hypothesised that repair of the defect in the posterior vaginal wall displaced the rectum out of the F. Ross : R. Dawson : J. Cooper University Hospital of North Staffordshire, Stoke on Trent ST4 6QG, UK