(3) A rectocele is formed by a herniation of the anterior rectal wall (posterior
vaginal wall) into the vaginal outlet. In general, the anterior rectal wall forms a bulging
mass beneath the posterior vaginal mucosa. It is created as the mass pushes
downward into the lower vaginal canal. The rectum, may be torn from its dense
connective tissue, the fascial and muscular attachments of the urogenital diaphragm,
and the pelvic wall. The levator ani muscles become stretched or torn. The
symptomatic signs are a mass protruding from the vagina, difficulty in evacuating the
lower bowel, and a feeling of pressure.
(4) An enterocele is a protrusion of the cul-de-sac of Douglas and some of
the pelvic small intestine within the peritoneal sac. It pierces through a weakened area
between the attenuated anterior rectal and posterior vaginal walls.
(5) An enterocele may also be seen in multiparous women as part of a
massive lesion, in which a large sac contains the bladder, lower portions of the ureters,
and the prolapsed uterus. In some cases, a Kelly or Marshall-Marchetti operation may
be necessary to treat urinary incontinence and uterine prolapse.
(6) During parturition, the outer fibrous layers of the vagina may be torn,
thereby permitting the adjoining viscera to herniate into the vaginal outlet. Because of
unrepaired perineal lacerations, gradual pulling apart of the underlying fascia and
muscles of the pelvic floor and outlet takes place. The woman has symptoms of
relaxation and displacement of the pelvic organs. Accidents, gradual deterioration of
tissues, or congenital weakness, may also result in mechanical disturbances of the
b. General Operative Procedure. Dilatation and curettage may be done. The
labia are held open with retractors and the cervix is grasped with a tenaculum. Adair
forceps are used to retract the cervix; self-retaining or Sims retractors are used to
expose the operative site.
c. Anterior Wall Repair.
(1) Areolar tissue between the bladder and vagina at the bladder reflection
is exposed with the knife handle. The full thickness of the vaginal wall is separated up
to the bladder neck, using a knife, curved scissors, tissue forceps, Adair or Allis forceps,
and sponges on holders. Bleeding vessels are clamped and tied with ligatures (see
figure 2-5 A).
(2) The urethra and bladder neck are freely mobilized, using a knife, gauze
sponges, and curved scissors (see figure 2-5 B), to develop the strong free edge of, the
vesicovaginal fascia on each side.
(3) The free edges of the fascia are sutured, using chromic gut sutures
number2-0. Sutures are placed in a manner that after they have been tied, there results