It is hypothesised that many women who have symptomatic rectocele experience voiding dysfunction in addition to vaginal and rectal symptoms. For some women, voiding dysfunction may be the predominant concern. This study aims to describe the relationship between rectocele and voiding dysfunction in women, demonstrate the efficacy of rectocele repair in relieving symptoms and highlight the importance of rectocele diagnosis in reducing morbidity in women

Retrospective, descriptive study evaluating the demographics, referral pathways, symptoms, voiding function (quantified by urodynamic studies) and operative outcomes of women who underwent rectocele repair by a urologist over a 10-year period. Records were reviewed and data extracted in a de-identified manner. Stata 16.0 was used to obtain descriptive statistics of the cohort regarding age, parity, prior relevant procedures, referral source, referral reason, urinary symptoms and other symptoms. Paired t-test was used to determine whether a statistically significant mean difference existed between pre-and post-operative post-void residual volumes (PVR), adjusted for age. This relationship was also examined by calculating the odds of elevated PVR pre- compared to post-intervention. The relationship between parity, traumatic birth and rectocele grade was explored. Comments on patient outcome and resolution of symptoms were collated.

177 women who underwent rectocele repair only, between 2010 and 2019, were included in this study. Regardless of reason for referral, 83.7% of women in this cohort reported experiencing lower urinary tract symptoms, while 60% and 16.5% of women reported concurrent rectal and vaginal symptoms respectively. 80% of women had a rectocele graded 3 or higher. The odds of at least grade 3 rectocele were increased by 50% for women reporting traumatic births compared to those that did not (CI 0.2 -1.1, p=0.09). 
Parity was not significantly associated with rectocele grade in this study.

Post-operative PVRs were, on average, 20.6mls less than pre-op PVR (CI -35.5 - -5.6mls, p=0.008), although this did not always represent a clinically significant difference. The odds of elevated post-void residual was 44% less in the post-operative PVR analysis compared to pre-operative (OR 0.44, CI 0.24 – 0.8, p=0.005). 

Mean age was 67 years (range 42 – 93 years). Mean vaginal deliveries was 2.4 (range 1-9) with 22% of the cohort experiencing complicated or traumatic deliveries. The main referral source was general practitioners (88.7%), with 4.5% of referrals from other urologists and the remainder from other specialists. The most common reason for referral was incontinence (45.5%), followed by lower urinary tract symptoms (20.5%). However, 48% of women reported sensation of incomplete voiding, 35% reported abnormal positioning required to void and 31.6% of the cohort were found to have a significantly elevated PVR (>50mls for those less than 70 years, >100mls for those older than 70 years) on urodynamic studies. 

Importantly,  91% (n=161) of women reported high post-operative satisfaction with resolution of their presenting complaint. Those without a satisfactory outcome most commonly had ongoing symptoms of bladder over-activity, consistent with their pre-operative urodynamic studies.

Women with rectocele may present with clinically significant voiding dysfunction and urinary obstruction. Although the difference in pre-and post-void residual did not reach statistical significance in this study, almost all women reported resolution of primary symptom and overall satisfaction with voiding post-operatively, which cannot be overlooked as a clinically significant outcome. Rectocele should be considered as a differential in selected women presenting with lower urinary tract symptoms and voiding dysfunction. Evaluation should include pelvic examination and urodynamic studies. Rectocele is an effective operative intervention for selected women with rectocele, resulting in symptomatic and functional improvement.

It is difficult to estimate the proportion of women who experience voiding dysfunction and urinary symptoms as a result of rectocele. The condition may coexist with other forms of pelvic floor prolapse, further reducing clarity. Anatomically, the relationship between rectocele and urinary obstruction is not difficult to appreciate. Exploration of referral pathways, clinical presentation, self-reported symptoms, urodynamic studies and operative outcomes in this cohort demonstrates that urinary symptoms are present in women with rectocele. Rectocele repair can reduce morbidity from voiding dysfunction. Gynaecologists and colorectal specialists should consider incorporating voiding function questions routinely in their evaluation of women with rectocele, in order to better understand the spectrum of symptoms. Urologists should consider rectocele as a differential for women with risk factors  who present with voiding dysfunction. Timely identification and operative intervention in selected patients can reduce morbidity for women with rectocele and voiding dysfunction.