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Posterior Colporrhaphy

Posterior colporrhaphy is the most commonly performed and recommended native-tissue repair for posterior vaginal wall prolapse (rectocele), with anatomic cure rates of up to 82–95% and strong evidence supporting its superiority over transanal approaches and graft-augmented repairs.[1][2][3]

Definition and Anatomy​

Posterior compartment prolapse occurs when the rectovaginal septum (Denonvilliers' fascia) — the fibromuscular layer separating the vagina from the rectum — becomes attenuated or disrupted, allowing the rectum to herniate anteriorly into the vaginal lumen (rectocele).[4] Posterior colporrhaphy corrects this by plicating the rectovaginal fascia in the midline, restoring the structural barrier between the vagina and rectum.[1][5]

Indications​

Surgery is considered when conservative measures (PFMT, pessary, behavioral therapy) have failed and the patient has:[6][7][3]

  • Bothersome vaginal bulge — sensation of tissue protruding, pelvic pressure / fullness
  • Defecatory dysfunction — incomplete evacuation, splinting / digitation, straining, sense of obstruction
  • Stage ≥ 2 posterior wall prolapse on POP-Q
  • Rectocele > 3 cm and / or symptomatic on clinical exam or defecography[8]

The ACG 2021 guideline emphasizes that rectoceles are frequently identified incidentally in asymptomatic women and usually do not require surgery. When defecatory dysfunction is the primary complaint without vaginal bulge symptoms, conservative management including biofeedback should be exhausted first. Features favoring surgery include rectocele size > 5 cm and evidence of trapping / non-emptying on defecography.[6]

Preoperative Evaluation​

The FIGO Working Group recommends:[7]

  • Detailed history (prolapse, bowel, sexual, urinary)
  • Quality-of-life questionnaires (PFDI-20, PFIQ-7, PISQ-12)
  • POP-Q staging
  • Assessment of all compartments — most posterior defects coexist with anterior or apical prolapse[3]
  • Complex anorectal symptoms → dynamic imaging (defecography / MR defecography) and anorectal manometry
  • Evaluation for occult SUI with prolapse reduction

Surgical Technique — Midline Fascial Plication (Standard)​

The most widely performed technique:[1][5][9]

  1. Incision — midline posterior vaginal wall, perineum (hymenal ring) → vaginal apex
  2. Dissection — vaginal epithelium sharply dissected off rectovaginal fascia bilaterally; plane developed laterally until the puborectalis / levator ani muscles are identified
  3. Fascial plication — attenuated rectovaginal fascia plicated in the midline with interrupted delayed-absorbable sutures (typically 2-0 polyglactin or PDS); apex → distal
  4. Perineorrhaphy — if perineal-body defect, deep sutures into the perineal muscles (bulbocavernosus, superficial / deep transverse perineal muscles)[1][5][10]
  5. Vaginal closure — excess epithelium trimmed, mucosa closed with running absorbable
  6. Vaginal pack and catheter typically placed at end of surgery[1][9]

Avoid levator plication.

ACOG specifically states that the repair should be performed without placing tension on the levator ani muscles because levator plication may lead to dyspareunia.[10]

Alternative Techniques​

Site-Specific (Defect-Directed) Repair​

Rather than a global midline plication, individual discrete defects in the rectovaginal fascia are identified and repaired. A finger placed in the rectum and directed anteriorly localizes specific fascial tears, which are then repaired individually with sutures (fascia-to-fascia or fascia-to-ATFP for lateral defects).[1][10]

Levator Ani Plication (Levatorplasty)​

Brings bilateral levator ani muscles together at the midline. Historically part of "traditional" posterior colporrhaphy but now generally discouraged due to higher dyspareunia rates without improved anatomic outcomes.[1][10][11]

Suture Material​

A Swedish population-based study (n = 577 posterior colporrhaphies) found that — unlike anterior colporrhaphy — the choice of suture material (rapidly vs slowly absorbable) does not significantly affect outcomes after posterior colporrhaphy. No difference in symptomatic recurrence or patient satisfaction. Most surgeons use delayed-absorbable sutures (2-0 polyglactin or polyglycolic acid).[12]

Outcomes​

Anatomic Success Rates​

StudynFollow-upAnatomic successKey finding
Kudish & Iglesia 2010 review[3]Multiple seriesVariableUp to 95%Traditional colporrhaphy provides excellent cure rates
Paraiso 2006 RCT[13]37 (colporrhaphy arm)17.5 mo86% (Bp ≤ −2)Superior to graft-augmented site-specific repair (54%)
Abramov 2005[14]183 (colp) vs 124 (site-specific)≥ 1 yr86% colp vs 67% site-specificColporrhaphy significantly better (p = 0.001)
Gillor 2019[15]935.3 yr80% (Bp ≤ −1)No difference between native tissue and mesh
Nüssler 2022 Swedish registry[16]32,0865–10 yr70% PRO cure11% reoperation at 5 yr; 15% at 10 yr

Functional Outcomes​

DomainOutcome
Bulge symptomsSignificant improvement on PFDI-20 across all studies[13][17]
Defecatory function65% cure of splinting; 55% cure of stooling difficulty; persistent obstructed defecation in 33% at 5 yr[15][17]
Quality of lifeSignificant improvement on PFDI-20 / PFIQ-7 and all daily-living domains[13][17]
Patient satisfaction> 70% at 5 yr in registry data[16]

Complications​

Dyspareunia — the central concern​

FindingReference
De novo dyspareunia 19–26% after posterior colporrhaphy[18]
Combination with Burch colposuspension especially likely (38%, p = 0.02)[18]
Levator plication increases dyspareunia risk (Grade C — modern technique avoids it)[10][11]
Site-specific repair has theoretically lower dyspareunia (16% vs 17%) — not significantly different[14]

Other Complications​

ComplicationRate
Postoperative constipation / obstructed defecation33–37%[14][15]
Fecal incontinence18–19%[14]
Intraoperative rectal injury (transvaginal)~ 2% (higher with transanal)[1][2]
Vaginal narrowing / stenosisPossible with excessive epithelial excision
Bleeding / hematomaUncommon
InfectionUncommon

Posterior Colporrhaphy vs. Other Approaches​

Transvaginal vs Transanal — Cochrane 2018, 4 RCTs, n = 191[1]​

The transvaginal approach is clearly superior:

OutcomeEffect (transvaginal vs transanal)
Recurrent posterior prolapseRR 4.12 (1.56–10.88) — 4× more likely after transanal
Awareness of prolapseRR 2.78 (1.00–7.70) — more after transanal
Obstructed defecationRR 1.67 (1.00–2.79) — more after transanal
DyspareuniaNo conclusive difference

Grade A recommendation — transvaginal preferred.[11]

Midline Plication vs Site-Specific Repair​

  • Abramov 2005 (n = 307): standard colporrhaphy had significantly lower recurrence — 14% vs 33% beyond midvaginal plane (p = 0.001); symptomatic bulge 4% vs 11% (p = 0.02). Dyspareunia and bowel symptoms similar.[14]
  • Paraiso 2006 RCT (n = 74): anatomic failure 14% colporrhaphy vs 22% site-specific (NS); functional outcomes similar.[13]
  • Recommendation: midline plication without levatorplasty is the procedure of choice (Grade B).[11]

Native Tissue vs Graft Augmentation​

ACOG and Cochrane are unequivocal — synthetic mesh and biologic grafts should not be used routinely for primary posterior wall repair:[1][10]

ComparisonResult
Native tissue vs biologic graft (2 RCTs, n = 191)Objective failure 10% vs 21% (RR 0.47, p = 0.02)[10]
Paraiso RCT graft-augmented site-specific46% failure vs 14% colporrhaphy (p = 0.02)[13]
Complications more common with biological repairRR 1.82 (1.22–2.72)[1]
Synthetic mesh exposure rate7%[1]

Exception — recurrent rectocele: Swedish registry n = 626 — for isolated recurrent posterior prolapse, mesh reinforcement may be beneficial (1-yr cure OR 2.06; satisfaction OR 2.38; symptom improvement OR 2.13), though minor complications more frequent.[19]

Posterior Colporrhaphy vs STARR​

Both effective in reducing rectocele size (PC 3.1 cm vs STARR 1.9 cm). STARR may be superior for obstructed defecation symptoms specifically; PC provides greater anatomic correction.[8]

Posterior Colporrhaphy vs Laparoscopic Ventral Mesh Rectopexy (LVMR)​

LVMR — better anatomic correction by defecography, greater improvement in constipation (CCCS 6 vs 9.2), better PISQ-12 (39.3 vs 35.8), comparable complications, but longer operative time.[20]

Guideline Recommendations​

SocietyKey recommendation
ACOG 2019Native-tissue posterior colporrhaphy without levatorplasty is preferred; mesh / grafts should not be used routinely for primary repair[10]
Cochrane 2018Transvaginal repair superior to transanal; no benefit of graft augmentation[1]
FIGO 2020Transvaginal route without mesh appears superior; comprehensive preoperative evaluation[7]
ICI / Karram & Maher 2013Midline fascial plication without levatorplasty is procedure of choice (Grade B); no evidence supports mesh / graft use (Grade B)[11]
ACG 2021Transvaginal native-tissue repair preferred; conservative management first for defecatory dysfunction without bulge symptoms[6]
Grimes 2019Native-tissue transvaginal rectocele repair should be preferentially performed for anatomical and symptomatic outcomes[2]

Concomitant Procedures​

Posterior colporrhaphy is frequently performed alongside other prolapse repairs. Addressing apical support is critical — failure to correct apical descent is a major risk factor for posterior wall recurrence:[3][16]

Long-Term Durability​

The Swedish National Registry (n = 32,086) provides the best long-term population-level data: posterior-compartment reoperation rates of 11% at 5 yr and 15% at 10 yr, with similar frequencies across compartments and surgery types. Despite this, patient satisfaction remained > 70% and symptom reduction was still significant at 5 yr.[16] At 5.3 years, Gillor et al. found persistent prolapse symptoms in 32% and obstructed defecation in 33%, with clinical recurrence (Bp ≥ −1) in 20%.[15]

See Also​

Videos​

Posterior Colporrhaphy: Rectocele Repair
Miyazaki / McKenzie, Urogynecology for Beginners (2020)
Posterior Colporrhaphy for Rectocele Repair
Antovska, Univ. Clinic ObGyn Skopje (2022)

References​

1. Mowat A, Maher D, Baessler K, et al. "Surgery for Women With Posterior Compartment Prolapse." Cochrane Database Syst Rev. 2018;3:CD012975. doi:10.1002/14651858.CD012975

2. Grimes CL, Schimpf MO, Wieslander CK, et al. "Surgical Interventions for Posterior Compartment Prolapse and Obstructed Defecation Symptoms: A Systematic Review With Clinical Practice Recommendations." Int Urogynecol J. 2019;30(9):1433-1454. doi:10.1007/s00192-019-04001-z

3. Kudish BI, Iglesia CB. "Posterior Wall Prolapse and Repair." Clin Obstet Gynecol. 2010;53(1):59-71. doi:10.1097/GRF.0b013e3181cd41e3

4. Richardson ML, Elliot CS, Sokol ER. "Posterior Compartment Prolapse: A Urogynecology Perspective." Urol Clin North Am. 2012;39(3):361-9. doi:10.1016/j.ucl.2012.06.005

5. Yeung E, Baessler K, Christmann-Schmid C, et al. "Transvaginal Mesh or Grafts or Native Tissue Repair for Vaginal Prolapse." Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2

6. Wald A, Bharucha AE, Limketkai B, et al. "ACG Clinical Guidelines: Management of Benign Anorectal Disorders." Am J Gastroenterol. 2021;116(10):1987-2008. doi:10.14309/ajg.0000000000001507

7. Doumouchtsis SK, Raheem AA, Milhem Haddad J, et al. "An Update of a Former FIGO Working Group Report on Management of Posterior Compartment Prolapse." Int J Gynaecol Obstet. 2020;148(2):135-144. doi:10.1002/ijgo.13006

8. Gluck O, Matani D, Rosen A, et al. "Surgical Treatment for Rectocele by Posterior Colporrhaphy Compared to Stapled Transanal Rectal Resection." J Clin Med. 2023;12(2):678. doi:10.3390/jcm12020678

9. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for Women With Pelvic Organ Prolapse With or Without Stress Urinary Incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2

10. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

11. Karram M, Maher C. "Surgery for Posterior Vaginal Wall Prolapse." Int Urogynecol J. 2013;24(11):1835-41. doi:10.1007/s00192-013-2174-z

12. Bergman I, Söderberg MW, Kjaeldgaard A, Ek M. "Does the Choice of Suture Material Matter in Anterior and Posterior Colporrhaphy?" Int Urogynecol J. 2016;27(9):1357-65. doi:10.1007/s00192-016-2981-0

13. Paraiso MF, Barber MD, Muir TW, Walters MD. "Rectocele Repair: A Randomized Trial of Three Surgical Techniques Including Graft Augmentation." Am J Obstet Gynecol. 2006;195(6):1762-71. doi:10.1016/j.ajog.2006.07.026

14. Abramov Y, Gandhi S, Goldberg RP, et al. "Site-Specific Rectocele Repair Compared With Standard Posterior Colporrhaphy." Obstet Gynecol. 2005;105(2):314-8. doi:10.1097/01.AOG.0000151990.08019.30

15. Gillor M, Langer S, Dietz HP. "Long-Term Subjective, Clinical and Sonographic Outcomes After Native-Tissue and Mesh-Augmented Posterior Colporrhaphy." Int Urogynecol J. 2019;30(9):1581-1585. doi:10.1007/s00192-019-03921-0

16. Nüssler E, Granåsen G, Bixo M, Löfgren M. "Long-Term Outcome After Routine Surgery for Pelvic Organ Prolapse — a National Register-Based Cohort Study." Int Urogynecol J. 2022;33(7):1863-1873. doi:10.1007/s00192-022-05156-y

17. Porter WE, Steele A, Walsh P, Kohli N, Karram MM. "The Anatomic and Functional Outcomes of Defect-Specific Rectocele Repairs." Am J Obstet Gynecol. 1999;181(6):1353-8. doi:10.1016/s0002-9378(99)70376-5

18. Weber AM, Walters MD, Piedmonte MR. "Sexual Function and Vaginal Anatomy in Women Before and After Surgery for Pelvic Organ Prolapse and Urinary Incontinence." Am J Obstet Gynecol. 2000;182(6):1610-5. doi:10.1067/mob.2000.107436

19. Nüssler E, Granåsen G, Nüssler EK, Bixo M, Löfgren M. "Repair of Recurrent Rectocele With Posterior Colporrhaphy or Non-Absorbable Polypropylene Mesh — Patient-Reported Outcomes at 1-Year Follow-Up." Int Urogynecol J. 2019;30(10):1679-1687. doi:10.1007/s00192-018-03856-y

20. Abdelnaby M, Fathy M, Abdallah E, et al. "Laparoscopic Ventral Mesh Rectopexy Versus Transvaginal Posterior Colporrhaphy in Management of Anterior Rectocele." J Gastrointest Surg. 2021;25(8):2035-2046. doi:10.1007/s11605-020-04823-z