Dear Editor;

A rectocele can be defined as a herniation of the rectal wall into the vagina (Figure 1). Rectocele almost always is a female disease, and it is also called as posterior vaginal prolapse. The rectovaginal septum weakness is considered as the main cause of the rectocele. The rectovaginal septum is composed of a fibromuscular layer of tissue which is contributed of the smooth muscle, collagen and elastin, it is referred as Denonvillier fascia by some clinicians. There are similar etiopathogenetic factors in both of fecal incontinence and rectocele, e.g. multiparity, difficult birth story and age. Constipation, obstructive defecation, and increase in vaginal bulging with Valsalva maneuver are the main complaints in the patients who have rectocele. A variety of surgical techniques have been described for rectocele treatment including posterior colporrhaphy, transanal or transperineal repair, and abdominal approaches, and posterior colporrhaphy is the most common used surgical technique, currently.

Anatomically, the rectocele is related with ischioanal compartment of the body. Based on current anatomical knowledges, the sublevator part of the lower rectum and the coil-like external anal sphincteric musculature surrounding it compose the nested two cylindrical musculer tube called as surgical anal canal in the ischional fossa. When looked from this point, the rectovaginal septum is situated between the vaginal wall and the external anal sphincteric musculature surrounding lower rectum. So, it is mean that the external anal sphincteric musculature should also be taken into consideration together with rectovaginal septum when the rectal wall becomes herniated into the vagina.

Incomplete anterior external sphincteric rupture accompaniments in which subcutaneous external anal sphincteric muscle stayed intact were observed in four female patients who operated for rectocele by using transvaginal ischioanal fossa access (Figure 2). The external anal sphincteric musculature should be considered as coil-like muscular tube surrounding the distal part of the lower rectum.¹ The main reason of the transvaginal access use in our technique was providing of the extrasphincteric rectal dissection in the ischioanal fossa. The patients were operated in Lloyd-Davies lithotomy position by using posterior vaginal fourchette incision for providing surgical access on the external anal sphincteric musculature in the ischioanal fossa in which surgical anal canal is situated. It has been observed that subcutaneous external anal sphincteric muscles have stayed intact in our patients.

Incomplete ventral (external anal) sphincteric defects detected in our patients were repaired, and prolen mesh application were added (Figure 3). The postoperative periods of our patients operated with transvaginal anterior sphincteroplasty were uneventful. When operational procedures are performed for surgical treatment of the rectoceles, incomplete external anal sphincteric muscle rupture in which subcutaneous external anal sphincteric muscle stays intact, and anterior sphincteroplasty procedure should be taken into account.

Ethics

Peer-review: Internally peer-reviewed.

Financial Disclosure: The author declared that this study received no financial support.