Successful Transperineal Posterior Colpoperineorrhaphy for Rectal Prolapse with Anterior Rectocele

Chief Complaints

The patient had a history of hypothyroidism and rheumatoid arthritis, both managed under regular medical care. She had also undergone a laparoscopic cholecystectomy in the past and reported a history of multiple medication allergies.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Abdominal examination was soft with no tenderness or distension. Perineal and pelvic evaluation revealed findings consistent with rectal prolapse with anterior rectocele, corresponding to a posterior vaginal wall bulge suggestive of weakened rectovaginal support. No acute signs of infection or peritonitis were noted. The remaining systemic examination was normal.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Surgical Gastroenterology team evaluated the patient for complaints of chronic constipation requiring digital evacuation, along with a review of her relevant past medical history.

Clinical examination revealed findings consistent with rectal prolapse with anterior rectocele, which was primarily established based on history and physical examination findings suggestive of pelvic floor weakness and posterior vaginal wall bulge.

Routine investigations, including complete blood picture, serum electrolytes, and renal function tests, were performed as part of the preoperative evaluation to assess the patient’s general medical status. These investigations were largely within acceptable limits and served as supportive assessments rather than definitive diagnostic tools.

Based on the confirmed diagnosis, the patient was advised to undergo Anterior Rectocele with Rectal Prolapse Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department.

After a detailed consultation with the surgical gastroenterologist Dr. CH. Madhusudhan, and cross consultation with cardiologist Dr. Seshi Vardhan Janjirala, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient’s history of chronic constipation requiring digital evacuation and clinical findings suggestive of rectal prolapse with anterior rectocele, further evaluation confirmed pelvic floor weakness with posterior vaginal wall bulge. Routine laboratory investigations revealed mild anemia with otherwise stable hematological, renal, and electrolyte parameters.

Based on clinical assessment and routine laboratory investigations showing stable parameters, it was determined that Transperineal Posterior Colpoperineorrhaphy under spinal anesthesia was the most appropriate and effective management strategy. This approach was chosen to correct the pelvic floor defect, reinforce the rectovaginal septum, relieve symptoms of obstructed defecation, and improve bowel evacuation while minimizing recurrence and ensuring better functional outcomes.

The patient and her family members were counselled regarding the diagnosis, clinical findings, planned procedure, and the importance of postoperative care and follow-up.

Following the decision, the patient was scheduled for Transperineal Posterior Colpoperineorrhaphy in Hyderabad at PACE Hospitals, under the expert care of the Surgical Gastroenterology Department.

The following steps were carried out during the procedure:

• Patient Preparation and Anaesthesia: The patient was taken up for surgery after proper preoperative evaluation and consent. Under strict aseptic precautions, spinal anaesthesia was administered, and the patient was positioned appropriately for perineal and vaginal access.

• Identification and Exposure of Lesion: A careful per vaginal examination revealed a bulge in the posterior vaginal wall measuring approximately 5 cm. The surgical field was prepared and draped. The introitus was exposed to provide adequate access to the operative site.

• Incision and Tissue Dissection: A curvilinear incision was made at the vaginal introitus over the bulging area. Local infiltration with lignocaine and adrenaline was given submucosally to reduce bleeding. Vaginal mucosal flaps were carefully raised to expose the underlying rectovaginal septum.

• Rectovaginal Septum Repair (Plication): The weakened rectovaginal septum was identified and reinforced by plication, using interrupted 3-0 Vicryl sutures. This step helped restore pelvic floor support and reduce the rectocele component.

• Closure and Completion: After adequate reinforcement, the posterior vaginal wall was closed in layers. A vaginal pack was placed to provide hemostasis and support, and a flatus tube was inserted to allow passage of gas and prevent postoperative discomfort. The procedure was completed without complications.

The patient had an uneventful post-procedural recovery. During the hospital stay, she received intravenous medications for infection prevention, pain control, and maintenance of hydration. She was discharged in a hemodynamically stable condition with appropriate postoperative advice.

Upon discharge, the patient was prescribed oral medications for prevention and treatment of postoperative infection, reduction of inflammation, control of pain on an as-needed basis, protection of gastric mucosa, nutritional support, and regulation of bowel movements to prevent constipation and avoid straining at the surgical site.

The patient was advised to continue sitz bath regularly to maintain local hygiene, promote healing, and provide symptomatic relief at the surgical site.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, abdominal pain, vomiting, increasing perineal discomfort, or any unusual discharge.

The patient was advised to return for a follow-up visit with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals after 5 days.

This case highlights chronic constipation secondary to rectal prolapse with anterior rectocele, managed successfully with transperineal posterior colpoperineorrhaphy. The procedure effectively corrected the pelvic floor defect and restored rectovaginal support, leading to an uneventful recovery. The case was discharged in stable condition with improvement in symptoms and advised regular follow-up care.