When a defective perineal body or perineal membrane is present, reconstruction is performed after accompanying posterior colporrhaphy. The superficial muscles of the perineum and bulbocavernous fascia are plicated in the midline and the skin closed as in an episiotomy repair. Detachments of the inferior portion of the Denonvillier’s fascia from the perineal body are also corrected. The puborectalis muscles are plicated concurrently with these procedures by some surgeons, but this approach is associated with a high incidence of sexual dysfunction and thus is not recommended routinely (91). It may be worth consideration in patients who have severe prolapse accompanied by a large genital hiatus with palpable levator weakness or who are unable to contract their pelvic ﬂoor muscles. Sutures should be placed carefully through the puborectalis muscles at least 3 cm or greater posterior to their insertion on the pubic rami, thereby decreasing the tension of the plication. For those women with an enlarged hiatus and weakened puborectalis muscles who desire sexual function, an attempt can be made to plicate the muscles far enough posteriorly to allow two fingers to easily pass through the vaginal introitus and to reconstruct the distal posterior vagina and perineum, whereby there will not be a ledge at the site of the puborectalis plication (91). Outcome data on such procedures are inadequate to make conclusions regarding its efficacy; however, it is reasonable to postulate that pelvic ﬂoor defects producing an enlarged genital hiatus are common reasons for failure of support procedures, and puborectalis plication may decrease the incidence of such failures.
A complete review of rectocele, anorectal functional disorders, and various repairs can be found elsewhere (92). Reported anatomic cure rates for traditional posterior colporrhaphy have ranged from 76% to 90% with variable follow-up intervals (93–97). Most studies show a benefit in ease of defecation if patients are using splinting preoperatively; however, overall defecatory dysfunction (defined as constipation) was not relieved in most patients and increased (approximately 30%) after the procedure in one study (95). These repairs appear to have little to no benefit in the treatment of fecal incontinence. It is not surprising that the repairs are not particularly effective for defecatory dysfunction related to disorders of constipation or for fecal incontinence because these problems have multifactorial causes. De novo dyspareunia is reported to occur in 8% to 26% of sexually active patients who have traditional posterior colporrhaphy and is not always associated with levator plication procedures (93–96,98,99). Potential causes for dyspareunia, other than vaginal strictures or introital tightness, include scarring with immobility of the vaginal wall, levator spasm, and neuralgia associated with sutures or dissection. Dyspareunia also may occur when a Burch procedure or other procedures that anteriorly displace the vaginal canal are combined with a posterior repair (96). Careful surgical technique and appropriate choice of procedure should decrease the incidence of postoperative dyspareunia.