Posterior vaginal wall prolapse develops due to weakening of pelvic floor support structures.

Common Causes

1. Childbirth-related injury:

   1. Vaginal deliveries, especially prolonged or forceps-assisted births, stretch and damage pelvic floor muscles.

   2. Multiple pregnancies increase risk.

2. Aging and menopause:

   1. Estrogen deficiency reduces elasticity of connective tissue.

   2. Natural aging leads to muscle weakening.

3. Chronic straining:

   1. Constipation and repeated heavy straining during bowel movements.

   2. Chronic coughing due to asthma or smoking.

   3. Heavy lifting in occupation or daily life.

4. Previous pelvic surgery:

   1. Hysterectomy or bladder repairs can disturb pelvic support balance.

5. Genetic factors:

   1. Inherited weakness of collagen and connective tissue.

6. Obesity:

   1. Extra abdominal pressure strains pelvic muscles over time.

Risk Factors of Posterior Repair Surgery

Although generally safe, surgery carries risks such as:

1. Infection, bleeding, or delayed wound healing.

2. Injury to bladder, rectum, or nerves.

3. Recurrence of prolapse.

4. Pain during intercourse (dyspareunia).

5. Risks from anesthesia, especially in elderly or those with comorbidities.

Women may notice symptoms gradually, especially after childbirth or menopause.

Common Symptoms

1. Bulging in the vagina: A soft tissue protrusion, especially while standing or straining.

2. Pelvic heaviness or pressure: Worsens during the day or after activity.

3. Bowel problems: Constipation, incomplete emptying, or needing to press on the vagina to pass stool (splinting).

4. Sexual difficulties: Pain or reduced satisfaction.

5. Lower back or pelvic pain.

Signs Noticed During Examination

1. Visible bulge in posterior vaginal wall.

2. Loss of vaginal tone.

3. Rectal bulge during straining.

4. In severe cases, prolapse extending outside the vaginal opening.

Symptoms often overlap with other prolapse types, so careful diagnosis is essential.

Clinical Examination

1. History taking: Review of symptoms, pregnancies, surgeries, and bowel/urinary function.

2. Pelvic examination: Patient may be asked to cough or strain to reveal prolapse.

3. Rectovaginal exam: To assess rectocele severity.

Staging the Prolapse

1. Prolapse is graded from Stage I (mild) to Stage IV (severe, protruding outside vaginal opening).

Supportive Investigations

1. Defecography: X-ray or MRI study during bowel movement to visualize rectocele.

2. Pelvic ultrasound or MRI: To check for associated prolapses.

3. Urodynamic testing: If bladder symptoms coexist.

Diagnosis helps tailor treatment - whether conservative measures suffice or surgery is needed.

1. Pelvic floor muscle training (Kegel exercises): Strengthens pelvic support.

2. Lifestyle modification: Weight loss, avoiding constipation, smoking cessation.

3. Pessary device: A removable silicone device placed in vagina to support prolapsed wall.

4. Hormonal therapy: Vaginal estrogen creams for post-menopausal women to improve tissue strength.

Surgical Treatment - Posterior Repair (Posterior Colporrhaphy)

Posterior repair is indicated when symptoms are moderate to severe or conservative therapy fails.

Procedure Overview:

1. Performed under general or spinal anesthesia.

2. A cut is made along the posterior vaginal wall.

3. The underlying connective tissue (rectovaginal fascia) is folded and tightened with sutures.

4. Excess vaginal lining may be trimmed.

5. The vaginal wall is closed with dissolvable stitches.

Variants:

1. Traditional repair: Uses patient's own tissue and sutures.

2. Augmented repair with grafts: Rarely, biologic or synthetic grafts may be used, though mesh use is now limited due to complications.

Recovery:

1. Hospital stay: Same day or 1-2 days.

2. Recovery period: 6 weeks.

3. Restrictions: Avoid lifting, straining, and sexual activity until healing.

Posterior repair may also be combined with anterior repair (for bladder prolapse), apical suspension, or hysterectomy if multiple prolapses exist.

Preventive Measures

1. Regular pelvic floor exercises (Kegels).

2. High-fiber diet and hydration to prevent constipation.

3. Avoiding heavy lifting.

4. Maintaining healthy body weight.

5. Early postpartum pelvic rehabilitation.

Post-Surgical Management

1. Follow wound-care instructions carefully.

2. Take stool softeners or mild laxatives to avoid straining.

3. Avoid sexual activity for at least 6 weeks.

4. Slowly return to exercise under guidance.

5. Long-term: Continue pelvic floor exercises to maintain support.

While most patients recover well, potential complications include:

1. Infection or bleeding at surgical site.

2. Painful intercourse (dyspareunia).

3. Scar tissue formation leading to tightness.

4. Bowel issues such as constipation or rectal injury (rare).

5. Recurrence of prolapse over time.

6. Urinary dysfunction if bladder is also affected.

With modern techniques, careful patient selection, and physiotherapy, complication rates are low.

Posterior repair often brings dramatic improvement in quality of life.

Benefits After Surgery

1. Relief from pelvic pressure and bulge.

2. Improved bowel function.

3. Enhanced sexual comfort.

4. Increased confidence and physical activity levels.

Long-Term Considerations

1. Maintain lifelong pelvic floor health with exercises.

2. Manage weight and bowel habits.

3. Attend regular follow-ups.

4. Understand that in some cases, other types of prolapse may occur later, requiring evaluation.

Emotional and Social Impact

Many women feel empowered and regain confidence in daily life and relationships after surgery. Counseling and support groups may help in adjusting emotionally to recovery and lifestyle changes.

1. What is a Posterior Repair (Prolapse Operation)?

Posterior repair, also called posterior colporrhaphy, is a surgical procedure to correct a rectocele, a type of pelvic organ prolapse. A rectocele happens when the rectum bulges into the vaginal wall due to weakened or stretched supportive tissues. The surgery strengthens and tightens the vaginal wall, restoring normal anatomy and improving symptoms.

2. Why is Posterior Repair needed?