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Posterior Colporrhaphy

Posterior colporrhaphy is an established native-tissue transvaginal repair for symptomatic posterior vaginal wall prolapse (rectocele). Short- and long-term success estimates vary with the population, outcome definition and follow-up. Comparative evidence suggests transvaginal repair may reduce recurrence relative to transanal repair; graft augmentation has not shown a routine advantage for posterior vaginal repair.[1][2][3]

Definition and Anatomy​

Posterior vaginal wall support involves the rectovaginal fibromuscular connective tissues between the vagina and rectum. Attenuation or a discrete defect can allow the rectum to bulge toward the vagina; an enterocele or apical defect may coexist.[3][4] Midline posterior colporrhaphy plicates this supporting tissue.[1][3]

Indications​

Surgery may be considered for bothersome symptoms attributable to a posterior defect after discussion of conservative options, including PFMT, pessary and bowel or behavioral measures.[3][7] Relevant findings can include:

  • Bothersome vaginal bulge. Sensation of tissue protruding, pelvic pressure or fullness
  • Defecatory dysfunction. Incomplete evacuation, splinting or digitation, straining, sense of obstruction
  • Posterior wall prolapse on POP-Q that corresponds to symptoms
  • Rectocele on exam or selected defecography when it plausibly explains symptoms[6][8]

When defecatory dysfunction predominates without a bothersome vaginal bulge, assess other causes, including defecatory dyssynergia, before attributing symptoms to an incidental rectocele. The 2026 IUGA opinion advises gastroenterology or colorectal referral when examination finds no clinically significant rectocele or enterocele, and colorectal collaboration for grade 3-or-higher rectal intussusception, rectal prolapse, fecal incontinence without sphincter trauma, or pelvic-floor dyssynergia.[34] Bowel measures and biofeedback are appropriate when indicated; no single defecographic size or POP-Q stage proves that repair will resolve bowel symptoms.[6][7] The 2026 Pelvic Floor Consortium consensus recommends pelvic floor physical therapy before rectocele surgery when posterior wall prolapse coexists with obstructed defecation and increased pelvic floor tone or dyssynergia; with decreased tone, therapy can be offered before or after surgery (statements 11 and 12, expert consensus).[21]

Preoperative Evaluation​

Preoperative assessment can include the following, tailored to symptoms and planned surgery:[3][7]

  • Detailed history (prolapse, bowel, sexual, urinary)
  • Quality-of-life questionnaires (PFDI-20, PFIQ-7 or PISQ-12) when useful for baseline and follow-up
  • POP-Q staging
  • Assessment of all compartments, especially apical support and any concomitant defect[3]
  • Complex or discordant anorectal symptoms: consider defecography or MR defecography and anorectal physiology testing when results would change management
  • Evaluation for occult SUI with prolapse reduction when a concomitant continence decision is being made

Surgical Technique — Midline Fascial Plication​

A commonly described native-tissue technique is outlined below; the incision length, tissue plane, suture choice and adjuncts vary with the actual defect.[3][11]

  1. Incision. Midline posterior vaginal wall, extending toward the perineum as needed for the defect rather than routinely to the vaginal apex
  2. Dissection. Vaginal epithelium separated from the underlying posterior vaginal or rectovaginal supporting tissue; identify the repairable plane and protect the rectum. Above the lower third of the vagina, a natural plane of cleavage can be developed bluntly to the level of the cul-de-sac; one chapter author recommends routinely extending dissection to this level to fully assess the extent of a rectocele and identify a coexisting enterocele, noting the pararectal space is also entered there, giving access to the sacrospinous ligament if an apical procedure is planned.[24] A high posterior wall defect raises particular concern for a coexisting enterocele: the vaginal epithelium over an enterocele sac often has a thinner, smoother appearance than the thicker-appearing mucosa over a rectocele, though this visual clue has not been validated as a diagnostic test; dissection to the vaginal apex to look for an enterocele sac is recommended for high posterior defects.[25]
  3. Fascial plication. Supporting tissue reapproximated in the midline with absorbable sutures (examples include 2-0 polyglactin or PDS); the extent and suture pattern vary 4.[3][11] Perineorrhaphy. If a separate perineal-body defect is present, reconstruct it deliberately[3][11]; see the dedicated technique
  4. Vaginal closure. Excess epithelium trimmed, mucosa closed with running absorbable
  5. Final rectal examination. After fascial repair and vaginal closure, examine the rectal lumen to check for sutures traversing its wall.[36][37]
  6. Pack and catheter. Use according to the operative and postoperative plan

Positioning and Room Setup​

Dorsal lithotomy with boot or candy-cane stirrups is commonly used for posterior colporrhaphy, often combined with other compartment repairs in the same setup. A randomized vaginal-surgery trial (138 analyzed) showed a greater mean six-week change in PROMIS physical-function score with boot than candy-cane stirrups (+1.9 versus −1.9); no between-group difference in adverse events was detected.[38] In a retrospective benign-gynecologic-surgery cohort, candy-cane stirrups were associated with more documented lower-extremity neuropathy through six weeks than boot stirrups (21/611 [3.4%] versus 29/1,838 [1.6%]); procedure mix differed.[39] Prolonged lithotomy is associated with lower-extremity compartment syndrome; a 2014 gynecologic-department survey found that all reported cases followed lithotomy, most after operations longer than four hours.[22] The 2020 DGGG/OEGGG/SGGG S2k positioning guideline (published 2021; valid through July 2025) recommended keeping lithotomy time as short as required, positioning the legs at or below right-atrial level where possible, and ensuring that staff recognize postoperative compartment-syndrome signs after lengthy lithotomy procedures (E.15, E.44 and E.48; expert consensus).[32] In a randomized trial of vaginal prolapse surgery, immediate postoperative catheter removal avoided any recatheterization in more than half of women and reduced symptomatic bacteriuria and length of stay compared with a suprapubic catheter left to a 48-hour voiding trial.[23] A retrospective comparison of sole posterior colporrhaphy with sole suburethral sling reported voiding-trial failure in 32.4% versus 15% (p = 0.030); among patients needing Foley replacement, total catheterization lasted 3.2 versus 1.8 days (p = 0.007). No patient developed long-term voiding dysfunction or required corrective surgery, and the authors suggested considering postoperative voiding assessment after posterior repair.[29] A separate retrospective cohort without hysterectomy found pre-discharge voiding-trial failure in 9.9% of 141 patients after posterior-compartment-only surgery versus 41.6% of 221 after surgery involving the anterior or apical compartment.[33] No posterior-colporrhaphy-specific VTE recommendation exists; apply the general risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page.

Fascial plication is not levator ani plication. The latter is a separate, usually avoided maneuver because of concern for postoperative pain or dyspareunia; the comparative evidence for its benefit is limited.[1][11]

Alternative Techniques​

Site-Specific (Defect-Directed) Repair​

Rather than a global midline plication, individual discrete defects in posterior vaginal support are identified and repaired. A rectal examination can help localize a suspected tear; the tissue edges are reapproximated according to the defect. Comparative evidence has not established a consistent functional advantage over midline plication.[1][11][14]

One described site-specific sequence sutures the usually-transverse defect with interrupted sutures placed cranial-to-caudal, in contrast to the horizontal suture direction of midline colporrhaphy. Where intact proximal and distal fascial edges are present, the edges can optionally be fixed to the arcus tendineus fascia pelvis (ATFP) with a permanent suture placed about 1 cm anterior and distal to the ischial spine, guided by a finger on the ischial spine and a suture-capture device, before three or four additional interrupted fascial sutures are placed; the authors note that approximating the ATFP sutures first can make the remaining fascial sutures difficult to place.[26]

Levator Ani Plication (Levatorplasty)​

Brings bilateral levator ani muscles toward the midline. It is historically described with some posterior repairs but is not the same as rectovaginal-tissue plication; concern about dyspareunia favors avoiding routine use. The small comparative trial in the Cochrane review was insufficient to establish an outcome advantage.[1][11]

Suture Material​

A Swedish observational cohort of 577 primary posterior colporrhaphies found no significant one-year symptom difference between rapidly and slowly absorbable suture groups.[12] In a randomized trial of 72 women undergoing posterior repair, with concurrent procedures permitted, barbed and nonbarbed delayed-absorbable sutures showed no detected difference in six-week posterior pain or patient-reported outcomes; 12-month follow-up was 73.6%.[31] Neither study proves the materials equivalent or determines an optimal caliber or brand; suture selection remains technique-specific.

Outcomes​

Anatomic Success Rates​

StudynFollow-upAnatomic successKey finding
Kudish & Iglesia 2010 review[3]Multiple seriesVariableReported rates varyHistorical series use different procedures, definitions and follow-up
Paraiso 2006 RCT[13]106 randomized; 28 colporrhaphy patients assessed at 1 yrOne-year anatomic endpoint; mean follow-up across returned subjects was 17.5 mo24/28 (86%) with Bp < −2 at 1 yrSite-specific native tissue 21/27 (78%) and graft-augmented site-specific 14/26 (54%) at 1 yr; overall graft-arm difference, not a proven colporrhaphy-versus-site-specific advantage
Abramov 2005[14]183 colporrhaphy vs 124 site-specific≥ 1 yr86% vs 67% without recurrence beyond midvaginal planeRetrospective, nonrandomized comparison; recurrence 14% vs 33% (p = 0.001)
Gillor 2019[15]93 total (39 native, 54 mesh)Mean 5.3 yr80% pooled without Bp ≥ −1Surgeon-selected groups; no major outcome difference demonstrated
Nüssler 2022 Swedish registry[16]32,086 all-compartment POP operations; 5,846 isolated posterior repairs5–10 yrAnatomic success was not measured in the registry surveyAfter isolated posterior repair, any-compartment reoperation was 11.5% at 5 yr and 16.4% at 10 yr; same-compartment reoperation was 3.5% and 4.4%. A separate five-year survey excluding reoperated patients found 70.2% patient-reported absence of bulge among 404 respondents in the isolated posterior subgroup

Functional Outcomes​

DomainOutcome
Bulge symptomsIn the Paraiso trial, PFDI-20 prolapse-scale scores improved significantly in all three arms with no between-group differences[13]
Defecatory functionGillor's selected cohort reported persistent obstructed-defecation symptoms in 33% at mean 5.3 yr.[15]
Quality of lifePFDI-20 and PFIQ-7 scores improved significantly in all three Paraiso arms[13]; in Porter's retrospective series of 125 site-specific repairs, all daily-living domains improved significantly[17]
Patient satisfactionAt five years, 70.2% of 408 respondents after isolated native-tissue posterior repair were satisfied or very satisfied; this survey excluded reoperated patients[16]

Complications​

Dyspareunia​

FindingReference
In Weber's mixed prolapse/incontinence cohort, 19% of 81 women sexually active before and after surgery reported postoperative dyspareunia; 26% of 53 after posterior colporrhaphy.[18]
38% of 21 with concomitant Burch colposuspension and posterior colporrhaphy reported dyspareunia[18]
Routine levator plication is generally avoided because of concern for dyspareunia; comparative benefit remains uncertain[1][11]
Abramov's nonrandomized groups had postoperative dyspareunia of 16% vs 17% after site-specific vs midline repair, without a significant between-group difference[14]
In a randomized trial of 60 sexually active women without bothersome baseline dyspareunia undergoing posterior colporrhaphy (30 per arm), daily vaginal dilator use from postoperative weeks 4–8 did not significantly reduce de novo dyspareunia versus no dilator use (9.5% vs 19.2% at 3 months; 12.5% vs 3.8% at 6 months; neither difference significant), nor did it change PGI-I or PISQ-12 scores. The trial was underpowered (13% loss to follow-up) and does not test dilators for established dyspareunia or stenosis[27]

Rectal Injury — Identification and Repair​

Rectal integrity can be checked intraoperatively by irrigating the field and gently instilling air into the rectum with a Toomey or bulb syringe while watching for bubbles, or by rectal irrigation with saline to confirm a smaller injury. For a recognized injury, one described sequence mobilizes enough rectum for tension-free exposure, closes the mucosa with a running delayed-absorbable suture, and imbricates the seromuscular layer with a Lembert-type permanent or delayed-absorbable suture, using adjacent fat or fascia to cover the repair when available. Described postoperative care keeps stools soft and avoids rectal instrumentation for about 6 weeks; diversion is usually unnecessary for a satisfactory primary repair, and colorectal input is reasonable when the extent of injury or repair is uncertain.[28]

Other Complications​

ComplicationRate
Persistent obstructed-defecation symptoms33% in Gillor's selected 93-patient mixed-repair cohort at mean 5.3 yr[15]
Constipation / fecal incontinenceAbramov reported postoperative constipation 34–37% and fecal incontinence 18–19% in its two repair groups[14]
Rectal injuryRecognized operative risk; the comparative review favored the transvaginal route, with a 2% estimate specific to its studies[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 review found that transvaginal repair may reduce recurrence, but individual endpoints were based on fewer participants and adverse-effect data were scanty:

OutcomeEffect (transanal vs transvaginal)
Recurrent posterior prolapseRR 4.12 (95% CI 1.56–10.88; 2 RCTs, n = 87), more after transanal[1]
Awareness of prolapseRR 2.78 (1.00–7.70; 2 RCTs, n = 87), more after transanal[1]
Postoperative obstructed defecationRR 1.67 (1.00–2.79; 3 RCTs, n = 113), more after transanal[1]
DyspareuniaDifference not established (RR 0.32, 0.09–1.15; 2 RCTs, n = 80)[1]

The older international consultation favored the transvaginal route.[1][11]

Midline Plication vs Site-Specific Repair​

  • Abramov 2005 (retrospective n = 307): standard colporrhaphy had lower observed recurrence: 14% versus 33% beyond the midvaginal plane (p = 0.001); symptomatic bulge 4% versus 11% (p = 0.02). Dyspareunia and bowel symptoms were similar.[14]
  • Paraiso 2006 RCT (37 randomized to each of these two arms; 28 and 27 assessed at one year): anatomic failure 4/28 (14%) after colporrhaphy versus 6/27 (22%) after site-specific repair; the difference was not established. Functional outcomes were similar.[13]
  • Interpretation. The older international consultation suggested midline plication without levatorplasty might have better objective outcomes (Grade B), while the 2018 Cochrane review judged the direct comparative evidence insufficient for a firm superiority conclusion.[1][11]

Native Tissue vs Graft Augmentation​

Routine graft augmentation is not supported for primary posterior vaginal repair. The posterior-specific Cochrane review found no established benefit and more postoperative complications with biologic graft repair; the broader 2024 vaginal-prolapse review covers multiple compartments.[1][5]

ComparisonResult
Biologic graft vs native-tissue posterior repairRecurrent posterior prolapse RR 0.55 (95% CI 0.30–1.01; 3 RCTs, n = 377): no conclusive difference[1]
Paraiso three-arm RCTAt one year, failure was 12/26 (46%) after graft-augmented site-specific repair, 6/27 (22%) after site-specific native repair and 4/28 (14%) after colporrhaphy; overall comparison p = 0.02[13]
Sung porcine small-intestinal-submucosa RCT160 women with symptomatic stage 2 or greater rectocele randomized; 137 with 12-month blinded POP-Q. Anatomic failure (Ap or Bp −1 or greater) 12% with graft vs 9% native (p = 0.5); bulge-symptom failure 3% vs 7%; defecatory-symptom failure 44% vs 45%. Both groups improved, and the graft was not superior[30]
Postoperative complications with biologic vs native repairRR 1.82 (95% CI 1.22–2.72; 3 RCTs, n = 448)[1]
Synthetic-graft trialMesh exposure 7% in its synthetic group[1]

Historical recurrent-rectocele comparison. A Swedish registry cohort of 626 reoperations reported higher one-year patient-reported cure with nonabsorbable transvaginal mesh than colporrhaphy (OR 2.06, 95% CI 1.03–4.35), with more minor complications. The FDA ordered the last posterior transvaginal POP mesh products off the US market in 2018 and all remaining transvaginal POP mesh products in 2019. This restriction does not apply to abdominal sacrocolpopexy mesh.[19] FDA regulatory history

Posterior Colporrhaphy vs STARR​

In one retrospective, surgeon-selected comparison (49 STARR, 24 colporrhaphy), mean rectocele-size reduction was 1.9 versus 3.1 cm, respectively. Baseline size and obstructed-defecation symptom burden differed substantially; neither the greater colporrhaphy size reduction nor the reported symptom changes establish causal superiority of one route.[8]

Posterior Colporrhaphy vs Laparoscopic Ventral Mesh Rectopexy (LVMR)​

In a nonrandomized 231-patient comparison (72 LVMR, 159 colporrhaphy), the LVMR group had lower one-year constipation scores (CCCS 6 versus 9.2) and higher PISQ-12 scores (39.3 versus 35.8), with longer operative time.[20] Rectopexy is a distinct abdominal mesh operation, not transvaginal POP mesh.[20] In a subsequent single-center RCT of 40 selected women (20 per route), constipation scores improved after both operations at 12 months without a significant between-group difference; the sexual-function analysis included only 17 women, and longer follow-up is unavailable.[35]

Guideline Recommendations​

SocietyKey recommendation
ACOG/AUGS PB214 (2019)Posterior repair (midline plication of the fibromuscular layer) should be performed without tension on the levator ani, which may lead to dyspareunia; perineorrhaphy reattaching the perineal muscles to the rectovaginal septum can be performed as needed when a perineal defect is present. Site-specific repair had higher symptomatic bulge recurrence than midline plication in a retrospective comparison (11% versus 4%, P = .02) but comparable outcomes in prospective data. In a systematic review, transvaginal repair was more effective than transanal repair. Mesh or biologic grafts in transvaginal posterior repair do not improve outcomes (Level A)[10]
Cochrane 2018Transvaginal repair may reduce recurrence versus transanal; comparative data for other techniques are insufficient, and routine graft/mesh augmentation is not supported[1]
FIGO working-group update 2020Basic evaluation and conservative treatment precede posterior-compartment surgery[7]
ICI / Karram & Maher 2013Midline plication without levatorplasty might have better objective outcomes than site-specific repair (Grade B in that older consultation)[11]
ACG 2021Addresses benign anorectal disorders and defecatory dysfunction[6]
Grimes 2019Systematic review with practice recommendations: native-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. Assess apical support and other compartments when planning repair.[3][16] In the Swedish registry, reoperation in another compartment was more frequent than repeat posterior repair after an isolated posterior operation.[3][16]

Long-Term Durability​

The Swedish National Registry (n = 32,086 across all POP compartments and operations) recorded overall reoperation in 11% by five years and 15% by ten years.[16] Among 5,846 isolated posterior native-tissue repairs, any-compartment reoperation was 11.5% at five years and 16.4% at ten years; same-posterior-compartment reoperation was 3.5% and 4.4%.[16] In a separate five-year patient-reported survey, the posterior subgroup had 70% bulge-symptom cure; reoperated patients were excluded from that survey.[16] In the separate five-year survey that excluded reoperated patients, 70.2% of 408 respondents after isolated native-tissue posterior repair were satisfied or very satisfied.[16] In a separate selected cohort of 93 posterior repairs, Gillor et al. found persistent prolapse symptoms in 32%, obstructed defecation in 33% and clinical recurrence (Bp ≥ −1) in 20% at mean 5.3 years; 54 of 93 repairs had mesh augmentation.[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​

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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

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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

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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

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35. Sanad A, Sakr A, Elfeki H, et al. "Outcomes of Laparoscopic Ventral Mesh Rectopexy Versus Trans-Vaginal Repair in Management of Anterior Rectocele, a Randomized Controlled Trial." Tech Coloproctol. 2025;29(1):125. doi:10.1007/s10151-025-03145-z

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