*Perspective Chapter: Surgical Management of Symptomatic Rectocele DOI: http://dx.doi.org/10.5772/intechopen.105505*

them. Thus, despite optimal surgical correction of the rectocele, part of the initial symptoms such as sexual dysfunction, dyspareunia, or constipation could persist (**Figure 1** and **Table 1**).

The diagnosis of rectocele is initially clinical, after a correct anamnesis and physical examination of the entire pelvic floor, ruling out other "celes" or associated pathologies. In addition, we must assess possible gynecological alterations, the integrity of the rectovaginal septum and anatomical defects or the tone of the anal sphincter and identify neurological lesions. An anoscopy can help to rule out a possible associated intussusception. The severity of symptoms should be evaluated with standardized scores such as the "Obstructed Defecation syndrome" score or the "Pelvic Organ Prolapse Scoring system" POP-SS. This should include associated symptoms such as urinary incontinence or fecal incontinence with validated scales, e.g., "Wexner Score" (Cleveland Clinic Incontinence Score). Additionally, the impact on the quality of life should be considered and measured through the numerous existing questionnaires.

**Figure 2.** *Videodefecography.*

#### **Figure 3.**

*Perineal ultrasound. It is usually performed in lithotomy position, with an empty rectum and with an optimums Valsalva maneuver of 6 seconds [6].*

Regarding the complementary examination, it may be useful to perform a defecography, currently considered the gold-standard test to diagnose pelvic organ prolapse or a dynamic pelvic resonance imaging (MRI). The latter have a high sensitivity of around 100% for the diagnosis of rectocele and a specificity of 57%. Rectocele is currently recognized as a classic indication for this test. Considering that the rectocele can be physiological when performing Valsalva maneuver, it is considered physiological in the imaging tests if it is asymptomatic and smaller than 2.5 cm (**Figures 2** and **3**).

Another technique that can be performed in case of incontinence associated or alterations of the anal sphincter suspected is the endoanal of perineal ultrasound [3, 4].
