524 SURGERY RECTOCELE, A HERNIATION of the anterior rectal wall into the lumen of the vagina, is a frequent finding in female patients and its clinical relevance is ques- tionable: from 20% to 81% of both asymptomatic women and patients with constipation may present with rectoceles. 1,2 If less than 2 cm in diameter, rectoceles are usually accepted as a normal find- ing, both in constipated patients and in healthy subjects, whereas those with a diameter of more than 2 cm can cause outlet obstruction and rectal emptying difficulties. 1-6 Although it has been suggested that some rec- toceles may be caused by failure of relaxation or paradoxical contraction of the puborectalis mus- cle occurring during attempted evacuation, 7-9 the reason for its formation is not clear. However, it is important to identify a rectocele when it is the primary cause of intractable obstructed evac- uation. Rectoceles may cause mild to severe anorectal symptoms that are usually associated with chron- ic constipation. It is probable that straining aggravates the rectocele, enlarges it, and makes evacuation even more difficult. 2 In patients with rectocele and paradoxical sphincter reaction, defecation has to occur through the unrelaxed pelvic floor. 2,3,7 Original communications Anterior rectocele due to obstructed defecation relieved by botulinum toxin Giorgio Maria, MD, Giuseppe Brisinda, MD, Anna Rita Bentivoglio, MD, Alberto Albanese, MD, Gabriele Sganga, MD, and Marco Castagneto, MD, Rome and Pesaro, Italy Background. Surgical repair of rectocele does not always alleviate symptoms related to difficulty in defe- cation, and some patients have impaired fecal continence after surgical treatment. To avoid complica- tions of surgical repair, we investigated the efficacy of botulinum toxin in treating patients with symp- tomatic rectocele. Methods. Fourteen female patients with anterior rectocele were included in the study. The patients were studied by using anorectal manometry and defecography, and then treated with a total of 30 units of type A botulinum toxin, injected into 3 sites, 2 on either side of the puborectalis muscle and the third anteriorly in the external anal sphincter, under ultrasonographic guidance. Results. After 2 months, symptomatic improvement was noted in 9 patients (P = .0003). At the same time, rectocele depth (mean ± SD) was reduced from 4.3 ± 0.6 cm to 1.8 ± 0.5 cm (P = .0000001) and rectocele area from 9.2 ± 1.3 cm 2 to 2.8 ± 1.6 cm 2 (P = .0000001). Anorectal manometry demonstrated decreased tone during straining from 70 ± 28 mm Hg at baseline to 41 ± 19 mm Hg at 1 month (P = .003) and to 41 ± 22 mm Hg at 2 months ( P= .005). No permanent complications were observed in any patient for a mean follow-up period of 18 ± 4 months. At 1 year evaluation, incomplete or digi- tally assisted rectal voiding was not reported by any patient, and a rectocele was not found at physical examination. Four recurrent, asymptomatic rectoceles were noted at defecography. Conclusions. Botulinum toxin injections should be considered as a simple therapeutic approach in patients with anterior rectocele. The treatment is safe and less expensive than surgical repair. A more precise method of toxin injections under transrectal ultrasonography accounts for the high success rate. Repeated injections may be necessary to maintain the clinical improvement. (Surgery 2001;129:524-9.) From the Department of Surgery and the Department of Neurology, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, and the Surgical Unit, San Salvatore Hospital, Pesaro, Italy Accepted for publication October 21, 2000. Reprint requests: Dr Giorgio Maria, Istituto di Clinica, Chirurgica, Policlinico Universitario A. Gemelli, Largo Agostino Gemelli, 8, I-00168 Rome, Italy. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/56/112737 doi:10.1067/msy.2001.112737