Surgical repair of the posterior compartment.

Introduction The support anatomy of the posterior vaginal wall is a byproduct of complex interactions among the pelvic floor muscles, nerves, and connective tissue. Before a surgeon can successfully plan and perform an operation to correct a posterior compartment defect, he or she must understand not only the anatomic principles outlined in chapter 1 of this text, but the methods for assessing prolapse symptoms outlined in chapter 4 as well. Generally, surgical intervention is only considered when 1) a posterior compartment defect produces symptoms (such as pressure, heaviness, pain, incomplete rectal emptying, and so on) or 2) when other significant prolapse is present. The connective tissue layer of the posterior vaginal wall, commonly referred to as the rectovaginal septum, runs laterally to the pelvic sidewall and fuses distally to the perineal body. A full description of the posterior wall anatomy is covered in chapter 1 of this text. For the purposes of this chapter, the term vaginal muscularis is used to refer to the ‘‘fascial’’ tissue that attaches to the pelvic sidewall. Stretching and/or tearing of this layer are generally considered the fundamental occurrence that results in posterior wall support defects. Although this chapter focuses on posterior wall surgery, it is important for the pelvic surgeon to recognize and address any other defects (especially apical descent) when planning surgery for a particular patient. In fact, some operations primarily aimed to correct apical prolapse—such as the sacral colpopexy (discussed in chapter 8)— can actually correct posterior wall prolapse at the same time. Nonetheless, this chapter strictly focuses on the various methods for surgically addressing the posterior compartment—focusing on the medical evidence supporting each operation. Correspondence: Patrick J. Culligan, MD, FACOG, FACS, Division of Urogynecology, 100 Madison Ave., Morristown, NJ 07962-1956. E-mail: patrick.culligan@ ahsys.org