1. Pelvic organ prolapse

2. POP

3. Rectocele

4. Rectocele

5. COCHRIAN REWIEW 50% of women with history of delivery have pelvic organ prolapse

6. RECTOCELE ASSOCIATED WITH: • SI. 30% • Rectal prolapse. 33% • Anismus. 10% • Enterocele2%

7. 42% of gynecologist's elective operations are RECTOCE • BUT • 16% of these patients are evaluated correctly • 85% of patients who are candidate for surgery by • proctologists ,have systematic evaluations

8. 30% of pop have occult SI

9. Bowel Bladder Sexual The effect of pop surgery on Function UNPREDICTABLE

10. Definition of cure in surgical treatment • No anatomic prolapse • No functional symptoms • Patient satisfaction • Avoidance of complication

11. In upper vaginal vault prolapse which option is preferred? -Abdominal approach(sacrocolpopexy) -Vaginal approach(sacrospinousfixation&post.colporraphy)

13. Sacrocolpopexy

14. Uterine or vaginal vault prolapse Abdominal sacrocolpopexy is better than vaginal sacrospinousfixation

15. In abdominal approach: -laparascopic -open. hysterectomy or Levatormyorraphy With&without

16. Hysterectomy +abdominal sacrocolpopexy

17. Comprehension of abdominal sacrocolpopexy&vaginalsacrospinousfixation: Abdominal approach has lower recurrence Less Dysparunia Longer operating time Longer recovery time Higher cost

18. In post.vaginal wall prolapse which approach has low recurrence ? Post.colporraphy with or without graft Transanal repair √Abdominal post.repair

19. In rectocele, vaginal approach is superior to transanal approach.

20. In post.colporraphy: -traditional colporraphy -mesh

21. NOT enough evidence about the use of mesh

22. Use of graft: Yes or No?

23. What kind of graft? -synthetic -Biologic. (autologous,alloplastic,cadave)

24. Use of absorbable or nonabsorbable graft in cystocele repair: Reduce the risk of recurrent cystocele on examination The effect of graft in patient's satisfaction & QOL is uncertain

25. In continent women, concomitant continence surgery don't reduce the rate of post.op SI In occult SI, concomitant continence surgery : 20% prevent of post op SI 60% will have unnecessary procedure For balance between cost&side effect more investigation must be done

26. Rectocele&ant,compartment prolapse: -Traditional ant.repair -Burch operation -Mesh

28. What kind of suture? -Absorbable -Non absorbable

29. It is referred to surgeon's preferred.

30. Rectocele + enterocele ?

31. Small enterocele : transperineal Large enterocele: transabdominal

32. Rectocele & vault prolapse & previous hysterectomy?

33. Abdominosacrocolpopexy

34. Rectocele + fecal incontinence?

35. Transperineal. If there is gap in Endoanalsono:+ Sphincteroplasty If there is no gap: + Levatoroplasty

36. Rectocele + Animus?

37. Biofeedback & conservative

38. Rectocele + Anorectalproblem?

39. Transanal

40. Rectocele + Severe dyspaurunia?

41. Transanal

42. Rectocele&(no anismus , no anorectal problem , no severe dyspaurunia , no fecal incontinence): Transvaginal & site specific repair

43. Comprehension of surgical repair with conservative management of pop: There is no any research .

44. Comprehension of surgical repair with mechanical device There is no any research .

45. Figure 1. Commonly used pessaries: (A) Smith; (B) Hodge; (C) Hodge with support; (D) Gehrung; (E) Risser; (F) Ring with diaphragm; (G) Ring; (H) Cube; (I) Shaatz; (J) Rigid Gellhorn; (K) Flexible Gellhorn; (L) Incontinence ring; (M) Inflatoball; (N) Donut. Image courtesy of CooperSurgical, Inc., Trumbull, CT.

46. Pessary Insertion

47. Indication of STARR : Rectocele with&withoutIRP

48. STARR