The transvaginal approach consists of an incision on the posterior vaginal wall and eventual plication of the rectovaginal fascia. Incorporating the underlying levator ani muscles with interrupted sutures from the levator plate to the perineal body, while reducing the anterior rectal wall, is the classic “posterior colporrhaphy”. The excess vaginal tissue is excised and repair is completed. This technique tends to be favored by the gynecologists given their natural comfort with a transvaginal operations. It also allows an avenue to address other gynecological concerns such as concomitant vaginal hysterectomy or cervical amputation. Since most of the reported studies describing transvaginal approaches are performed by gynecolo­gists, the great majority of patients do not have the functional preoperative workup to assess the type of constipation (outlet obstruction vs. slow transit) or the imaging (defecography) that colon and rectal surgeons tend to employ. Much of this vari­ability is due to differences in training, but this may also be by natural selection, as the gynecologists’ patients will have presenting symptoms typically more gyne­cologically focused: i.e., vagina l bulge and dyspareunia. Therefore, anal manom­etry, colonic transit studies and defecography are less utilized in gynecology preoperative workup and also the reported postoperative complications is also gynecologically focused. For example, in the gynecology literature frequently defines recurrence as the relapse of the vaginal bulge with a generalization of the postoperative defecatory complaints. Karram and Maher [49] as part of the Fifth International Collaboration on Incontinence summarized an extensive review of studies and outcomes (Table 9.1). The patients were followed a minimum of 12 months in most studies. Anatomic cure ranged from 76 to 96%, vaginal bulge persisted 4–31%, vaginal digitation continued 0–33%, defecatory dysfunction was seen in 8–36%, and dyspareunia in 8–45%. Many of the trials did not include rates of dyspareunia or defecatory disorders preoperatively to allow postoperative comparison. The postoperative dyspareunia incidence can be assumed to be underestimated as many of the subjects are elderly women and sexually inactive. While the Maher study [50] noted 37/38 wom en with dyspareunia preoperatively and only 2 postoperatively, the Abramov [51] study noted an increase from 8/183 to 31/183 respectively. Kahn [52] also reported worsening postoperative dyspareunia. Weber illustrate in her study that the resultant vaginal dimension did not correlate with sexual function [53].