A rectocele presents as:
There may be a bulge or palpable mass in the vagina which may partially obstruct the vaginal canal causing pain during intercourse, vaginal bleeding and difficult labor. There may also be persistent pain in the pelvic cavity which increases during defecation and is slightly relieved after fecal evacuation.
Patients suffering from a rectocele may often complain of constipation, difficulty in evacuation, straining, the need to press against the vagina or near the rectum to be able to evacuate, a feeling of incomplete evacuation and pain. Fecal incontinence may also occur as well as rectal prolapse from the anus.
Entire Body System
Recently, with the advancement of imaging and computational modeling techniques, a plethora of finite element (FE) models have been developed to study vaginal prolapse from different perspectives and allow a better understanding of dynamic interactions [ncbi.nlm.nih.gov]
Turkish Journal of Colorectal Disease, vol. 27, no. 4, 2017, p. 165+. Accessed 21 Apr. 2020. Gale Document Number: GALE|A538725297 [go.gale.com]
Rectoceles are usually found during routine physical examinations because the majority of them are asymptomatic.
A defecography, which is a special procedure in which a contrast medium is inserted into the rectum as an enema, and then x-rays are taken during bowel movement, is an accurate test to diagnose a rectocele .
The results of a defecography are diagnostic. This test also shows the size, exact location and degree of obstruction of the rectocele.
Rectoceles are only treated if they present with significant symptoms. Treatment depends upon the severity of the condition. It is of two types: Conservative and Surgical.
Rectoceles are conservatively treated by a controlled high fiber diet. By supplementing high fiber cereals and fiber bars into the diet along with an increased water intake, bulk is increased. This may be accompanied with stool softeners to help in evacuation and to lessen straining during defecation . A hormone replacement therapy may also be started in post menopausal women to replenish the level of oestrogen to help with muscle strength. Pelvic floor muscle exercises, known as Kegel exercises, may be carried out to increase muscle power and strength.
Surgical repair can be done either by suturing up the tears in the vaginal wall or by inserting a mesh or patch to support and strengthen the tissues. Often the tissue from the rectocele itself is removed and used for patching up the tears. Repair of the rectovaginal septum can also be carried out .
It should be noted that surgical repair is carried out only if conservative management has totally failed or if the rectocele is so enlarged that it is causing a significant reduction in quality of life .
Rectoceles if mild, usually do not require any treatment as they do not present with any symptoms. In such cases, the affected female is usually unaware that she has a rectocele .
Mild cases may remain mild, content in staying in a 'latent' stage. But if the underlying cause is not removed or treated, some may progress to becoming symptomatic.
In cases of moderate and symptomatic to severe rectoceles, treatment is needed to alleviate the symptoms.
Complications are rare but if left untreated, a rectocele may result in vaginal bleeding, dyspareunia, obstructed labor, rectal prolapse through anus and general discomfort due to incomplete bowel emptying .
Rectocele in women is a common condition and can be due to a number of factors. Some of which are mentioned below:-
This is the most common cause of a rectocele. During childbirth, there is increased strain on the pelvic floor muscles and the rectovaginal septum leading to their weakness. Particularly during birthing of a child weighing 8-9 pounds or more, the weakened muscles and fascia result in a wide, dilated and weakened vaginal wall. This allows the rectum to bulge forward into the vaginal canal, creating a rectocele. The more vaginal deliveries a women has, the more the chance of developing a rectocele.
This cause of developing a rectocele is slightly different from childbirth. During delivery, if the person performing the operation is not an appropriately trained professional, as in many rural areas of 3rd world countries, or if there is malpractice, for example the wrong use of forceps to pull the baby out, vacuum delivery, episiotomy during vaginal delivery, etc. there may be tearing of the muscles. The tearing may be on the vaginal wall itself, or sometimes on the supporting muscles and fascia. Either way, the rectum can push through the openings, into the vagina.
During surgical procedures of the pelvic cavity, such as a hysterectomy, the surrounding fascia may be damaged. Or after a hysterectomy, the muscles of the pelvic floor may become weak and lead to a rectocele .
Long standing constipation causes undue straining of the pelvic muscles during defecation. This results in weakening of the pelvic floor muscles which are then unable to support the rectum and vagina, resulting in a rectocele.
The exact epidemiology of rectocele can not be calculated as many women who have this condition do not come forward, and many others have it in such a mild form that they do not know they have it .
It is more prevalent in older aged women.
Rectoceles are much more common in females than in males.
According to the results of the Women's Health Initiative Study, 41% of females showed some degree of pelvic organ prolapse between 50-80 years of age. Out of this, 19% had a rectocele.
The rectovaginal septum, sometimes also known as the Fascia of Otto, is a thin sheet-like fibrous band of connective tissue that covers the vaginal wall posteriorly and the rectum anteriorly. It's function is to separate the two structures and give them support .
If due to any reason as stated in the previous section, this septum is damaged or weakened, the rectum may start bulging forward, into the vagina. Sometimes, damage to the septum only may not lead to a rectocele but a torn septum along with weakened pelvic muscles may cause a rectocele to develop.
A rectocele is a defect in the rectovaginal tissue or septum which results in bulging of the anterior wall of the rectum into the vagina. This condition is similar to a hernia where rectal tissue protrudes into the vaginal canal.
The rectum and the vagina are separated from each other by a tough, fibrous band of tissue called the rectovaginal fascia or septum. This sheet like septum serves to not only separate the two structures but to also lend support to the vaginal wall. If due to any reason, this layer gets damaged, weakened or lacerated, a portion of the anterior wall of the rectum bulges forward and into the posterior wall of the vagina.
This condition is usually asymptomatic in most females, however, in moderate to severe cases, patients may complain of constipation, a bulge or mass in the vagina, difficulty in evacuation, pain in the rectum and pain during intercourse.
Rectocele occurs in males too, but since the prostate gland gives support anteriorly, the herniation of the rectum happens posteriorly through the rectoprostatic fascia or septum. It should be noted that rectocele is a very rare occurrence in males.
On the contrary, a rectocele is a very common condition in females and that is why, this article is based on occurrence of this condition in females only.
Signs and Symptoms
Mild cases are asymptomatic. Moderate to severe cases present with pelvic pain, constipation, straining and difficulty in evacuation, a bulge or mass in the vagina, pain during intercourse and vaginal bleeding.
A rectocele can be treated conservatively by a change in diet, HRT and stool softeners. Surgical treatment includes suturing up of vaginal wall or supporting muscles and mesh repair.
- Boyles SH, Weber AM, Meyn L. Procedures for pelvic organ prolapse in the United States, 1979-1997. Am J Obstet Gynecol. Jan 2003;188(1):108-15
- ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. Sep 2007;110(3):717-29.
- Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol. Dec 2004;104(6):1403-21
- DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. Jun 1992;166(6 Pt 1):1717-24; discussion 1724-8.
- Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct. Jan 2006;17(1):84-8
- Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol. Dec 2006;195(6):1762-71
- Gauruder-Burmester A, Koutouzidou P, Rohne J, Gronewold M, Tunn R. Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse. Int Urogynecol J Pelvic Floor Dysfunct. Sep 2007;18(9):1059-64
- Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol. Mar 1959;77(3):490-502
- Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. Apr 1997;89(4):501-6
- Silva WA, Karram MM. Scientific basis for use of grafts during vaginal reconstructive procedures. Curr Opin Obstet Gynecol. Oct 2005;17(5):519-29.