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Rectocele


Presentation

A rectocele presents as:

Urogenital

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.

Gastrointestinal

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.

Wound Infection
  • Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted.[ncbi.nlm.nih.gov]
  • Please call us if you have a fever over 100.5 F consistently at home, pain that worsens or is not controlled by medicines, excess discharge or concerns for wound infection, heavy vaginal bleeding or discharge, nausea or vomiting, leg pain or swelling,[sclhealth.org]
Constipation
  • OBJECTIVES: Rectocele with constipation might be related to methane (CH4) producing intestinal bacteria. We investigated the breath CH4 levels and the clinical characteristics of colorectal motility in constipated patients with rectocele.[ncbi.nlm.nih.gov]
  • BACKGROUND: Rectocele is frequently associated with constipation, but it is not known whether a causal relationship exists. OBJECTIVE: To determine the effect of rectocele repair on symptoms of constipation.[ncbi.nlm.nih.gov]
  • […] scale), and quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire).[ncbi.nlm.nih.gov]
  • The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4.[ncbi.nlm.nih.gov]
  • Abstract BACKGROUND The aim of this study was to evaluate the curative effect of transvaginal mesh repair (TVMR) and stapled transanal rectal resection (STARR) in treating outlet obstruction constipation caused by rectocele.[ncbi.nlm.nih.gov]
Buttock Pain
  • These complications include: mesh exposure (10%), prolapse recurrence, rectal injury (1%), vascular injury, rectovaginal fistulas, buttock pain (5%) and dyspareunia.[glowm.com]
Suggestibility
  • The clinical experience and review of the literature by the authors suggest that a porcine-derived acellular mesh is non-cytotoxic, pyrogenic or allergenic, and the application of a biomesh in the management of rectocele is effective and safe, and the[ncbi.nlm.nih.gov]
  • CONCLUSION: In a considerable proportion of patients, constipation persists after rectocele repair, suggesting that these symptoms are related to an underlying dysfunction.[ncbi.nlm.nih.gov]
  • OBJECTIVE: A growing body of evidence suggests an increased role for apical support in the treatment of pelvic organ prolapse regardless of phenotype.[ncbi.nlm.nih.gov]
  • The mean Wexner constipation score decreased significantly from 16 to 4 (0-4: n 68) (6: n 6) (7: n 1) (P CONCLUSION: Current trial results suggest that TRREMS procedure is a safe and effective technique for the treatment of anorectocele associated with[ncbi.nlm.nih.gov]
  • If the woman is postmenopausal, with mild to moderate symptoms, the doctor may suggest estrogen therapy.[healthcentral.com]
Dyspareunia
  • None of the patients encountered de novo dyspareunia after the procedure. CONCLUSION: Anterolateral rectopexy provides an effective tool for anatomical correction of rectoceles and does not result in dyspareunia as a side effect.[ncbi.nlm.nih.gov]
  • Three out of four patients with initial symptoms of dyspareunia (75%) reported significant improvement in dyspareunia, while 2 out of 19 patients without initial symptoms of dyspareunia (11%) reported mild dyspareunia following the repair.[ncbi.nlm.nih.gov]
  • Questionnaires were used to assess constipation and dyspareunia. De novo dyspareunia and cure rates for constipation and dyspareunia were not statistically different between the two groups.[ncbi.nlm.nih.gov]
  • One patient developed de novo dyspareunia. Some 92% of the patients (47/51) would recommend local anesthesia.[ncbi.nlm.nih.gov]
  • Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score].[ncbi.nlm.nih.gov]
Overflow Incontinence
  • When an individual is able to tolerate increased volumes without signs of increased discomfort or the urge to defecate, overflow incontinence may occur.[glowm.com]

Workup

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 [3].

Test Results

The results of a defecography are diagnostic. This test also shows the size, exact location and degree of obstruction of the rectocele.

Treatment

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.

Conservative Treatment

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 [6]. 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 Treatment

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 [1].

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 [5].

Prognosis

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 [7].

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

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 [8].

Etiology

Rectocele in women is a common condition and can be due to a number of factors. Some of which are mentioned below:-

Childbirth

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.

Delivery procedures

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.

Pelvic surgery

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 [10].

Bowel disturbance

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.

Old Age

As women age, they no longer have a sufficient supply of estrogen to maintain the elasticity of the pelvic muscles. As a result rectoceles, cystoceles and other pelvic organ prolapse may occur.

Epidemiology

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 [9].

Race

A study reveals that white women are at greater risk of developing a rectocele and pelvic organ prolapse than women of African-American origin [2].

Age

It is more prevalent in older aged women.

Sex

Rectoceles are much more common in females than in males.

Incidence

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.

Sex distribution
Age distribution

Pathophysiology

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 [4].

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.

Prevention

Rectoceles can be prevented by taking a high fiber diet and large quantity of water to help soften stools. Kegel exercises to strengthen muscles and hormone replacement therapy after menopause open link should be begun to prevent pelvic organ prolapse.

Summary

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.

Patient Information

Definition

Rectocele is a bulge of a portion of the rectum into the vagina due to weakened supporting muscles in the pelvis.

Cause

It may be due to childbirth, old age, prolonged constipation, pelvic surgeries, etc.

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.

Treatment

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.

Prevention

Rectocele development can be prevented with a high fiber diet, Kegel exercises and hormone replacement therapy after menopause.

References

Article

  1. 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
  2. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. Sep 2007;110(3):717-29.
  3. 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
  4. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. Jun 1992;166(6 Pt 1):1717-24; discussion 1724-8. 
  5. 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
  6. 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
  7. 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
  8. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol. Mar 1959;77(3):490-502
  9. 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
  10. Silva WA, Karram MM. Scientific basis for use of grafts during vaginal reconstructive procedures. Curr Opin Obstet Gynecol. Oct 2005;17(5):519-29.

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Last updated: 2019-07-11 22:41