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.

• Surgical Procedure

  A surgical procedure called anterior colporrhaphy tightens the front walls of the vagina, while posterior colporrhaphy tightens the back walls. [my.clevelandclinic.org]

  Of course, it may be safe to perform a surgical procedure under spinal anesthesia with a transvaginal, transanal, or transperineal approach in elderly patients or those with significant medical comorbidities. [e-jmis.org]

  Moderate to severe cases are often treated with a vaginal pessary (a support device inserted into the vagina) or rectocele repair (a minimally invasive surgical procedure). [hopkinsmedicine.org]

  CONCLUSIONS: The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. [ncbi.nlm.nih.gov]

• Severe Pain

  […] not causing any pain or discomfort. [everestpharmacy.co.uk]

  Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes ... [fascrs.org]

• Swelling

  Our case was admitted with complaints of a swelling in her vagina, constipation, and difficulty in emptying her bowels. The diagnosis and treatment utilizing transvaginal approach in this case is discussed in comparison with the literature. [ncbi.nlm.nih.gov]

  Eight women presented with some complaint of stool trapping, constipation, anal swelling and bright red blood per rectum. Rectocele and grade 3–4 hemorrhoids were diagnosed based on the history, physical examination, colonoscopy and defecography. [link.springer.com]

  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]

  The swelling of the rectum wall might increase during bowel movement. Rectocele makes the rectovaginal wall weak and thin. How is Rectocele graded? Rectocele is graded according to the degree of its inclination into the vagina of women. [howshealth.com]

• Inguinal Hernia

  If we could artificially produce tissue of the density and More information Yu-Li Lin 1, Tien-Jye Chang 2 Formos J Surg 009;4:6-67 6 Original Articles Effect of a Pediatric Surgeon on Pediatric Inguinal Hernia Repair --- Evaluation of the Importance of [docplayer.net]

• Constipation

  If you suffer from chronic constipation, then I strongly advise you to get my book, Listen To Your Colon: The Complete Natural Healing Guide For Constipation, as you need a comprehensive constipation treatment that addresses all of the variables. [blog.listentoyourgut.com]

  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]

• Vomiting

  […] temperature of 101° F (38.3º C) or higher More vaginal bleeding than when you were in the hospital Pain that doesn’t go away with pain medication Severe bladder spasms Not had a bowel movement for more than 48 hours Not passed gas for 24 hours Nausea, vomiting [mskcc.org]

  This helps to keep you from vomiting during the procedure. Your provider may ask you to take an enema or medicine to clean out your bowel before surgery. Follow any other instructions your healthcare provider gives you. [summitmedicalgroup.com]

  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]

  […] progressing as expected or you develop complications such as: Signs of infection, including fever and chills Excessive bleeding or any discharge from the incision site Unusually heavy vaginal bleeding or foul-smelling discharge from the vagina Nausea or vomiting [wnyurology.com]

  You vomit several times in a row. Your bowel movement is bright red or black. When should I call my doctor? Your pain does not go away, even with treatment. Your pessary falls out. You have heavier vaginal bleeding than usual. [drugs.com]

• Nausea

  Have: A temperature of 101° F (38.3º C) or higher More vaginal bleeding than when you were in the hospital Pain that doesn’t go away with pain medication Severe bladder spasms Not had a bowel movement for more than 48 hours Not passed gas for 24 hours Nausea [mskcc.org]

  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]

  […] is not progressing as expected or you develop complications such as: Signs of infection, including fever and chills Excessive bleeding or any discharge from the incision site Unusually heavy vaginal bleeding or foul-smelling discharge from the vagina Nausea [wnyurology.com]

  Complications The complications that might occur due to the surgery are: The anesthesia used can make the patient feel nausea; blood passes out with urine, headache, cut lips or vomiting. [howshealth.com]

• Abdominal Bloating

  Those symptoms are Lumpy or hard stool, Straining, Sensation of anorectal obstruction, sensation of incomplete defecation, Fewer than 2-3 bowel movements per week, Abdominal bloating and digital maneuvering to defecate. [medcraveonline.com]

• Dyschezia

  "Dyschezia and rectocele-a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation". Dis Colon Rectum, vol 36(11), pp. 1030-6. 116. Skandalakis Lee John (1995). [ambn.vn]

• Prolapse

  Natural Treatment for Rectal Prolapse Treating the underlying causes of rectal prolapse usually cures the problem. [blog.listentoyourgut.com]

  If there are other associated problems (eg. prolapse higher up in the vagina), a laparoscopic operation through the abdomen may be more appropriate. [oxfordgynaecology.com]

  Risk factors for vaginal wall prolapse are Age Obesity Vaginal delivery Severity of vaginal wall prolapse can be graded by the Baden-Walker system, which is based on level of protrusion: Grade 0: No prolapse Grade 1: Halfway to the hymen Grade 2 : To [merckmanuals.com]

  Rectal prolapse is when rectal walls have prolapsed to the degree they protrude through the anus and are visible outside the anal canal. Frequently patients with rectal prolapse have fecal incontinence. [pelvicorganprolapsesupport.org]

  Common symptoms include symptoms of prolapse and obstructed defecation. AIMS: To describe subjective, anatomical and functional results of defect-specific rectocele repair. [ncbi.nlm.nih.gov]

• Stroke

  Critical Care Our emergency medicine physicians and nurses who are dedicated to the care of patients with broken arms and “broken” hearts to stroke or sudden pain and more. [excelahealth.org]

  With general anesthesia the risks are of heart attack and strokes. Blood may clot in the legs of the patient, a few days after the surgery were done. This causes pain in the leg. Bleeding can continue after or during the surgery. [howshealth.com]

  Ovarian conservation before menopause is particularly important in patients with a personal or strong family history of cardiovascular disease or stroke. [choosingwisely.org]

• 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]

• Urinary Incontinence

  Urge Incontinence Utero Vaginal Prolapse Prolapse/Incontinence Videos Cystocele Rectocele Stress Urinary Incontinence Urinary Urge Incontinence Urinary Incontinence Utero Vaginal Prolapse Vaginal Vault Prolapse Instructional Robotic Videos Robotic Burch [frmiu.com]

  Mrs Sarah Hussain Consultant gynaecologist Menopause, Endometriosis, Urinary incontinence, Vaginal prolapse, Laparoscopy, Ovarian cyst Loading... [topdoctors.co.uk]

  Objective: This study aimed to compare some factors associated with urinary incontinence in women with and without urinary incontinence. [hnmj.gums.ac.ir]

  Bladder function 6.1 Stress urinary incontinence 6.2 De novo stress urinary incontinence 6.3 Surgery for stress urinary incontinence 6.4 De novo bladder overactivity or urge incontinence 6.5 Urinary voiding dysfunction 7. [doi.org]

• Urinary Stress Incontinence

  The most common prolapse symptoms were reducible vaginal lump, urinary stress incontinence, constipation and flatus incontinence, sexual dysfunction and dypareunia. The degree e of the prolaps was staged according to POPQ system. [ncbi.nlm.nih.gov]

  The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. [emedicine.medscape.com]

  Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence. [ajog.org]

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.

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].

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].

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.

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.

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.

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.

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.

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.

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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. 
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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.