WHAT IS A RECTOCELE?
A rectocele refers to a herniation (bulging) of the front wall of the rectum
into the back wall of the vagina. This condition occurs when the rectovaginal
septum, the tissue separating the rectum and vagina, becomes thin and weak
over time. Small rectoceles often do not cause symptoms and can simply be an
incidental finding. They can occur independently or alongside a more
widespread weakening of the pelvic floor muscles. Bulging of other pelvic
organs, such as the bladder (cystocele) and the small intestine (enterocele),
into the vagina can also lead to similar symptoms seen in rectocele.
WHAT CAUSES A RECTOCELE?
The exact cause of a rectocele is not fully understood, but symptomatic rectoceles often occur simultaneously with weakening of the rectovaginal septum and/or pelvic floor. Various factors can contribute to this weakening including advanced age, multiple vaginal deliveries, and trauma during vaginal childbirth (such as forceps delivery, vacuum delivery, tearing with a vaginal delivery, and episiotomy during vaginal delivery). Chronic constipation and frequent straining during bowel movements are believed to be contributing factors in the development of a rectocele. Additionally, undergoing multiple gynecological or rectal surgeries can weaken the pelvic floor and contribute to the formation of a rectocele.
Some patients have simultaneous non-relaxation of their pelvic floor during
defecation. This can cause patients to strain excessively during bowel
movements in order to evacuate. This excessive straining can cause a rectocele
to get bigger. In these patients, it is important to address pelvic floor
dysfunction with pelvic floor physical therapy and biofeedback.
WHAT ARE THE SYMPTOMS ASSOCIATED WITH A RECTOCELE?
As previously mentioned, the majority of patients with a rectocele do not experience symptoms. In fact, approximately 40% of women will have a rectocele detected during routine physical examination. However, when symptoms do occur, they can be categorized as either rectal or vaginal.
Rectal symptoms may include difficulty with bowel movements and the need to push against the back wall of the vagina or space between the rectum and the vagina (perineal body) to facilitate bowel movements. Vaginal symptoms can include the sensation of bulging or fullness in the vagina, protrusion of tissue from the vagina, and discomfort during sexual intercourse.
Symptomatic rectoceles can cause several issues including straining during
bowel movements, frequent urges to have multiple bowel movements throughout
the day, and discomfort in the rectal area. Fecal incontinence or smearing can
occur when small pieces of stool are trapped in a rectocele and later leak out
of the anus. Significant stool trapping can also increase the sensation of
incomplete evacuation after attempted bowel movements. When the patient stands
after a bowel movement, the trapped stool stuck in the rectocele returns to
the lower rectum, causing the urge to defecate again.
HOW CAN A RECTOCELE BE DIAGNOSED?
Examination of the pelvic region typically involves both vaginal and rectal examinations. A digital rectal exam is conducted, which often reveals weakness in the anterior wall of the rectum (the side closest to the vagina).
For further assessment, a special x-ray called defecography can be performed
to visualize and confirm the presence of a rectocele. During this exam, the
patient will sit on a specially-designed commode and be asked to defecate
after contrast material is inserted in the rectum and vagina. This allows
visualization of the rectocele and assessment of its size and the ability to
completely empty the rectum. Generally, if the rectocele is larger than 2
centimeters and/or shows significant retention of contrast material, it is
considered abnormal.
HOW CAN A RECTOCELE BE TREATED?
Treatment for a rectocele is typically considered only when significant symptoms impact quality of life. Prior to any treatment, it’s crucial to undergo a thorough evaluation by your doctor. There are both medical and surgical treatment options available for rectoceles. In many cases, symptoms associated with a rectocele can be managed with medical management, however, treatment depends on the severity of symptoms. Surgical treatment is typically reserved for the most severe cases of symptomatic rectocele.
Non-surgical treatment
The majority of symptoms associated with a rectocele can often be effectively managed without surgery. A key aspect of management involves establishing a good bowel regimen in order to prevent constipation and minimize straining during bowel movements. This includes maintaining a high fiber diet of 25-30 grams daily. In addition to a standard high-fiber diet, this may be achieved through fiber supplements, high fiber cereals, or high fiber bars. Sufficient hydration is also crucial, with a recommended intake of 6-8 ten-ounce glasses of water daily. The combination of fiber and water promotes softer, bulkier stools that reduce the need for straining during bowel movements which lowers the risk for developing a symptomatic rectocele. Occasional use of stool softeners may be recommended as well. During bowel movements, it is important to avoid straining, therefore, if there is no urge to defecate, forcing a bowel movement should be avoided. Additionally, prolonged periods of sitting on the toilet should be minimized to prevent excessive strain on the pelvic floor.
Biofeedback involves exercises performed with a pelvic floor physical therapist to strengthen and retrain the pelvic floor muscles. This approach can also help alleviate the symptoms associated with a rectocele.
Surgical Treatment
Surgical treatment for rectoceles should be considered only if symptoms continue despite the use of conservative measures such as dietary fiber, adequate hydration, and pelvic floor strengthening exercises. These symptoms should be significant enough to interfere with daily activities and quality of life. Colorectal surgeons, gynecologists, and urogynecologists specialize in diagnosing and treating this condition. These trained physicians can perform surgical procedures aimed at repairing a rectocele and relieving symptoms.
Surgical treatment options for rectoceles include several approaches: transanal (through the anus), perineal (the space between the anus and vagina), and vaginal approaches. The goal of these procedures is to remove excess tissue that forms the rectocele and strengthen the rectovaginal septum (the tissue between the rectum and the vagina). This is typically done by plication, which involves stitching the tissue together.
Rectocele repair can also be performed through the abdomen, either
laparoscopically or using open surgery. This approach utilizes mesh (a
prosthetic material or patch) strategically placed between the rectum and
vagina to strengthen the wall. This method has been proven safe and effective,
however, there may not be any benefit over other types of rectocele
repair. The choice of approach depends on factors such as the size of the
rectocele and the symptoms associated with it.
WHAT ARE THE OUTCOMES OF SURGICAL REPAIR?
The success of surgery for rectocele repair depends on factors such as the severity and duration of symptoms and surgical approach. As with any surgical procedure, there are potential risks involved, including bleeding, infection, new-onset dyspareunia (pain during intercourse), fecal incontinence, and rectovaginal fistula (an abnormal connection between the rectum and vagina). Additionally, there is a risk that the rectocele may recur or worsen post-surgery.
Certain studies indicate that approximately 75-90% of patients experience
significant improvement following rectocele repair. However, the success rates
tend to diminish over time, with only 50-60% of patients maintaining
significant improvement at the two-year mark. For patients dealing with fecal
incontinence, opting for a vaginal approach may have better outcomes. This is
because the transanal approach occasionally worsens continence issues.
Choosing a surgeon who is well-versed in repairing rectoceles and has
experience in performing these procedures will achieve the best results.
ABOUT COLON AND RECTAL SPECIALISTS
Colon and Rectal Specialists was founded in 1913. We are a group of dedicated
fellowship-trained colorectal surgeons. We are experts in the surgical and
non-surgical treatment of diseases of the colon, rectum, and anus. Our
surgeons have all completed advanced surgical training in the treatment of
these diseases in addition to full general surgical training. We are
well-versed in the treatment of both benign and malignant diseases of the
colon, rectum, and anus and are able to perform routine screening examinations
and surgically treat conditions when indicated.
ABOUT C.A.R.E.S. CENTER
Colon and Rectal Endoscopy and Surgery (CARES) Center is our state-of-the-art Ambulatory Surgery Center. Our center has been accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and has been given Medicare Deemed Status by CMS. We perform a variety of services including: screening colonoscopies, hemorrhoidectomy, abscess and fistula surgery, fissure surgery, pilonidal surgery, and surgery to treat fecal incontinence. Learn more about us at www.crspecialists.com.
