Rectocele is the structural abnormality that occurs in the part of the rectovaginal septum allowing the rectum to push and bulge on the vaginal area. It is a kind of pelvic organ prolapse, which is a condition that happens mainly because of weak support on the rectal-vaginal wall. The vaginal wall is made up of fibrous tissues and muscles that separate the rectum from the vagina. Weakening of this structure allows the anterior part of the rectum to create a projection into the vaginal canal.
Although the incidence of rectocele is higher in child-bearing women, the condition may also affect women that did not bear child. Rectocele frequency increases with age, parity, and obesity. Around 200,000 women undergo operation for treatment of rectocele every year and the rate of incidence is projected to increase further in the future.
Rectocele occurs when the rectovaginal wall becomes weak and thin. This normally happens as the result of multiple concurring factors. Contributing factors commonly associated with the condition include: genetic predisposition to weak pelvic structure support; various activities that cause intra-abdominal pressure on the pelvic floor, such as heavy lifting and straining caused by chronic cough and chronic constipation; pregnancy and delivery, particularly prolonged and difficult delivery due to overweight babies or multiparity (most common cause); the use of forceps during delivery; episiotomy and perineal tears.
In some instances, pelvic surgery or the removal of the uterus can also contribute to the development of rectocele. Clinical studies suggest that menopause may also play a role in this condition since the decrease in estrogen production is associated with the decrease in the elasticity of the pelvic wall tissue.
Rectocele may at times be unnoticed in asymptomatic patients. Mild cases may produce a sense of pressure or protrusion within the vagina. Most people diagnosed with the condition report uncomfortable feeling associated with certain activities, such as during defecation or sexual activity. The following conditions usually become noticeable for people with at least more than a 1 inch rectal protrusion into the vaginal canal:
- Bulging sensation or mass within the vaginal opening.
- Difficulty in defecation that can be relieved by manually pressing the protrusion backward to help push the stool outside of the rectum.
- Rectal or vaginal fullness
- A feeling that the stool was not completely emptied just after defecation.
- Rectal pain
- Dyspareunia – painful intercourse
- Feeling of weakened vaginal tissues.
- Lower back pain that is temporarily relieved by lying down.
Rectocele can be accompanied by other related conditions as cytocele, enterocele and uterine prolapse.
After a general exam has been performed to assess and guide in diagnosis and treatment, pelvic examination is done to determine the size and location of the rectal protrusion. The inspection is done with the patient either lying down or standing up while the doctor touches the rectum to search for a protrusion as the patient bears down. Sometimes, a simple pelvic examination may not be sufficient to fully assess the degree of rectocele, especially if it is a mild form. During those cases, magnetic resonance imaging and x-ray examination could be performed.
Milder forms of rectocele that do not cause any symptoms do not need medical attention. However, prevention and treatment is still necessary. Diets high in fiber are usually encouraged in addition to drinking at least 6 to 8 glasses of water per day. The patient is also informed about means to avoid straining during defecation, such as using stool softeners like glycerine suppositories. Manually compressing the protrusion within the vaginal canal is also advised to aid in defecation comfortably. Activities causing intra-abdominal pressure (such as heavy lifting) are also discouraged.
For those women who are with a lack of estrogen as the cause of rectocele, hormonal replacement therapy is the treatment of choice in order to bring back the strength of the pelvic musculature. Consistent and continuous Kegel exercises from time to time are also recommended to strengthen the rectovaginal muscles.
In some instances where surgical measures are found necessary, colporrhaphy is the standard surgery. Colporrhaphy involves pulling together the lateral muscles of the vagina and suturing them above the rectum to bring it back to the normal anatomical position within the rectal and vaginal area.
Patients are encouraged to eat foods with high fiber content to avoid constipation. Activities or bodily responses that cause intra-abdominal pressure such as straining and heavy coughing should also be avoided. Measures to strengthen pelvic floor muscles such as Kegel's exercise should be continued.
Rectocele is a condition with excellent prognosis. The outcome is usually good in mild or moderate cases after following supportive treatments and preventable measures. However, the condition is likely to develop again if preventable measures are not maintained overtime, for instance, avoiding continuous activities that result in straining. For severe cases of recetocele, the symptoms are relieved after a surgical procedure, although a reported incidence of painful intercourse is remarkable after a surgery, especially when the repair is made too tightly.
Keep a healthy and balanced diet to manage the consistency of your stools. Avoid activities that involve intense and prolonged mechanical stress of the pelvic floor muscles.
A person suffering from rectocele may experience bouts of pain and uneasiness causing them to hinder during normal physical functions. An early treatment is commendable once the first symptoms are felt for a better chance of prevention as well as recovery. Supportive care is encouraged to the partner as the condition will sometimes affect the self-esteem of the woman suffering from such a condition due to dyspreunia and a feeling of weakness in the vaginal muscles.
Most studies conducted today regarding treatment of rectocele are focused on how to make surgical repairs more bearable for the patient by minimizing negative effects and risks for the patient. In particular, there is a significant concern with dyspareunia, which is common after vaginal surgical repair specifically used for rectocele treatment. Rectocele repair using biometrical augmentation is the most recent surgical innovations being tested.
Antibiotic therapy using cefuroxime are also currently under trial for the purpose of minimizing infection for the vaginal repair operations.