What is a rectocele?
A rectocele is a bulge of the front wall of the rectum into the vagina. The rectal wall may become thinned and weak, and it may balloon out into the vagina when you push down to have a bowel movement. Most rectoceles occur in women where the front wall of the rectum is up against the back wall of the vagina. This area is called the rectovaginal septum and may be a weak area in the female anatomy. Other structures may also push into the vagina. The bladder bulging into the vagina is called a cystocele. The rectum bulging into the vagina is termed a rectocele. And the small intestines pushing down on the vagina from above may form an enterocele. Although uncommon, men may also develop a rectocele.
A rectocele may be present without any other abnormalities. In some cases, a rectocele may be part of a more generalized weakness of pelvic support and may exist along with a cystocele, urethrocele, and enterocele, or with uterine or vaginal prolapse, rectal prolapse, and fecal or urinary incontinence. This is called pelvic floor prolapse.
What can cause a rectocele?
The underlying cause of a rectocele is a weakening of the pelvic support structures and thinning of the rectovaginal septum. Certain factors may increase the risk of a woman developing a rectocele. These include birth trauma such as multiple, difficult or prolonged deliveries, the use of forceps or other assisted methods of delivery, perineal tears, or an episiotomy into the rectum or anal sphincter muscles. In addition, a history of constipation and straining with bowel movements, or hysterectomy may contribute to the development of a rectocele. Commonly, these problems develop with age but they may occasionally occur in younger women or in those that have not delivered children.
What are the symptoms of a rectocele?
Many women have rectoceles but only a small percentage of women have symptoms related to the rectocele. Some level of small rectocele is simply a part of aging for women. Symptoms may be primarily vaginal or rectal. Vaginal symptoms include vaginal bulging, the sensation of a mass in the vagina, pain with intercourse or even something hanging out of the vagina that may become irritated. Vaginal bleeding is occasionally seen if the vaginal lining of the rectocele is irritated, but other sources of the bleeding should be checked by your doctor. Rectal symptoms include constipation, particularly difficult evacuation with straining. Often this is associated with bulging in the vagina when straining to have a bowel movement. Some women find that pressing against the lower back wall of the vagina or along the rim of the vagina helps to empty the rectum. At times, there will be a rapid return of the urge to have a bowel movement after leaving the bathroom because stool that was trapped in the rectocele may return to the low rectum after standing up. Often patients will complain they stool and then return several times to completely empty, a general feeling of pelvic pressure or discomfort is often present but this may be due to a variety of problems.
How is a rectocele diagnosed?
Most rectoceles may be identified on a routine office examination of the vagina and rectum. At times it may be difficult to assess the size and significance of the rectocele. For these cases, there is a method of assessing the rectocele in an x-ray study called a defecography. This study shows how large the rectocele is and if it empties with evacuation.
When should a rectocele be treated?
You should consider having your rectocele treated when it causes significant symptoms. It takes an experienced doctor to help you decide whether your symptoms are caused by a rectocele. If there are multiple abnormalities present, it may be best to address them all at once as this will result in the best chance for improvement.
What treatment is available for a rectocele?
Rectoceles that are not causing symptoms do not need to be treated. In general, you should avoid constipation by eating a high fiber diet and drinking plenty of fluids.
A bowel management program is the best first step. This includes a diet high in fiber and 6 to 8 glasses of fluids each day. Fiber acts like a sponge. It soaks up fluid so that less is removed as the stool travels around the colon. The stools will be larger, softer and easier to pass. You may wish to add a fiber supplement and/or a stool softener to this regimen to improve stool consistency. Most fiber supplements are made of psyllium, a seed product, or of a hydrophilic colloid (gel) that absorbs water. Most stool softeners are composed of docusate. This helps to smooth and lubricate the stool. Active laxatives are best avoided in most cases.
Avoid prolonged straining. If you cannot completely empty, get up and return later. Holding pressure with a finger to support the rectocele and encourage the stool to go in the correct direction is often helpful. This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina. Avoid placing a finger inside the anus to pull the stool out as this may cause harm. A pessary may be used to support the pelvic organs, although this is more for older patients. It is a ring that is inserted into the vagina and must be individually fit to each woman.
If symptoms persist even with medical therapy, then surgical repair may be indicated. For younger patients with these symptoms, surgery is preferred as they will tend to have worsening issues over time without repair. There are several surgical techniques used to repair a rectocele. The most successful and minimally invasive approach, which is used in this office, is via the vaginal opening with some biologic (slowly absorbing) mesh. If there are other issues and a complex pelvic floor prolaps, then your doctor may refer you to a urogynocologist to do a more extensive repair if indicated.
Who should treat me for this problem?
Both colorectal surgeons and gynecologists are trained to deal with these problems. If the symptoms are entirely vaginal, then it is appropriate for your gynecologist to address the problem. If your symptoms are rectal, then a colorectal surgeon should be involved. If there is any question, seek opinions from physicians of both specialties. If there is a known associated cystocele then often the urogynecologist is the best option for a good repair. Our physicians are happy to assist in defining the scope of the issue and appropriately intervene for the patient.