What is a rectocele?
A rectocele is the protrusion of the rectal wall into the vagina in front of it. A weakness in the thin wall of tissue which separates the vagina from the rectum leads to the development of a rectocele [Figure 1]. Any process that causes weakness in this part of the pelvis can lead to rectocele. Past pelvic operations, childbirth, aging, and abnormal defecation with incomplete relaxation of the pelvic muscles can lead to rectocele. It is important to note that patients with no prior childbirth can present with rectocele. Chronic constipation, increase pressure on the pelvic floor from excessive straining, heavy lifting, chronic cough, or obesity can contribute to the development of a rectocele.
Figure 1 – Protrusion of the rectum into the vagina (rectocele)
What are the symptoms of a rectocele?
While some patients with small rectocele are asymptomatic (protrusion noted on pelvic examination only), many patients present with 1 or more of the following symptoms:
- Difficulty with evacuation or incomplete evacuation with retained stool
- Finger digitation to remove residual stool inside the rectum during or after evacuation
- Manual splinting/supporting the back aspect of vagina or perineal skin in front of the anus to assist with defecation
- Pain during sexual intercourse
- Pressure, fullness, or heaviness inside the vagina
- Tissue bulge through the vaginal opening
Patients may experience other pelvic symptoms such as urine leakage or difficulty passing urine in the presence of other pelvic weakness that can affect the bladder or uterus.
How is a rectocele diagnosed?
The most important part of the evaluation is the history provided by the patient and the office-based examination performed by Dr. Maher Abbas. Visual inspection of the exterior aspect of the pelvis and anus, a brief testing of the sensation, an evaluation of the anal muscles, palpation of the rectal and vaginal wall, and Anoscopy is performed to check the inside of the anus. The diagnosis is made in the majority of patients during the initial office visit. Additional testing maybe necessary to further investigate contributing factors such as constipation, the overall status of pelvic musculature, or additional symptoms such as urinary incontinence. These tests include:
Blood tests: thyroid hormone and calcium level in cases of new onset of severe constipation
Imaging studies: an endoanal ultrasound to look at the anal muscles or alternatively an MRI scan of the pelvis to assess the anus and pelvic floor muscles. In patients with abnormal defecation, a dynamic MRI (magnetic resonance imaging) defecography to check for pelvic floor function. During this procedure, gel material is inserted into the rectum and in some cases the vagina. MRI pictures are obtained at rest and when the patient tries to defecate. This test provides the opportunity to visualize the internal pelvic organs in action. In addition to documenting the presence, size, and degree of the rectocele, other disorders such as cystocele (prolapse of the bladder), uterine prolapse, internal rectal prolapse (intussusception), enterocele (herniation of small bowel into the deep pelvis) can be documented
Procedures: Flexible sigmoidoscopy or Colonoscopy to visualize the inside of the rectum and colon. Such procedures are indicated to further investigate constipation or other gastrointestinal symptoms which maybe present such as bleeding or abdominal pain. Anorectal manometry with testing of rectal compliance and a balloon expulsion test to evaluate the anal sphincter muscle function and coordination of the pelvic floor musculature. Pudendal nerve testing and anal electromyography (EMG) can evaluate the function of the nerve supply to the anus
It is important to note that in most patients additional testing is not needed. Dr. Maher Abbas personalizes the care of each patient based on the clinical history, symptoms, and physical examination during the initial visit.
What treatment options are available for rectocele?
Most patients with rectocele can be successfully treated medically. Surgical intervention is an option for patients with severe symptoms from rectocele and those patients who do not respond to initial medical therapy. Medical treatment consists of several options including the following:
Dietary modifications. The patient is advised to maintain a diet and bowel diary for a couple of months to identify factors that exacerbate the symptoms and food products that relieve them. A review of a properly maintained diary can provide valuable information for dietary modification which can significantly control the symptoms of some patients with difficulty evacuating. Relieving Constipation with increasing dietary fiber consumption, fiber supplements, the judicious use of laxatives, and a higher fluid intake is customized based on the patient’s degree of constipation
Lifestyle modifications. Losing weight, avoidance of severe straining or bearing down, and controlling chronic cough can be helpful when present. Splinting the back aspect of the vagina or perineal skin in front of the anus is fine if done briefly and it helps with complete evacuation
The insertion of a plastic or rubber ring (vaginal pessary) into the vagina can support some of the pelvic bulge or weakness. A pessary is a good option for elderly women or those with significant medical issues who are at risk for surgical intervention
Physical therapy. Biofeedback/Kegel Exercises strengthen the anus and pelvic floor musculature. A prolonged course of daily therapy is needed for a minimum of 2 to 3 months to see a significant effect. Working with a physical therapist specialized in pelvic floor disorders is very important
- Rectal enemas or irrigation. The cleansing of the rectum with an enema or rectal irrigation can be helpful in patients with significant constipation and inability to properly evacuate
Young patients or women with significant symptoms related to the rectocele can benefit from surgical intervention. The decision of which operation to perform is based on an individual patient’s findings including the presence of other conditions such as bladder, uterus, or rectal prolapse. Dr. Maher Abbas individualizes the care of every patient. For rectocele repair, three different approaches are available: through the vagina, through the rectum, or through the perineum (the skin area between the vagina and the rectum). In some cases, an abdominal approach (laparoscopic camera surgery through the abdomen) is needed. Tissue reinforcement with a mesh patch is needed in patients with extremely weak tissues. When mesh is needed, Dr. Maher Abbas uses biologic mesh (material from human or animal sources) which incorporates well with the patient’s own tissue with minimal complications.
Why seek care with Dr. Maher Abbas?
Dr. Maher Abbas is an American Board Certified Colon and Rectal Surgeon with special interest in rectocele and pelvic floor disorders. He provides the entire spectrum of operations for rectocele.
If you would like to schedule a consultation with Dr. Maher Abbas to discuss and evaluate your condition, click here. If you have previously undergone any operation or tests related to your condition, kindly bring all outside reports for Dr. Maher Abbas to review the day of your consultation.