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, including 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, obesity, 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 who have not delivered children.

Many women have rectoceles but only a small percentage of women have symptoms related to the rectocele. 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 and 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. A general feeling of pelvic pressure or discomfort is often present, but this may be due to a variety of problems.

Most rectoceles may be identified on a routine office examination of the vagina and rectum. However, It may be difficult to assess the size and significance of the rectocele. A more accurate method of assessing the rectocele is an X-ray study called a defecogram. This study shows how large the rectocele is and if it empties with evacuation.

You should consider having a 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.

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 six to eight glasses of fluids each day. Fiber acts like a sponge, soaking up fluid so that stool is softer, travels more easily through the colon and is easier to pass. You may wish to add a fiber supplement and/or a stool softener 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 (a ring-like appliance inserted into the vagina) may be used to support the pelvic organs.

If symptoms persist even with medical therapy, then surgical repair may be indicated. There are several surgical techniques to repair a rectocele. A rectocele repair may be performed through the anus, through the vagina, through the perineum between the anus and vagina, or through the abdomen. When there Is extensive pelvic relaxation and prolapse, the best approach may be a combined repair.

Both colorectal surgeons and gynecologists are trained to deal with rectocele and similar problems. If the symptoms are entirely vaginal, it is appropriate for your gynecologist to address the problem. If your symptoms are rectal, a colorectal surgeon should be involved. If there is any question, seek opinions from physicians of both specialties.