Rectocele

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina. Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The degree of severity varies; for example, in mild cases the rectocele may be felt as a small bulge high inside the vagina while, in severe cases, the bulge may be hanging outside of the vagina. Milder cases can be treated by measures such as management of constipation, Kegel exercises to strengthen the pelvic floor and the insertion of a vaginal pessary to prop up the pelvic organs. Surgery may be needed in severe cases.

Symptoms of rectocele

The symptoms of rectocele may be vaginal, rectal or both, and can include:

• A sensation of pressure within the pelvis
• The feeling that something is falling down or falling out within the pelvis
• Symptoms worsened by standing up and eased by lying down
• Lower-abdominal pain
• Lower-back pain
• A bulging mass felt inside the vagina
• Vaginal bleeding that’s not related to the menstrual cycle
• Painful or impossible vaginal intercourse
• Constipation
• Problems with passing a bowel motion, since the stool becomes caught in the rectocele
• The feeling that the bowel isn’t completely empty after passing a motion
• Faecal incontinence (sometimes).

The rectovaginal septum and rectocele

Our pelvic organs are supported by our pelvic floor muscles. Structures including ligaments and connective tissue help to keep the pelvic organs tethered in place.

In women, the front wall of the rectum is situated behind the rear wall of the vagina. The front wall of the rectum and rear wall of the vagina, and the thin layer of tissue between them, are together called the rectovaginal septum (or wall). This wall can become weak or stretched by pressure such as childbirth, straining while going to the toilet, or ageing. A weak or thinned rectovaginal septum allows the front wall of the rectum to bulge into the vagina.

Causes of rectocele

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:

• Vaginal (normal) childbirth
• Giving birth to multiple babies
• A long and difficult labour
• Assisted delivery during childbirth, including the use of forceps
• Tearing during childbirth, particularly if the tear extended from the vagina to the anus
• Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and baby), particularly if the cut extends to the anus
• Hysterectomy
• Pelvic surgery
• Chronic constipation
• Straining to pass bowel motions
• Advancing age, as older women are more prone to rectocele.

Rectocele and related problems

A rectocele sometimes occurs by itself. In other cases, the woman may also have other problems including:

• Cystocele – the bladder protrudes into the vagina
• Enterocele – the small intestines push down into the vagina
• Uterine prolapse – the cervix and uterus drop down into the vagina and may protrude out of the vaginal opening
• Vaginal prolapse – in cases of severe uterine prolapse, the vagina may slide out of the body too
• Rectal prolapse – the rectum protrudes through the anus.

Diagnosis of rectocele

A doctor can diagnose rectocele by using a number of tests including:

• Pelvic examination
• Special x-ray (proctogram or defaecagram).

Treatment for rectocele

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:

• High-fibre diet
• Fibre supplements
• At least six to eight glasses of water per day
• Stool softeners (don’t use laxatives)
• Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a finger against the rear wall of the vagina while toileting
• Don’t strain on the toilet
• Hormone replacement therapy for postmenopausal women
• Pelvic floor (‘Kegel’) exercises
• Insertion of a pessary – a ring-like device worn high in the vagina that helps to support the pelvic organs.

Surgery for rectocele

Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms. Depending on individual factors, such as the severity of the rectocele and the presence of other prolapsed structures, the operation can be performed in different ways, including:

• Through the vagina
• Through the anus
• Through the area between the vagina and anus (perineum)
• Through the abdomen
• In some cases, a combination of surgical techniques may be necessary.

The aim of surgery is to repair and strengthen the wall between the vagina and rectum. Procedures for vaginal repair include:

• One or more incisions are made along the back wall of the vagina to expose the underlying structures.
• Weakened pelvic floor muscles around the vagina and rectum are strengthened with absorbable stitches.
• The wall is repaired using absorbable stitches.
• Sometimes, the perineum (area between the vagina and anus) needs to be repaired at the same time, with deep stitches into the muscle.
• If the vagina has been stretched (from childbirth, for example), the excess tissue may be removed.
• The vaginal incisions are stitched closed.
• The vagina is packed with gauze.
• A urinary catheter is inserted to allow urine to drain from the bladder.

Immediately after surgery for a rectocele

After your operation for a rectocele, things you can expect include:

• Hospital staff will observe and note your temperature, pulse, breathing and blood pressure.
• You will have an intravenous fluid line in your arm to replace fluids in your body.
• You will receive pain-relieving medications. Tell your nurse if you need more pain relief.
• You may have a catheter to drain off urine for the next day or so, or until you can empty your bladder by yourself.
• If you have a vaginal pack, this will be taken out later the same day or the day after surgery.
• You may be in hospital for three to six days following surgery.
• You will need to make follow-up appointments with your doctor.

Complications of surgery for a rectocele

Possible complications of surgery include:

• Allergic reaction to the anaesthetic
• Haemorrhage
• Infection
• Injury to nearby nerves or blood vessels
• Damage to other pelvic organs, such as the bladder or rectum
• Death (necrosis) of the rectal wall
• Recurrence of the rectal prolapse.

Taking care of yourself at home after surgery for a rectocele

Be guided by your doctor, but general suggestions include:

• Rest as much as you can.
• Avoid heavy lifting or straining for a few weeks.
• Don’t strain on the toilet.
• Take measures to prevent constipation, such as eating high-fibre foods and drinking plenty of water.
• After rectocele surgery, expect bloody vaginal discharge for about four weeks.
• Contact your doctor if you experience any unusual symptoms, such as difficulties with urination, heavy bleeding, fever, or signs of infection around the wound sites.
• You can expect to return to work around six weeks after surgery.
• Attend follow-up appointments with your surgeon.

Where to get help

• Your doctor
• Gynaecologist
• Colorectal or general surgeon

Things to remember

• Some of the causes of a rectocele include vaginal childbirth, hysterectomy, pelvic surgery and chronic constipation.
• A rectocele may occur by itself or present alongside other pelvic abnormalities, such as a prolapsed bladder (cystocele).
• Surgery may be needed if the rectocele doesn’t respond to simpler treatments.