Rectocele

In gynecology, a rectocele (Template:IPAc-en Template:Respell) or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina.<ref name=":0">Template:Cite journal</ref> Two common causes of this defect are childbirth and hysterectomy.<ref name=gloqm>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.<ref name=":0" />

Although the term applies most often to this condition in females, males can also develop it. Rectoceles in men are uncommon, and associated with prostatectomy.

Signs and symptoms

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Large rectocele.

Mild cases may simply produce a sense of pressure or protrusion within the vagina, and the occasional feeling that the rectum has not been completely emptied after a bowel movement. Moderate cases may involve difficulty passing stool (because the attempt to evacuate pushes the stool into the rectocele instead of out through the anus), discomfort or pain during evacuation or intercourse, constipation, and a general sensation that something is "falling down" or "falling out" within the pelvis. Severe cases may cause vaginal bleeding, intermittent fecal incontinence, or even the prolapse of the bulge through the mouth of the vagina, or rectal prolapse through the anus. Digital evacuation, or, manual pushing, on the posterior wall of the vagina helps to aid in bowel movement in a majority of cases of rectocele. Rectocele can be a cause of symptoms of obstructed defecation.<ref name=Coloproctology>Template:Cite book</ref>

Causes

Rectoceles result from the weakening of the pelvic floor also called pelvic organ prolapse. Weakened pelvic structures occur as a result of an episiotomy during previous births, even decades later. Other causes of pelvic floor prolapse can be advanced age, multiple vaginal deliveries, and birthing trauma. Birthing trauma includes vacuum delivery, forceps delivery, and perineal tear.  In addition, a history of chronic constipation and excessive straining with bowel movements are thought to play a role in rectocele.  Multiple gynecological or rectal surgeries can also lead to weakening of the pelvic floor.<ref name="gloqm" /> Births that involve babies over nine pounds in weight, or rapid births can contribute to the development of rectocele.Template:Medical citation needed

A hysterectomy or other pelvic surgery can be a cause,<ref name="titleRectocele: Risk factors - MayoClinic.com">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> as can chronic constipation and straining to pass bowel movements. It is more common in older women than in younger ones because estrogen which helps to keep the pelvic tissues elastic decreases after menopause.Template:Medical citation needed

Diagnosis

The diagnosis of a rectocele primarily occurs with a physical examination and an interview where symptoms of difficulty defecating are reported.  Women often mention the need to insert a finger in the vagina or use of suppositories and/or enemas to aid in having a bowel movement. They may report that strenuous pushing to defecate causes bleeding and pain.  Surveys about the impact on quality of life may be administered to aid in determining the need for treatment.<ref name=":1">Template:Cite journal</ref>

A pelvic exam and digital rectal exam are done to evaluate the amount of protrusion and anal sphincter tone.<ref name=":1" /> Fluoroscopic defecography (FD), evacuation proctography, or dynamic magnetic resonance imaging (MR defecography, MRD) may be used to evaluate functional and anatomic conditions.<ref>Template:Cite journal</ref>

Treatment

Non-surgical

Treatment depends on the severity of the problem, and may include non-surgical methods such as changes in diet (increase in fiber and water intake), pelvic floor exercises such as Kegel exercises, use of stool softeners, hormone replacement therapy for post-menopausal women and insertion of a pessary into the vagina. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms.<ref>Template:Cite journal</ref> A high fiber diet, consisting of 25–30 grams of fiber daily, as well as increased water intake (typically 6–8 glasses daily), help to avoid constipation and straining with bowel movements, and can relieve symptoms of rectocele.<ref name=Speranza2012>Rectocele Template:Webarchive, by Jennifer Speranza, MD at American Society of Colorectal Surgeons. Reviewed 2012</ref><ref>Template:Cite news</ref>

Surgical

Surgery can be done to correct rectocele when symptoms continue despite the use of non-surgical management, and are significant enough to interfere with activities of daily living.<ref name=Speranza2012/>

Surgery to correct the rectocele may involve the reattachment of the muscles that previously supported the pelvic floor.<ref name=":0" /> Another procedure is posterior colporrhaphy, which involves suturing of vaginal tissue. Surgery may also involve insertion of a supporting mesh (that is, a patch).<ref name="Speranza2012" /> There are also surgical techniques directed at repairing or strengthening the rectovaginal septum, rather than simple excision or plication of vaginal skin which provides no support. Both gynecologists and colorectal surgeons can address this problem.<ref name="Speranza2012" /> Potential complications of surgical correction of a rectocele include bleeding, infection, dyspareunia (pain during intercourse), as well as recurrence or even worsening of the rectocele symptoms.<ref name="Speranza2012" /> The use of synthetic or biologic grafts has been questioned.<ref name="AUSFive">Template:Citation, which cites:

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External links

• Rectocele details, description, video (in Russia)