Rectocele

What is Rectocele?

Rectocele is a type of condition known as pelvic organ prolapse (POP), where the rectum, part of your digestive system, pushes through an area of the vagina, creating a bulge. To understand how this happens, it’s helpful to know a little about the anatomy of the area.

The vagina starts at the hymen and ends at the cervix. The bladder lies in front of the vagina, and the rectum is situated behind it. The vagina is held in place by support at three levels. At the top, it’s supported by ligaments attached to the uterus. In the middle, it’s supported by muscles in the pelvis, and towards the bottom, it is held in place by tissue known as endopelvic fascia. The wall of the vagina is made up of several layers of different types of tissue.

An area called the rectovaginal septum attaches to the endopelvic fascia near an area called the perineal body. When the tissue connecting these areas weakens, the rectum can herniate, or push into the vagina, creating a bulge along the back of the vaginal wall. This can be more noticeable with efforts like straining or coughing.

These protrusions also might be connected to enteroceles, a condition where the bowel pushes into the vaginal area if the connective tissue separating them becomes detached. This type of pelvic organ prolapse is found in two-thirds of women who have given birth. But not every woman with a rectocele will have symptoms. As the hernia grows larger over time, it can cause symptoms like a visible vaginal bulge, difficulties with bowel movements, constipation, and a feeling of pressure in the area between the vagina and rectum. If the bulge grows large enough, it can protrude outside the vagina which can risk skin irritation and bleeding.

Treatment for this condition depends on how severe the prolapse is and how bad the symptoms are. This could range from changes in lifestyle, medication, non-surgical devices to hold the organs in place, or in serious instances, surgery.

What Causes Rectocele?

The back wall of the vagina is held in place by different structures: one is a complex of ligaments connected to the uterus at the top, another is a set of muscles in the middle, and, finally, a sheet of tissue called the endopelvic fascia at the bottom. Between the vagina and the rectum, there is a dividing layer known as the rectovaginal septum, which is also connected to the endopelvic fascia at the point where your body’s exterior meets your anus. If this separating layer weakens or breaks down, rectal tissue could bulge into the vagina and can be identified as a bulge during a medical examination.

Certain elements can contribute to the weakening of the rectovaginal septum. Some of these factors are changeable, while some are not. Some factors that can’t be changed include advanced age and your genetic makeup. However, there are other factors that you have more control over, like having many children, having had a vaginal delivery, having had surgery in the pelvic area, being overweight, being less educated, suffering from chronic constipation, and conditions that increase pressure in your belly over a long period of time like COPD or chronic coughing.

Age, body mass index (a measure of body fat based on height and weight), the number of pregnancies a woman has had, and vaginal delivery have been identified as the biggest risk factors.

Risk Factors and Frequency for Rectocele

Pelvic organ prolapse is a condition that’s hard to track because many people don’t have symptoms and don’t seek medical care. So, we don’t really know how common it is. Another reason we don’t know the number of cases is that there isn’t a unified way to classify rectoceles, a form of this condition. But we do know this – about 67% of women who have given birth will experience some form of pelvic organ prolapse. And by the age of 80, around 11.1% of women will have had surgery to fix this issue.

Signs and Symptoms of Rectocele

Rectoceles, or hernias of the rectum, can cause a variety of symptoms. For some people, there may be no noticeable symptoms, while others can experience significant discomfort, affecting their overall quality of life. Common symptoms may include:

• Pelvic pain or pressure
• Vaginal bulge at the back
• Difficulty passing stool
• Feeling of incomplete bowel movements
• Constipation
• Painful sexual intercourse
• Sores and bleeding on the inner lining of the rectum due to exposure to the outside environment

Medical examination of the condition usually involves checking the vagina, rectum, abdomen, and the level of muscle tone and contraction in the pelvic floor. This can be accomplished through various tests:

• Vaginal and rectal exams
• Abdominal exam
• Neurological exam focused on the pelvic muscles

The severity of rectocele is usually assessed through grading systems like the Baden-Walker system or the POP-Q exam. The Baden-Walker system uses a single measurement – the distance of the prolapsed part from the hymen, assigned grades from 0 to 4:

• Grade 0 – normal position
• Grade 1 – Descent halfway to the hymen
• Grade 2 – Descent to the hymen
• Grade 3 – Descent halfway past the hymen
• Grade 4 – Maximal descent past the hymen

The POP-Q system involves multiple measurements and is considered very accurate. It involves noting specific points while the patient performs a muscle-straining activity. Various points are evaluated, such as the total length of the vagina, the width of the vaginal opening, and the depth of the cervix among others. The severity of the rectocele is then determined based on the measurements at specific points, categorized into stages ranging from 0 to IV.

Testing for Rectocele

When a doctor needs to check if you have a medical condition called a rectocele, they primarily do so using a simple physical examination. In general, they don’t need to order any extra laboratory tests or X-ray based procedures.

However, a special X-ray test called defecography can be used to confirm a rectocele. In this test, a contrast medium (a substance that helps make the results clearer to see) is filled into your bladder, vagina, and rectum. You are then asked to go to the toilet while an X-ray picture is taken. This test helps your doctor see the size of the rectocele. If it is larger than 2 cm, it is often considered abnormal.

For people with rectocele who also have complicated urinary problems, another test called urodynamic studies can be valuable. This test measures how well the bladder and urethra are storing and releasing urine. It can be helpful especially if you are going to have surgery, because it helps to identify if there is any urine leaking when the rectocele is pushed back into place. If it is found, your doctor may plan to add a special surgical procedure to stop the leakage of urine.

Another useful tool is dynamic MRI (DMRI), this gives your doctor very clear images of the rectocele and shows how the pelvic floor moves. DMRI can be important when your symptoms seem more serious than what the docotor discovers during the physical examination. This imaging method is increasingly being used to plan surgery.

Treatment Options for Rectocele

The best way to treat a rectocele, or a bulging of the rectum into the vagina, depends on how severe the symptoms are. The first step is usually to make some lifestyle changes. Eating a diet high in fiber and drinking lots of fluids (preferably not counting alcohol or caffeine) can help reduce issues with constipation, which can help improve quality of life. Regularly doing Kegel exercises, which strengthen the pelvic floor muscles, can also help; some people might find it useful to work with a physiotherapist who specializes in the pelvic floor.

If lifestyle changes aren’t enough, the next step might be to use a vaginal pessary, a device that’s inserted into the vagina. It supports the pelvic floor and help manage other issues like cystocele (bladder bulging into the vagina) and prolapse of other organs. The pessary needs to be fit to each patient, as they come in many shapes and sizes. If it can’t be inserted manually, it may be done under anesthesia or might not be an option for the patient. Common side effects include vaginal discharge, bleeding, and odor. There’s little evidence on how often it should be cleaned or changed, but patients can be taught to clean the pessary themselves.

If none of these treatments work, surgery might be the next step. This is saved for people with bothersome symptoms who haven’t seen any improvement from other treatments. The point of the surgery is to fix the vaginal wall or tissue to reduce the prolapsing rectum. The best method or approach to surgery can depend on many factors like age, desire for sexual activity, how far the prolapse has progressed, and symptoms of bowel dysfunction. The methods range from vaginal, abdominal, or rectal approaches. It’s common for the surgeon to cut along the back wall of the vagina, separate the vaginal cavity from the rectovaginal septum (the tissue dividing the vagina and rectum), and then stitch up the tissue to reinforce the rectovaginal fistula (a tunnel between the vagina and rectum). Extra weak spots are often stitched up too. Recent studies suggest that using mesh to strengthen the tissue may not improve the failure rates for these surgeries.

What else can Rectocele be?

While a physical exam may help identify the condition, there are other conditions that can show similar symptoms. These include:

• Rectocele
• Rectal prolapse
• Enterocele
• Sigmoidocele

What to expect with Rectocele

Rectoceles, along with other types of pelvic organ prolapse, have a good outlook as they’re not conditions that threaten life. However, they can impact a person’s quality of life. A type of pelvic organ prolapse called Baden-Walker type I has an annual recovery rate of 22% for every 100 women per year. Baden-Walker types II and III have a slower recovery rate.

The term “parity” here refers to the number of times a woman has given birth. The more children a woman has delivered, the more likely it is for a rectocele (a herniation or bulging of the front wall of the rectum into the back wall of the vagina) to get worse over time.

Possible Complications When Diagnosed with Rectocele

Making some changes in your lifestyle and engaging in pelvic floor physical therapy are relatively safe with minimal risk of complications. On the other hand, using pessaries might slightly increase the risk of developing ulcers if not used and cared for correctly.

However, surgery carries the most significant risk of complications. Apart from the standard risks linked with surgery, such as bleeding and infection, the type of surgery and the use of a mesh can lead to other problems. For instance, the mesh can potentially damage the tissue. The most serious problem that can happen after surgery is the risk of the prolapse happening again.

Notably, studies have shown that using transvaginal mesh repair for surgery can lead to a higher possibility of needing another surgery (11%) compared to using native tissue repair (3.7%). Furthermore, posterior vaginal repairs are associated with less recurrent prolapse symptoms and a lower recurrence rate on physical examination compared to transanal repairs.

Common Side Effects:

• Minimal risk with lifestyle changes and pelvic floor physical therapy
• Slight risk of ulcers with improper pessary usage
• Standard surgical risks such as bleeding or infection
• Potential tissue damage with mesh use
• Risk of recurrent prolapse post-surgery
• Higher reoperation rate with transvaginal mesh repair
• Less recurrence with posterior vaginal repairs

Preventing Rectocele

The American Society of Colon and Rectal Surgeons (ASCRS) and the American Urogynecologic Society (AUGS) provide useful resources for patients with rectoceles, a condition where the rectum bulges into the back wall of the vagina. Both of these medical societies offer patient information sheets that doctors can use to explain the condition. ASCRS also provides educational videos on various health conditions, including pelvic floor dysfunction, which is commonly associated with rectoceles.

There is also a special tool available for doctors to use, which is designed to help illustrate and explain the severity of the rectocele to the patient. This tool allows the doctor to input the patient’s measurements, and then creates a digital model of the patient’s anatomy. Along with this tool, patient information handouts are provided, including instructions on how to care for a pessary. A pessary is a device that some patients choose to use. It works by providing support to the area, helping to manage the symptoms of their rectocele.