WHAT IS A RECTOCELE?
It is a condition in which the front wall of the rectum protrudes into the vagina. This condition is due to the weakening of the front wall of the rectum in the area adjacent to the vagina, making it thinner and weaker. This results in the formation of a true "sac" in which feces can accumulate during and after defecation. Between the rectum and the vagina, there is a thin recess called the recto-vaginal space. If the pressure in the rectum increases, for example, due to excessive straining during evacuation, this space enlarges to the point of forming a true sac. Depending on the size of the rectocele, the patient may notice the appearance of swelling in the posterior region of the vagina.
Other organs can exert pressure on the vagina: if it's the bladder, it's referred to as "cystocele," and the swelling is evident on the anterior wall of the vagina. The intestine itself can also exert pressure on the vaginal walls, which is known as "enterocele." In men, rectocele is much less common than in women and is mainly posterior. It's important to note that rectocele is very common and almost always present in all women after the age of 40, especially if they have had pregnancies. However, most rectocele patients are asymptomatic. After the age of 45-50, rectocele, cystocele, enterocele, and rectal prolapse can be associated, resulting in a particular clinical condition called "descending perineum syndrome" in which symptoms related to defecation (constipation or incontinence), urination (urinary incontinence), and sexual function (dyspareunia, vaginismus) can coexist.
WHAT ARE THE CAUSES OF RECTOCELE?
The main cause of rectocele is the weakening of the muscle layer in the rectal area behind the vagina (recto-vaginal space). A concomitant weakening of the pelvic support structures has also been demonstrated. Certain factors can increase the risk of rectocele formation, such as childbirth traumas (use of forceps, extensive episiotomies, difficulty in fetal expulsion), chronic constipation with difficulty in fecal expulsion, and the consequences of hysterectomy (surgical removal of the uterus). Usually, these issues appear in women over 50 years of age, but occasionally, they can occur in young nulliparous women (who have never given birth).
WHAT ARE THE SYMPTOMS OF RECTOCELE?
As mentioned earlier, rectocele is very common, but only in some women does it lead to the development of symptoms that can be vaginal or rectal in nature. Among vaginal symptoms, the most frequent is the presence of a bulge on the posterior wall of the vagina with a sensation of a mass in the vagina itself. Vaginal pain is less common but can occur during sexual intercourse (dyspareunia). Rectal symptoms are more common and include difficulty with evacuation, significant straining during defecation, a sense of incomplete evacuation, and/or incomplete and fragmented emptying. The sensation of incomplete emptying is due to the fact that feces become "trapped" in the rectocele and cannot continue their descent for expulsion.
Many women resort to using their hands to facilitate rectal emptying: by pressing on the swelling in the vagina with their fingers, the patient aids in the emptying of trapped feces in the rectocele. Sometimes they must insert a finger through the anus to aid in evacuation (digitization). These intimate symptoms are rarely communicated to the specialist by the patient. Therefore, it is essential that the specialist be very tactful in taking the medical history. Patients are often forced to resort to frequent enemas or excessive use of laxatives. This symptom picture represents the "Obstructed Defecation Syndrome": some symptoms (such as the "sense of a plug," excessive straining during defecation, anal bleeding, hemorrhoid prolapse) are due to the concomitant presence of rectal prolapse, as mentioned earlier.
HOW IS THE DIAGNOSIS OF RECTOCELE MADE?
Diagnosis of rectocele can be made through rectal and vaginal examination. However, if symptomatic, the rectocele should be "measured," and any concomitant pathologies, such as rectal prolapse, cystocele, enterocele, or others, should be investigated. Therefore, a defecography is essential, which, in addition to studying the rectum, includes the study of the bladder, vagina, and small intestine (colpocystoenterodefecography). Another important examination is the MRI defecography, which is a defecographic study using Magnetic Resonance Imaging. The results of these examinations are very important as they provide useful information for deciding the type of therapy to be performed.
HOW IS RECTOCELE TREATED?
It's essential to emphasize that rectocele should be treated only if symptomatic. Many women have large rectoceles without any symptoms, while others have significant symptoms with small rectoceles. Therefore, a comprehensive assessment of the entire pelvic floor, thorough medical history, and a good doctor-patient relationship are essential. Medical treatment should always be attempted. Dietary changes to prevent constipation and hard stools should always be recommended. The diet should be rich in fiber and fluids (consumption of 1.5 to 2 liters of water per day). Fiber promotes the formation of soft stools and regulates bowel transit. To facilitate the production of soft stools, mucilages such as Psyllium or stool softeners that absorb water can be used. Another important measure is to avoid excessive straining during evacuation and prolonged time spent on the toilet.
If a sense of incomplete evacuation is felt, it is preferable to use the bathroom multiple times rather than persist in excessive and prolonged efforts. The use of prokinetic laxatives is not recommended as, in the long run, they can damage the nervous and muscular structures of the intestine, leading to sometimes irreparable damage. Surgical treatment, once only within the purview of gynecology, is reserved for cases in which medical and physical therapy fails. Over the years, many surgical techniques have been proposed to repair rectocele, either transvaginally, transrectally, or transperineally. When rectocele is associated with other pathologies such as cystocele, enterocele, or rectal prolapse, surgical procedures with abdominal or transrectal approaches can be used. When rectocele is associated with rectal prolapse in obstructed defecation syndrome, transanal surgical procedures are more commonly performed (see transanal procedures described in the "rectal prolapse" chapter).
For more information, please refer to the website www.siucp.org.
It is a condition in which the front wall of the rectum protrudes into the vagina. This condition is due to the weakening of the front wall of the rectum in the area adjacent to the vagina, making it thinner and weaker. This results in the formation of a true "sac" in which feces can accumulate during and after defecation. Between the rectum and the vagina, there is a thin recess called the recto-vaginal space. If the pressure in the rectum increases, for example, due to excessive straining during evacuation, this space enlarges to the point of forming a true sac. Depending on the size of the rectocele, the patient may notice the appearance of swelling in the posterior region of the vagina.
Other organs can exert pressure on the vagina: if it's the bladder, it's referred to as "cystocele," and the swelling is evident on the anterior wall of the vagina. The intestine itself can also exert pressure on the vaginal walls, which is known as "enterocele." In men, rectocele is much less common than in women and is mainly posterior. It's important to note that rectocele is very common and almost always present in all women after the age of 40, especially if they have had pregnancies. However, most rectocele patients are asymptomatic. After the age of 45-50, rectocele, cystocele, enterocele, and rectal prolapse can be associated, resulting in a particular clinical condition called "descending perineum syndrome" in which symptoms related to defecation (constipation or incontinence), urination (urinary incontinence), and sexual function (dyspareunia, vaginismus) can coexist.
WHAT ARE THE CAUSES OF RECTOCELE?
The main cause of rectocele is the weakening of the muscle layer in the rectal area behind the vagina (recto-vaginal space). A concomitant weakening of the pelvic support structures has also been demonstrated. Certain factors can increase the risk of rectocele formation, such as childbirth traumas (use of forceps, extensive episiotomies, difficulty in fetal expulsion), chronic constipation with difficulty in fecal expulsion, and the consequences of hysterectomy (surgical removal of the uterus). Usually, these issues appear in women over 50 years of age, but occasionally, they can occur in young nulliparous women (who have never given birth).
WHAT ARE THE SYMPTOMS OF RECTOCELE?
As mentioned earlier, rectocele is very common, but only in some women does it lead to the development of symptoms that can be vaginal or rectal in nature. Among vaginal symptoms, the most frequent is the presence of a bulge on the posterior wall of the vagina with a sensation of a mass in the vagina itself. Vaginal pain is less common but can occur during sexual intercourse (dyspareunia). Rectal symptoms are more common and include difficulty with evacuation, significant straining during defecation, a sense of incomplete evacuation, and/or incomplete and fragmented emptying. The sensation of incomplete emptying is due to the fact that feces become "trapped" in the rectocele and cannot continue their descent for expulsion.
Many women resort to using their hands to facilitate rectal emptying: by pressing on the swelling in the vagina with their fingers, the patient aids in the emptying of trapped feces in the rectocele. Sometimes they must insert a finger through the anus to aid in evacuation (digitization). These intimate symptoms are rarely communicated to the specialist by the patient. Therefore, it is essential that the specialist be very tactful in taking the medical history. Patients are often forced to resort to frequent enemas or excessive use of laxatives. This symptom picture represents the "Obstructed Defecation Syndrome": some symptoms (such as the "sense of a plug," excessive straining during defecation, anal bleeding, hemorrhoid prolapse) are due to the concomitant presence of rectal prolapse, as mentioned earlier.
HOW IS THE DIAGNOSIS OF RECTOCELE MADE?
Diagnosis of rectocele can be made through rectal and vaginal examination. However, if symptomatic, the rectocele should be "measured," and any concomitant pathologies, such as rectal prolapse, cystocele, enterocele, or others, should be investigated. Therefore, a defecography is essential, which, in addition to studying the rectum, includes the study of the bladder, vagina, and small intestine (colpocystoenterodefecography). Another important examination is the MRI defecography, which is a defecographic study using Magnetic Resonance Imaging. The results of these examinations are very important as they provide useful information for deciding the type of therapy to be performed.
HOW IS RECTOCELE TREATED?
It's essential to emphasize that rectocele should be treated only if symptomatic. Many women have large rectoceles without any symptoms, while others have significant symptoms with small rectoceles. Therefore, a comprehensive assessment of the entire pelvic floor, thorough medical history, and a good doctor-patient relationship are essential. Medical treatment should always be attempted. Dietary changes to prevent constipation and hard stools should always be recommended. The diet should be rich in fiber and fluids (consumption of 1.5 to 2 liters of water per day). Fiber promotes the formation of soft stools and regulates bowel transit. To facilitate the production of soft stools, mucilages such as Psyllium or stool softeners that absorb water can be used. Another important measure is to avoid excessive straining during evacuation and prolonged time spent on the toilet.
If a sense of incomplete evacuation is felt, it is preferable to use the bathroom multiple times rather than persist in excessive and prolonged efforts. The use of prokinetic laxatives is not recommended as, in the long run, they can damage the nervous and muscular structures of the intestine, leading to sometimes irreparable damage. Surgical treatment, once only within the purview of gynecology, is reserved for cases in which medical and physical therapy fails. Over the years, many surgical techniques have been proposed to repair rectocele, either transvaginally, transrectally, or transperineally. When rectocele is associated with other pathologies such as cystocele, enterocele, or rectal prolapse, surgical procedures with abdominal or transrectal approaches can be used. When rectocele is associated with rectal prolapse in obstructed defecation syndrome, transanal surgical procedures are more commonly performed (see transanal procedures described in the "rectal prolapse" chapter).
For more information, please refer to the website www.siucp.org.