Rectocoele

Rectocele - Comprehensive overview covers symptoms, complications and possible treatment, including surgical repair. Definition

A rectocele occurs when the fascia - a wall of fibrous tissue separating the rectum from the vagina - becomes weakened, allowing the front wall of the rectum to bulge into the vagina.

Childbirth and other processes that put pressure on the fascia can lead to a rectocele. Generally, rectoceles occur after menopause, when estrogen - which helps keep your pelvic tissues strong - decreases.

A small rectocele may cause no signs or symptoms. If a rectocele is large, it may create a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it's rarely painful.

Illustration showing normal rectum and rectocele

When treatment of a rectocele is necessary, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.

Symptoms

A small, mild rectocele may cause no signs or symptoms. Otherwise, you may notice:

  • A soft bulge of tissue in your vagina that may or may not protrude through the vaginal opening
  • Difficulty having a bowel movement
  • The need to press your fingers on the bulge in your vagina to help push stool out during a bowel movement
  • Sensation of rectal pressure or fullness
  • A feeling that the rectum has not completely emptied after a bowel movement
  • Difficulty controlling the passage of stool

Many women with a rectocele also experience related conditions, such as:

  • Cystocele, when the bladder bulges into your vagina
  • Enterocele, when the small intestines push down into your vagina
  • Uterine prolapse, when the uterus descends into your vagina

A rectocele occurs when the connective tissue that separates a woman's rectum from her vagina weakens, allowing the front wall of the rectum to bulge into the vagina.

Pregnancy and delivery are the most common causes of rectoceles. This is because the muscles, ligaments and fascia that hold and support your vagina become stretched and weakened during pregnancy, labor and delivery. As a result, the more pregnancies you have, the greater chance you have of developing a rectocele.

Not everyone who has delivered a baby develops a rectocele. Some women have very strong supporting muscles, ligaments and fascia in the pelvis and may never have a problem. Women who have only Caesarean deliveries are less likely to develop a rectocele.

Other conditions and activities that can put pressure on the pelvic floor and cause a rectocele include:

  • Chronic constipation or straining with bowel movements
  • Chronic cough or bronchitis
  • Repeated heavy lifting
  • Being overweight or obese

Risk factors

The following factors may increase your risk of experiencing a rectocele:

  • Genetics. Some women are born with weaker connective tissues in their pelvic area, making them naturally more susceptible to rectoceles. Others are born with stronger connective tissues.
  • Childbirth. If you have vaginally delivered multiple children, you have a higher risk of developing a rectocele. If you've had tears in the tissue between the vaginal opening and anus (perineal tears) and incisions that extend the opening of the vagina (episiotomies) during childbirth, you also may be at higher risk.
  • Aging. Your risk of experiencing a rectocele increases as you age because you naturally lose muscle mass, elasticity and nerve function as you grow older, causing muscles to stretch or weaken.
  • Having a hysterectomy. Having your uterus removed may contribute to weakness in the muscles, ligaments and fascia surrounding your vagina.
  • Obesity. Although the reasons aren't entirely clear, a high body mass index is linked to an increased risk of rectocele. This may be due to the chronic stress that excess body weight places on pelvic floor muscles.

When to seek medical advice

When a rectocele is small, you don't need medical care. In fact, in mild cases, you may not even know you have a rectocele.

In moderate or severe cases, however, rectoceles can be bothersome, uncomfortable and, in a few cases, painful. Make an appointment with your doctor if you experience:

  • A soft bulge of tissue that protrudes from within your vagina through your vaginal opening
  • Rectal pain or bleeding
  • A feeling of fullness or pressure in your rectum
  • Difficulty emptying your rectum
  • Chronic constipation

Tests and diagnosis

In most cases, your doctor can confirm a diagnosis by physical examination of the vagina and rectum.

During the exam, your doctor may ask you to bear down as if having a bowel movement. This may cause the rectocele to bulge, so your doctor can assess its size and location. To check the strength of your pelvic muscles, you may also be instructed to contract them, as if you are stopping the stream of urine.

If anything found during the physical exam seems unrelated to your symptoms, your doctor may want you to undergo an imaging test, such as magnetic resonance imaging (MRI) or an X-ray exam, to determine the size of the rectocele and how efficiently your rectum empties (defecography). Otherwise, imaging tests are rarely needed to diagnose a rectocele.

Treatments and drugs

Treatment depends on the severity of the rectocele. If your case is mild - with few or no obvious symptoms - you may need no treatment or find that simple self-care measures work well, such as performing exercises called Kegels to strengthen your pelvic area muscles.

If these measures fail to help, your doctor may recommend:

  • Pessary. A vaginal pessary is a plastic or rubber ring inserted in the vagina to support the bulging tissues. Several types of pessaries are available, including some you can remove to clean, and others your doctor must remove periodically to clean. Because they have a high "hassle factor," many women choose not to use this method.
  • Surgery. If the rectocele protrudes outside your vagina and is especially bothersome, you may opt for surgery. More commonly, your doctor may suggest surgery if the rectocele accompanies another condition, such as a cystocele, an enterocele or uterine prolapse. In these cases, surgical repair for each condition can be completed at the same time.

    Surgery usually consists of repairing the weakness in the connective tissue between your rectum and vagina. In most cases, this is done by reinforcing the tissue with stitches. Occasionally, surgery may involve using a mesh patch to support and strengthen the wall between the rectum and vagina.

Prevention

You may be able to prevent a rectocele by:

  • Doing exercises called Kegels that are designed to strengthen your pelvic floor muscles. This is especially important after you have a baby.
  • Treating and preventing constipation. The best approach is to drink plenty of fluids and eat high-fiber foods.
  • Treating a chronic cough.
  • Not smoking, because many smokers eventually develop a chronic cough.
  • Maintaining a healthy weight. Talk to your doctor to determine your ideal weight.

Lifestyle and home remedies

Depending on the severity of the condition, self-care measures may provide the relief you need.

Self-care measures you can take:

  • Perform Kegel exercises.
  • Avoid constipation by eating high-fiber foods and drinking plenty of fluids.
  • Avoid heavy lifting.
  • Try to control coughing.
  • Lose weight if you're overweight or obese.

Kegel exercises
Kegel exercises, designed to strengthen your pelvic floor muscles (including your fascia), can help both prevent and treat a rectocele. To perform Kegel exercises:

  • Pull in your pelvic floor muscles - the muscles you use to stop urinating.
  • Hold them for a count of five and then relax for a count of five.
  • Work up to 10 to 15 repetitions at a time.
  • Repeat three times daily.

Kegel exercises may be most successful when they're taught by a therapist using biofeedback. Biofeedback uses information from a variety of (pain-free) monitoring devices to help teach you to control certain involuntary body responses, such as muscle tension. In this case, biofeedback can help ensure you're contracting the proper muscles, and that the intensity and duration of the muscle contractions are optimal.