Rectocele

A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina that may interfere with emptying of stool from the rectum. The rectum is the bottom section of your colon (large intestine). The vagina and the rectum can be thought of as two muscular tubes running parallel to each other and sharing a common muscular wall between them – the back wall of the vagina and the front wall of the rectum together make up what is called the “rectovaginal septum”.  A rectocele occurs when the rectovaginal septum becomes weak and the rectum bulges forwards into the vagina. 

CAUSES

Rectoceles are usually caused by thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. There are many things that can lead to weakening of the pelvic floor, including:

• Vaginal deliveries
• Trauma from vaginal delivery (e.g. the use of forceps or vacuum during delivery, tearing or episiotomy, which is a surgical cut in the muscular area between the vagina and the anus made just before delivery)
• History of constipation
• Chronic straining with bowel movements
• Gynecological (e.g. hysterectomy) or rectal surgeries

SYMPTOMS

Most people with a small rectocele do not have symptoms. When the rectocele is large, there is usually a noticeable bulge into the vagina.

Rectal Symptoms

• Difficulty having a complete bowel movement
• Stool getting stuck in the bulge of the rectum
• The need to press against the vagina and/or space between the rectum and the vagina to have a bowel movement
• Straining with bowel movements
• The urge to have multiple bowel movements throughout the day
• Constipation
• Rectal pain

Vaginal Symptoms

• Pain with sexual intercourse (dyspareunia)
• Vaginal bleeding
• A sense of fullness in the vagina

DIAGNOSIS

Colon and rectal surgeons as well as gynecologists are trained in the diagnosis and treatment of this condition. A rectocele is often found during a routine physical examination. However, other tests may be needed to help evaluate its severity or possible connection to symptoms. The following test may be ordered to confirm the diagnosis.

• Defecography: A special X-ray or MRI test that shows the rectum and anal canal as they change during defecation. This study is very specific and can pinpoint the size of the rectocele and the degree to which the rectum is emptied. 

TREATMENT METHODS

Rectocele treatment is needed only when they cause symptoms that interfere with daily living. Before any treatment, your physician will assess whether all your symptoms are related solely to the rectocele. There are nonsurgical and surgical treatment options for rectoceles. Most symptoms associated with a rectocele can be resolved with nonsurgical treatment, however, this depends on the severity of symptoms.

NONSURGICAL TREATMENT

The goal is to have good daily bowel habits and softer stools. Avoiding constipation and straining with bowel movements will reduce the risk of a bulge associated with a rectocele.

Preventive and Medical Tips

• Eating a high-fiber diet and taking over-the-counter fiber supplements (25-35 grams of fiber/day)
• Drinking more water (typically 6-8 glasses daily)
• Avoiding excessive straining with bowel movements
• Applying pressure to the back of the vagina during bowel movements
• Pelvic floor exercises such as Kegel
• Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction
• Stool softeners
• Hormone replacement therapy

SURGICAL TREATMENT

The surgical management of rectoceles should only be considered when nonsurgical methods have not resolved or improved symptoms and the condition interferes with daily living. This can be done through abdominal, perineal, rectal or vaginal surgery. The choice of procedure depends on the size of the rectocele and its symptoms. The goal of surgery is:

• To reduce the bulge caused by the rectocele
• To strengthen the wall between the rectum and vagina with surrounding tissue or use of a mesh patch

Colorectal surgeons, gynecologists and urogynecologists are trained in the diagnosis and treatment of this condition.  These trained physicians can perform surgeries to attempt repair of a rectocele. 

There are multiple ways to approach the surgery including: transanally (through the anus), through the perineum (the space between the anus and vagina), and through the vagina.  All of these aim to remove the extra tissue that makes up the rectocele and reinforce the rectovaginal septum (the tissue between the rectum and the vagina).  This can be done by plication (stitching the tissue together).  Occasionally, mesh (a prosthetic material or patch) can be used to reinforce the repair. A rectocele can also be repaired through the abdomen, either laparoscopically, robotically or open. The approach will depend on the size of the rectocele and the symptoms associated with the rectocele.

POSTSURGERY PROGNOSIS

The success rate of surgery depends on the specific symptoms and their duration. Risks of surgical correction include bleeding, infection and pain during intercourse (dyspareunia). There is also the chance of the rectocele recurring or worsening as well as a formation of a rectovaginal fistula (communication between the rectum and the vagina).

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum, and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum, and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.