The normally tough, fibrous, sheet-like divider between the rectum and vagina can tear, causing a bulge to protrude as a hernia into the vagina during a bowel movement.
It is mainly caused by childbirth or a hysterectomy, but the risk can also increase with age. It is more likely to occur as a result of childbirth if the baby weighs over nine pounds, or if the birth was fast.
By the age of 50 years around half of all women have some symptoms of a pelvic organ prolapse, and by the age of 80 years, 1 in every 10 will have had surgery for a prolapse.
If the rectocele is small, the patient may not notice it. If it is large, there may be a perceptible protrusion of tissue through the vaginal opening. The woman may experience some discomfort, and, in rare cases, pain.
Normally, the patient can treat the rectocele at home. Surgery may be required in severe cases.
Males may also develop a rectocele, but it is uncommon.
A rectocele can lead to discomfort in the pelvic area.
A rectocele is one type of pelvic organ prolapse, in which the rectum bulges into the back wall of the vagina.
Other types of prolapse are:
- Anterior wall prolapse or cystocele, where the bladder bulges into the back wall of the vagina
- Uterine prolapse when the uterus hangs down into the vagina
- Vault prolapse, in which the top (or vault) of the vagina bulges down after a hysterectomy.
They can also vary according to severity.
In mild cases, the woman may notice pressure within the vagina, or she may feel that her bowels have not been completely emptied after using the bathroom.
In moderate cases, an attempt to evacuate can push the stool into the rectocele rather than out through the anus. There may be pain and discomfort during evacuation. There is a higher chance of having constipation, and some women may experience pain during sexual intercourse.
Some women say it feels as if "something is falling out" or down within the pelvis.
In severe cases, there may be vaginal bleeding, fecal incontinence, and sometimes the bulge may prolapse through the mouth of the vagina, or through the anus.
Many women have a rectocele, but only a few notice any symptoms.
The underlying cause is a weakening of the pelvic support structures and of the rectovaginal septum, which is the layer that separates the vagina from the rectum.
The most common cause is childbirth, especially if the newborn is big, weighing over nine pounds, or if the birth is rapid.
The more vaginal births a woman has had, the higher her risk. The risk is significantly lower with a cesarean delivery.
Women who have never given birth can also develop a rectocele.
The following are risk factors:
- A drop in estrogen levels at the menopause, making pelvic tissues less elastic
- A hysterectomy
- Chronic constipation
- Long-term coughing, as in chronic bronchitis
- Pelvic surgery
- Sexual abuse during childhood
- Being obese or overweight.
There may be an indirect link with hemorrhoids. In a patient who already has risk factors has chronic constipation, a forced bowel movement may increase intra-abdominal pressure and may trigger a rectocele.
Diagnosis is normally possibly after examining the vagina and rectum, but it can be hard to determine the size of the rectocele.
The patient's account of how the rectocele impacts her life may help to assess the degree of prolapse.
Occasionally, the doctor may detect something during the physical examination that requires identification through MRI imaging or an X-ray.
A defecogram is a type of X-ray study that helps the doctor determine the size of the rectocele and how well the patient is evacuating.
In mild cases, where symptoms do not cause much trouble, treatment can be through pelvic exercises, such as Kegel exercises.
A rectocele can lead to a feeling of constipation or of not emptying the bowels properly.
The patient should consume plenty of fluids and eat fiber to avoid constipation. It is important to avoid prolonged straining when defecating.
A woman with a rectocele should try to avoid any type of heavy lifting or prolonged coughing.
If the patient is overweight or obese, the doctor will advise her to try to lose weight.
The doctor may prescribe stool softeners. Hormone replacement therapy (HRT) may be recommended for post-menopausal women.
A vaginal pessary, which is a plastic or rubber ring inserted into the vagina, can help to support the protruding tissues.
If necessary, surgery to repair the damaged tissue can be carried out through an incision of the vaginal skin.
The surgeon can remove the stretched or damaged tissue, and repair the damage using a mesh or graft inlay to reinforce the wall between the vagina and the rectum.
Various interventions are possible for pelvic organ prolapse, including sacral colpopexy, sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. The technique can vary from open surgery to minimally invasive.
The gynecologist will discuss the options with the patient, and the choice is likely to depend on the extent of prolapse, and the patient's individual situation, including age, general health and whether or not they want to have more children.
A number of actions can reduce the chance of developing a rectocele or making it worse.
Women who have recently given birth should do the recommended Kegel exercises regularly.
Anyone with a chronic cough, chest infections, and other lung problems should seek medical attention. Smoking makes lung conditions more likely and should be avoided.
Maintaining a healthy body weight can reduce the risk. A healthy diet and drinking plenty of water can help to avoid constipation. In the case of constipation, individuals should avoid prolonged straining when trying to empty the bowels.
A woman who already has a prolapse should avoid activities such as heavy lifting, as they can make it worse.