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RECTOCELE
Rectocele is one of many pelvic organ support problems. Each year many women endure pelvic organ prolapse, and many undergo surgical procedures for correction of these problems. These disorders usually are the result of trauma to the pelvic connective tissue and muscles, which often are the result of childbirth. Surgical procedures to correct these defects are considered elective since women are at no medical risk.
Q. What is a rectocele?
A. Rectocele is a downward displacement of the rectum. This pelvic organ defect often occurs in conjunction with other pelvic organ defects including cystocele (downward displacement of the bladder), enterocele (displacement/herniation of the small bowel into the vagina), and uterine prolapse (a downward displacement of the uterus and cervix toward the vaginal opening). Rectocele occurs from a defect in the posterior vaginal wall and often is associated with episiotomies and vaginal/perineal lacerations associated with childbirth.
Women may notice various symptoms with rectocele including pain with defecation (having a bowel movement), difficulty defecating, and incomplete defecation. Some women must insert a finger in the vagina and push the bulging area back into the vagina in order to completely defecate. Some women's only complaint is the sensation of a vaginal bulge. Other women are totally without symptoms.
Q. Who is most likely to get a rectocele?
A. Rectocele results from pelvic floor trauma. Often this is the result of childbirth. During the second stage of labor (the pushing stage), some of the tissues that normally support the pelvic organs are stretched and damaged. This weakens the support of the pelvic organs. As a woman ages, the problems may be worsened by loss of tissue integrity from loss of the female hormone estrogen. Other causes of loss of pelvic support include excess intra-abdominal pressure over a prolonged period of time such as heavy lifting, excessive coughing such as in long- term smokers, or chronic constipation and straining with bowel movements.
Diagnosis of a Rectocele
The diagnosis of rectocele is made by clinical exam by your physician. A woman usually presents to her physician with one or more of the above listed symptoms. To make an accurate diagnosis your doctor will get your complete medical history, and will then perform a pelvic exam. Your doctor may examine you in both the lying and standing positions. This is necessary to differentiate a rectocele from an enterocele, which requires a different surgical correction.
Treatments for a Rectocele
Your physician may offer you a variety of treatments for your rectocele ranging from just watching the problem to see if it worsens, to basic lifestyle changes, to exercises in an attempt to strengthen your pelvic floor muscles, to surgery.
Many women with rectoceles are asymptomatic. If you have no difficulty having a bowel movement, discomfort voiding, or discomfort from a vaginal bulge, it is reasonable to follow your rectocele with no further treatment. A rectocele has no associated medical problems that must be addressed, and should only be treated surgically if you are having symptoms.
One nonsurgical treatment for rectocele is performing Kegel's exercises. These exercises are used to strengthen the pelvic floor muscles. To perform these exercises a woman squeezes the pubococcygeus muscle, which is done by squeezing the muscles around the vagina. These muscles are contracted for 10 seconds, and then relaxed for 10 seconds. This repetitive activity is done in sets of 10 to 20 about 3 to 5 times a day. Maximum results are obtained in 3 to 6 months.
Due to the increased deterioration of the integrity of the pelvic tissues as you age, your physician may recommend that you start a regimen of estrogen if you are postmenopausal. Estrogen replacement therapy has been shown to have many potential benefits for the postmenopausal woman including a decrease in heart disease and osteoporosis (thinning of the bones), as well as improvement in pelvic support. Estrogen replacement therapy may be prescribed in many different forms, including pills or a transdermal patch. If you have not had a hysterectomy, progesterone therapy will be necessary to prevent endometrial hyperplasia (a precursor to endometrial cancer). Your physician can discuss the risks and benefits of hormone replacement therapy with you further.
Your physician may suggest a pessary for support of the vaginal vault and relief of symptoms from rectocele. A pessary is a rubber device that is inserted into the vagina. It is fitted to provide support to the vaginal walls. Your physician will teach you how to insert and remove your pessary, and you will need to remove and clean your pessary on a regular basis.
Finally, your physician may suggest surgery as an option for correction of rectocele. This procedure is performed from a vaginal approach. The posterior wall of the vagina is opened and the pararectal fascia and levator ani muscles (the damaged tissues that normally support the rectum) are reinforced surgically. There is no entry into the abdominal cavity with this procedure, and you may be allowed to go home after one to two nights in the hospital. Your physician will ask you to take a laxative to prevent constipation and unnecessary strain on the sutures he or she has placed. The physician may additionally ask you to avoid high fiber foods, to prevent high volume to your stools.
In an attempt to decrease the chances of recurrence of rectocele, you should continue to avoid those things that may have led to the initial rectocele. These include avoiding smoking, avoiding constipation, avoiding heavy lifting, etc.
Recovery from rectocele repair is usually complete in 4 to 6 weeks. Most patients feel well enough to return to work in approximately 2 weeks.
Prevention of a Rectocele
Rectoceles are commonly the result of obstetrical trauma and /or tissue deterioration due to aging. At this point there is no recommendation for prevention of rectocele, except avoidance of prolonged increases in intra-abdominal pressure, such as excessive coughing or straining.
Indu S. Anand, MD
Dr. Anand is a former Assistant Professor in the Department of Obstetrics and Gynecology at the University of Tennessee Health Science Center, in Memphis, Tennessee. She now is in private practice in Atlanta, GA.
Date Published: 2000-09-21
7800 Wolf Trail Cove, Germantown, TN 38138
Phone: (901) 682-9222; Fax: (901) 682-9505