Sagittal section of the lower part of a female trunk, right segment. (Rectovaginal fascia not labeled, but region is visible.)
|Classification and external resources|
A rectocele (// REK-tə-seel) results from a tear in the rectovaginal septum (which is normally a tough, fibrous, sheet-like divider between the rectum and vagina). Rectal tissue bulges through this tear and into the vagina as a hernia. There are two main causes of this tear: childbirth, and hysterectomy.
Although the term applies most usually to the phenomenon of rectal herniation into the vagina in females, males may suffer with a condition likewise named. Rectoceles in men are uncommon, and usually the protrusion is backwards rather than forwards, as the prostate gland provides structural support anteriorly in men. Prostatectomy appears to be associated with rectoceles in men.
Mild cases may simply produce a sense of pressure or protrusion within the vagina, and the occasional feeling that the rectum has not been completely emptied after a bowel movement. Moderate cases may involve difficulty passing stool (because the attempt to evacuate pushes the stool into the rectocele instead of out through the anus), discomfort or pain during evacuation or intercourse, constipation, and a general sensation that something is "falling down" or "falling out" within the pelvis. Severe cases may cause vaginal bleeding, intermittent fecal incontinence, or even the prolapse of the bulge through the mouth of the vagina, or rectal prolapse through the anus. Digital evacuation, or, manual pushing, on the posterior wall of the vagina helps to aid in bowel movement in a majority of cases of rectocele. Rectocele can be a cause of symptoms of obstructed defecation.
It can be caused by many factors, but the most common is childbirth, especially with babies over nine pounds in weight, or rapid births. The use of forceps is more likely a marker for the vaginal injury, than a direct cause of the tear. Episiotomy or lower vaginal tears play little role in the formation of a cystocele, but may in rectoceles. The risk increases with the number of vaginal births, although it can also happen in women who have never borne a child.
A hysterectomy or other pelvic surgery can be a cause, as can chronic constipation and straining to pass bowel movements. It is more common in older women than in younger ones; estrogen which helps to keep the pelvic tissues elastic decreases after menopause.
Treatment depends on the severity of the problem, and may include non-surgical methods such as changes in diet (increase in fiber and water intake), pelvic floor exercises such as Kegel exercises, use of stool softeners, hormone replacement therapy for post-menopausal women and insertion of a pessary into the vagina. A high fiber diet, consisting of 25-30 grams of fiber daily, as well as increased water intake (typically 6-8 glasses daily), help to avoid constipation and straining with bowel movements, and can relieve symptoms of rectocele.
Surgery to correct rectocele should only be considered when symptoms continue despite the use of non-surgical management, and are significant enough to interfere with activities of daily living. It is usually done by posterior colporrhaphy, which involves suturing of vaginal tissue. Surgery may also involve insertion of a supporting mesh (that is, a patch). There are also surgical techniques directed at repairing or strengthening the rectovaginal septum, rather than simple excision or plication of vaginal skin which provides no support. Both gynecologists and colorectal surgeons can address this problem. Potential complications of surgical correction of a rectocele include bleeding, infection, dyspareunia (pain during intercourse), as well as recurrence or even worsening of the rectocele symptoms. Synthetic or biologic grafts should not be used in rectocele repairs.
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- Wexner, edited by Andrew P. Zbar, Steven D. (2010). Coloproctology. New York: Springer. ISBN 978-1-84882-755-4.
- "Rectocele: Risk factors - MayoClinic.com". Retrieved 2007-11-21.
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- Rectocele, by Jennifer Speranza, MD at American Society of Colorectal Surgeons. Reviewed 2012
- American Urogynecologic Society (May 5, 2015), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Urogynecologic Society), retrieved June 1, 2015, which cites:
- Maher, C; Feiner, B; Baessler, K; Schmid, C (30 April 2013). "Surgical management of pelvic organ prolapse in women.". The Cochrane database of systematic reviews 4: CD004014. doi:10.1002/14651858.CD004014.pub5. PMID 23633316.
- Paraiso, MF; Barber, MD; Muir, TW; Walters, MD (December 2006). "Rectocele repair: a randomized trial of three surgical techniques including graft augmentation.". American Journal of Obstetrics and Gynecology 195 (6): 1762–71. doi:10.1016/j.ajog.2006.07.026. PMID 17132479.
- Sung, VW; Rardin, CR; Raker, CA; Lasala, CA; Myers, DL (January 2012). "Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial.". Obstetrics and gynecology 119 (1): 125–33. doi:10.1097/aog.0b013e31823d407e. PMID 22183220.