Rectocele

Symptoms and complaints

Rectocele is mostly asymptomatic, meaning that there are no complaints.
Complaints are usually only reported in an advanced stage.

A large rectocele leads to swelling in the vagina with specific additional complaints, i.e. more difficult stool and a feeling of incomplete bowel emptying afterwards. Sometimes patients have to push against the bulge or the recto-vaginal septum to produce bowel movement. Rectal pain or elevated stool frequency may occur sporadically. Vaginal symptoms, e.g. experiencing pain during sex (dyspareunia) and vaginal bleeding may also occur. Furthermore, associated symptoms to the pelvic floor are possible.

Rectocele or external rectal prolapse diagnosis

A rectocele is mostly discovered coincidently during a regular medical check-up.  Extensive clinical examination and an ultrasound are essential for diagnosing rectocele and potentially expose other anomalies of the pelvic floor.

In case the patient experiences difficulty in defecating, a special RX study is usually conducted. An RX-defecography involves injection of contrast material through the rectum after which several RX-photos are made while the patient defecates. This test gives doctors a clear image of the size of the rectocele size and other possible anomalies.

Nowadays, doctors often turn to NMR-tests or NMR-defecographies as well to avoid using X-rays. This type of test also provides a clearer image of the pelvic floor’s anatomy.

In some cases, a dynamic perineal ultrasound may be recommended.

Rectocele treatment

Treatment is only necessary when the rectocele’s symptoms have a negative effect on the patient’s daily functioning.

There are several medical and surgical options for treatment. The severity of the rectocele determines the doctor’s choice of treatment.

Preventing and reducing complaints

Initial treatment includes dietary measures and physio-therapy. To prevent constipation and excessive pushing, the patient must have a regular bowel pattern. A high-fiber diet (25-30 grams per day) and a daily fluid-intake of at least 6 glasses are recommended.

Additionally, pelvic floor exercises or laxatives may be recommended. Sometimes  local pressure to the posterior vaginal wall can help defecation.

Surgery

For correcting a rectocele, several surgical procedures with minimal morbidity exist. The most appropriate type of surgery depends on the size of the defect and the associated symptoms. Therefore, a successful surgical rectocele procedure requires a multi-disciplinary and specialized team.

Depending on the point of access, the procedure is trans-anal, trans-vaginal or trans-abdominal.

• Trans-vaginal reconstruction is carried out by suturing (plication) of the recto-vaginal septum, either with or without a synthetical mesh for reinforcement. Even though this procedure causes more blood loss and requires more pain medication, it tends to yield better results than a trans-anal procedure.

• Trans-anal reconstruction is mostly recommended when the patient has considerable difficulty expelling stool and in case of rectal prolapse (intussusception). The excess tissue is removed using a circular stapler.
• Finally, doctors may opt to perform a trans-abdominal procedure, openly or laparoscopically. In both cases, the recto-vaginal septum is completely dissected, and the front rectal wall is reinforced with a mesh. Next, the surgeon fixates the rectum to the tailbone (ventral rectopexy). This procedure is also an option when constipation and prolapse coexist. Furthermore, trans-abdominal repair is recommended when there are other pelvic floor defects as well.

Possible complications include bleeding, mesh infection and relapse.