Rectocele is a diverticular–like protrusion of the rectal wall towards the vagina, accompanied by a disorder of the act of defecation. It can manifest itself as constipation, a feeling of incomplete bowel emptying, the need for pressure on the perineum, buttock area or vaginal wall to empty the intestine. Hemorrhoids, anal fissures, cryptitis, pararectal fistulas and other complications may develop. Rectocele is diagnosed on the basis of complaints, examination data, rectal examination, rectoromanoscopy and proctography with straining. Treatment – correction of eating behavior, physical therapy, physiotherapy, drug therapy, surgery.
Rectocele is a pathological condition caused by the prolapse of the pelvic organs and manifested by the protrusion of the rectal wall into the vagina. It is a widespread pathology, accounting for 2.5% of the total number of diseases of the female genital organs. Rectocele is usually detected in patients who have had a difficult birth. It can also occur as a result of obesity, weakness of the pelvic floor muscles, excessive physical exertion, congenital anomalies of the pelvic organs and gynecological diseases.
With age, the probability of rectocele increases. Pathology is accompanied by a disorder of the evacuation function of the intestine, while the degree of violation of the act of defecation directly depends on the severity of the rectocele. In severe cases, defecation without additional assistance (squeezing fecal masses through the vaginal wall) becomes impossible, other proctological and gynecological diseases develop. The treatment is carried out by specialists in the field of clinical proctology and gynecology.
The causes of pathology are various processes that cause a violation of the mutual disposition of the pelvic organs and weakening of the pelvic muscles. The first place in the list of such reasons, according to most researchers, is occupied by severe childbirth, accompanied by excessive peak load of the pelvic organs and pelvic floor muscles.Along with peak loads, less intense repetitive loads that occur in obese patients and patients who constantly perform heavy physical work can play an important role in weakening the muscles of this anatomical area and the development of rectocele.
Sometimes, due to a constant cough, accompanied by a sharp increase in pressure on the organs and muscles of the pelvis, rectocele occurs in people suffering from chronic bronchitis. Gynecological diseases and congenital malformations that contribute to a change in the location of the pelvic organs relative to each other further increase the likelihood of rectocele development. Due to the natural age-related weakening of the pelvic floor muscles, the situation worsens with aging, which explains the frequent development of rectocele in the elderly.
Rectocele is a condition in which part of the rectum protrudes towards the vagina and gradually prolapses its wall, forming a bag-like pocket in which fecal masses are retained. The protrusion of the rectum is the cause of the disorder of the act of defecation and the development of severe constipation. A patient with rectocele has to push harder to empty her intestines. The pressure in the intestine during defecation increases more and more, this entails an increase in protrusion and further progression of pathology.
In the end, the rectocele reaches a degree at which the effectiveness of conservative measures decreases more and more, the only way to restore normal anatomical relationships between the pelvic organs and establish an act of defecation is surgical intervention.
Taking into account the symptoms , modern proctologists distinguish the following degrees of rectocele:
- Grade 1 – there are no complaints, the act of defecation is not violated. Rectal examination palpates the protrusion of the anterior wall of the rectum of a small size. Due to the lack of complaints, patients do not go to the doctor, the rectocele becomes an accidental find when conducting an examination for other reasons.
- Grade 2 – patients with rectocele complain of difficulties during defecation and a feeling of incomplete bowel movement. Rectal examination reveals a bag-like pocket reaching the border of the vestibule of the vagina. Sometimes the remains of fecal masses are found in the protrusion.
- Grade 3 – patients with rectocele complain of pronounced difficulties in defecation and the need for pressure on the vaginal wall for the successful discharge of fecal masses. The anterior wall of the rectum and the posterior wall of the vagina of a rectocele patient protrude beyond the genital slit. The protrusion contains feces, sometimes fecal stones. There are sclerotic changes in the vaginal wall, ulceration is detected in some patients.
Taking into account the level of lesion, the following types of rectocele are distinguished: low (accompanied by changes in the sphincter), medium (manifested by the formation of a sac-like protrusion above the sphincter), high (accompanied by the formation of a pocket in the upper part of the vagina).
The clinical picture develops gradually. At first, defecation becomes less regular, there is a tendency to constipation, there is a feeling of incomplete emptying or an extraneous body in the rectum. As the symptoms worsen, the patient with rectocele is increasingly forced to take laxatives or use enemas. Artificial stimulation of the act of defecation contributes to the aggravation of the existing pathology. Rectocele is progressing.
Constipation is becoming more persistent. Over time, the ability to defecate normally disappears; in order to achieve the release of fecal masses, a sick rectocele has to press with his hands on the buttocks, perineum or the back wall of the vagina. Stagnation of feces and traumatization of the intestinal walls with solid feces cause the development of proctitis or rectosigmoiditis. Due to repeated excessive straining, the rectocele is complicated by hemorrhoids, a crack in the anus, other diseases of the rectum and the anus area. Possible prolapse of the uterus. Some patients develop cystocele (protrusion of the bladder into the vagina). Sometimes there is fecal incontinence.
The diagnosis of rectocele is made taking into account the characteristic symptoms, examination data of the perineum and perianal region, gynecological examination, rectal examination, endoscopy and radiological diagnostic techniques. When examining the anus area in patients with rectocele, anal fissures and enlarged hemorrhoids may be detected. With fecal incontinence in the anal area, traces of fecal masses and areas of irritation are visible. During gynecological and rectal examination, a patient with rectocele is asked to strain. When straining, the intestinal wall protrudes into the vagina. The doctor determines the size and location of the protrusion (high, medium, low), notes the presence or absence of the contents of the rectocele (feces, fecal stones), assesses the thickness of the vaginal septum and the condition of the pelvic floor muscles.
During rectoromanoscopy, a characteristic pocket in the anterior wall of the rectum is found in patients with rectocele. For a more accurate assessment of the severity of the disorder of the act of defecation and the degree of rectocele, defecography (evacuation proctography) is prescribed. A thick barium suspension is injected into the intestine, and then a series of pictures are taken during the act of defecation. Sometimes radiological examination is replaced by magnetic resonance imaging. Differential diagnosis of rectocele is carried out with hernias of the rectal-vaginal septum.
Treatment of rectocele
Treatment of the disease of the 1st degree is conservative. At the 2nd and 3rd degrees of pathology, combined techniques are used, including surgical intervention, pre- and postoperative conservative measures aimed at eliminating constipation, restoring intestinal peristalsis and improving the evacuation of contents from the rectum. A mandatory part of the treatment of rectocele is a diet that provides for an increase in the amount of coarse vegetable fiber (to stimulate the motor function of the intestine) and a sufficient amount of water (to ensure the softness of fecal masses).
To restore the regularity of the act of defecation, patients with rectocele are prescribed mild laxatives of osmotic action. Combined probiotics are used to correct the composition of the intestinal microflora. To normalize the motor function of the intestine, prokinetics (domperidone and its analogues) are used. Rectocele drug therapy is supplemented with physiotherapy and special exercise therapy complexes aimed at strengthening the pelvic floor muscles.
Conservative therapy can slow down the development of the disease, but it cannot ensure a full recovery. The only radical way to treat rectocele is surgery. All surgical interventions in this pathology can be divided into two groups: aimed at eliminating the pocket formed by the rectum, and aimed at strengthening the septum between the vagina and the rectum. To correct the rectocele, access is used through the vagina, rectum, perineum or anterior abdominal wall.
During the operation, the doctor sutures and fixes the anterior wall of the intestine, strengthens the rectovaginal septum and takes measures to restore the sphincter. In case of combined pathology, along with rectocele, which includes hemorrhoids, anal fissure, cystocele or rectal polyps, a combined surgical intervention is performed aimed at eliminating all existing disorders. Operations can be performed both in the traditional way and with the use of endoscopic equipment.
During therapeutic endoscopy, a mesh implant is installed in a rectocele patient, which strengthens the rectovaginal septum and prevents the rectum from protruding into the vagina. In the pre- and postoperative period, physical therapy, physiotherapy, probiotics and prokinetics are prescribed. If there are contraindications to surgery, patients with 2 and 3 degrees of rectocele are recommended to use a pessary – a special device that is inserted into the vagina to maintain the correct position of the pelvic organs.
Prognosis and prevention
With the timely start of treatment, the prognosis of rectocele is quite favorable. The list of measures to prevent the development of pathology includes the exclusion of excessive physical exertion, a balanced diet, regular monitoring of patients during pregnancy, timely treatment of emerging disorders, adequate obstetric care and special exercise therapy complexes to strengthen the pelvic floor muscles.