Rectocele: Symptoms, Causes and Treatment

A rectocele affects many women worldwide, causing discomfort and concerns about their daily activities. Understanding rectocele helps patients make informed decisions about their health and rectocele treatment options. Treatment options start from conservative approaches like lifestyle changes to surgical procedures, depending on the symptoms and their impact on quality of life.

What is a Rectocele?

A rectocele is a unique type of pelvic organ prolapse that occurs when the supportive tissue between the rectum and vagina becomes weak or damaged. This condition affects the posterior (back) vaginal wall, causing the bulging of the rectum into the vaginal space. Doctors also refer to this condition as posterior vaginal wall prolapse.

The condition develops when the pelvic floor, which consists of muscles and ligaments that support various organs, loses its strength. When this happens, the front wall of the rectum (the lower part of the large intestine) pushes against and protrudes into the vaginal wall.

Key characteristics of a rectocele include:

• A bulging or sagging of the rectum into the vaginal wall
• Possible protrusion through the vaginal opening in severe cases
• Involvement of the pelvic floor muscles and supporting tissues
• Often occurs alongside other forms of pelvic organ prolapse

Symptoms of Rectocele

Symptoms of rectocele can vary significantly among individuals, with some experiencing no noticeable signs while others face daily discomfort. 

Common symptoms include:

• A sensation of pressure or fullness in the rectum or vagina
• A soft bulge of tissue in the vaginal area that may protrude through the vaginal opening
• Incomplete bowel emptying after defecation
• Frequent urges to have bowel movements throughout the day
• Discomfort during sexual intercourse
• Noticeable loss of muscle tone or looseness in the vaginal area
• Need for manual assistance during bowel movements (splinting)
• Urinary complications such as frequent urination or involuntary leakage

Risk Factors and Causes of Rectocele

The development of a rectocele primarily stems from weakening or damage to the pelvic floor tissues. This condition typically results from prolonged pressure on the pelvic floor or specific traumatic events that affect the supporting structures.

Several factors can increase the susceptibility to developing this condition:

• Pregnancy and Childbirth:
  • Multiple vaginal deliveries
  • Birth-related tears or episiotomies
  • Forceps or operative vaginal deliveries
  • Prolonged labour
• Health-related Factors:
  • Chronic constipation with repeated straining
  • Long-lasting cough or bronchitis
  • Obesity places extra stress on pelvic tissues
  • Previous pelvic surgeries, including hysterectomy
• Natural Factors:
  • Ageing and associated loss of muscle mass
  • Genetic predisposition to weaker connective tissues
  • Menopause-related changes in the body
  • Regular heavy lifting

Diagnosis

The primary diagnostic process begins with a thorough pelvic examination, where the doctor assesses the vaginal and rectal areas.

• Pelvic Examination: During the physical examination, patients may be asked to perform specific actions:
  • Bearing down as if having a bowel movement
  • Tightening pelvic muscles (similar to stopping urination)
  • Coughing or straining to observe tissue movement
• Diagnostic Tests: In some cases, advanced diagnostic tests may be necessary. These typically include imaging studies such as MRI or X-rays to determine the exact size and location of the tissue bulge. 
• Defecography: A specialised defecography test might be performed, combining contrast agents with imaging to evaluate how well the rectum empties.
• Additional Tests: For complex cases involving multiple pelvic floor issues, doctors may recommend additional evaluations like urodynamic testing for bladder function assessment or anorectal physiologic testing.

Treatment

The main treatment approaches include:

• Conservative Management:
  • Pelvic floor strengthening exercises
  • Lifestyle modifications
  • Increasing fibre intake to prevent constipation and reduce straining during bowel movements
• Non-surgical treatments (rectocele treatment without surgery): A vaginal pessary, a silicone device inserted into the vagina, helps support bulging tissues and must be removed regularly for cleaning. 
• Surgical Intervention: 
  • Rectocele Repair: Posterior colporrhaphy, the most common surgical procedure, involves removing damaged tissue and strengthening the wall between the vagina and rectum. This procedure typically requires a hospital admission of one to three days, with a recovery period of three to six weeks.
  • Vaginal Mesh or Graft: In more severe cases, doctors use a mesh or tissue graft to reinforce the vaginal wall.

When to See a Doctor

Medical attention becomes crucial when certain symptoms of rectocele begin to interfere with daily activities. Individuals experiencing persistent discomfort or difficulty with bowel movements should consult a doctor for proper evaluation. Seeking immediate medical attention becomes necessary when patients regularly need manual assistance for bowel movements. This process, known as splinting, requires proper medical guidance to prevent complications.

Prevention

While complete prevention of rectocele may not always be possible, implementing specific lifestyle changes can significantly reduce the risk of developing this condition. 

Several key strategies can help minimise the risk of developing a rectocele:

• Maintain Healthy Weight: Excess weight places additional pressure on pelvic floor muscles
• Practise Proper Lifting: Use leg muscles instead of waist or back when lifting heavy objects
• Manage Chronic Conditions: Treat respiratory conditions that cause frequent coughing
• Address Constipation: Consume adequate fibre and maintain proper fluid intake
• Regular Exercise: Perform structured physical activities that strengthen pelvic muscles
• Smoking Cessation: Reduce chronic coughing associated with smoking
• Proper Nutrition: Focus on high-fibre foods and adequate hydration

Conclusion

Rectocele management requires a clear understanding of its symptoms, causes, and available treatments. Medical science offers various solutions, from simple lifestyle changes to surgical procedures, helping women find relief from this challenging condition. Doctors can create personalised treatment plans based on symptom severity, overall health, and individual circumstances, leading to successful outcomes for most patients.

Early recognition of rectocele symptoms and prompt medical consultation remain crucial for optimal treatment results. Women can actively protect their pelvic floor health through proper exercise, maintaining a healthy weight, and following recommended lifestyle changes. Regular medical check-ups and open communication with doctors ensure that any concerns about rectocele can be addressed promptly, helping maintain a good quality of life while preventing potential complications.

FAQs

1. Who do rectoceles affect?

Rectoceles most commonly affect women over 60, though they can develop at any age. While the condition primarily affects women, men may rarely develop rectoceles following prostate surgery.

2. How common are rectoceles?

Doctors find rectoceles in approximately 40% of women during routine physical examinations. By age 50, about half of all women show some signs of pelvic organ prolapse, including rectoceles.

3. Can rectocele go away on its own?

No, rectoceles do not heal independently without treatment. The condition occurs due to weakened pelvic floor tissues, requiring specific interventions for improvement.

4. What happens if a rectocele goes untreated?

Untreated rectoceles can lead to several complications:

• Increased difficulty with bowel movements
• Worsening of pelvic pressure and discomfort
• Potential sexual dysfunction
• Risk of faecal incontinence

5. What is the difference between a rectocele and a cystocele?

While both conditions involve pelvic organ prolapse, they affect different areas. A rectocele involves the rectum bulging into the back vaginal wall, while a cystocele occurs when the bladder protrudes into the front vaginal wall.

6. Is walking good for rectocele?

Regular walking can benefit individuals with rectocele as part of an overall exercise routine. However, one should restrain herself from high-impact activities to prevent additional strain on pelvic floor muscles.

7. Are rectoceles painful?

Most rectoceles cause discomfort rather than acute pain. Individuals might experience:

• Pressure or fullness in the vaginal area
• Discomfort during bowel movements
• Occasional pain during physical activity

8. What should I eat if I have rectocele?

A proper diet plays a key role in managing rectocele symptoms. Focus on:

• High-fibre foods (25-35 grammes daily)
• Adequate water intake (2-3 litres per day)
• Foods that promote regular bowel movements

Dr. Anjali Masand