A rectocele is a form of pelvic organ prolapse where the front wall of the rectum bulges into the back wall of the vagina, creating a visible or palpable lump. This condition occurs because the recto-vaginal septum, the sheet of tissue separating the two organs, has become weakened or torn. The primary causes involve events that place chronic strain on the pelvic floor, such as childbirth, chronic constipation, or persistent heavy lifting. Treatment depends on the severity of symptoms, ranging from simple lifestyle adjustments for mild cases to surgical intervention for severe, debilitating bulges.
Non-Surgical Conservative Methods
Initial management for a mild or asymptomatic rectocele focuses on preventative habits to reduce pressure on the pelvic floor and prevent the condition from worsening. A primary goal is to ensure soft, easy bowel movements, which is achieved through specific dietary changes. Increasing daily fiber intake from sources like whole grains, fruits, and vegetables, along with ensuring adequate hydration, helps to bulk and soften stool, reducing the need to strain.
Patients should also adopt proper bowel movement techniques to minimize straining force. This includes using a step stool to elevate the knees above the hips, which straightens the angle of the rectum. Some women with difficulty evacuating find relief by using a technique called “splinting,” where they apply gentle pressure to the back wall of the vagina to support the prolapse during a bowel movement.
Strengthening the muscles that support the pelvic floor is another foundational conservative step. Targeted pelvic floor exercises, often called Kegels, involve contracting the muscles used to stop the flow of urine. When performed correctly and consistently, these exercises help to reinforce the levator ani muscles. Physical therapy, sometimes utilizing biofeedback to ensure correct muscle activation, can be highly effective for strengthening the pelvic floor and reducing symptoms.
Utilizing Pessary Devices for Support
A pessary offers a distinct, non-surgical mechanical solution for managing symptomatic rectoceles. This removable device, typically made of medical-grade silicone, is inserted into the vagina to provide direct support to the prolapsed tissue. The pessary works by acting as an internal scaffolding, holding the rectal wall back in its correct anatomical position and relieving the feeling of a vaginal bulge.
Ideal candidates for pessary use include women who wish to avoid or delay surgery, those who are not medically fit for an operation, or those who are planning future pregnancies. Pessaries come in a wide range of shapes and sizes, with the choice depending on the type and severity of the prolapse. For rectoceles, types like the supportive Ring pessary, the Donut, or the Cube pessary are frequently used to hold the posterior wall in place.
Proper care and maintenance of the device are important for long-term success and to prevent complications. Patients are typically taught how to remove, clean, and reinsert the pessary themselves. If a patient cannot manage the device independently, they must schedule regular follow-up appointments, often every three to six months, for a healthcare provider to clean the device and check the vaginal tissue for irritation or ulceration.
Surgical Repair Procedures
For women with severe symptoms, such as significant difficulty with bowel evacuation or a large, bothersome vaginal bulge, surgical repair is often the definitive treatment option. The most common surgical approach is called a posterior colporrhaphy, which is performed through the vagina. The procedure involves making an incision along the back wall of the vagina to access the weakened recto-vaginal septum.
The main goal of the surgery is to reinforce the weakened tissue plane between the rectum and the vagina. The surgeon tightens the supporting fascia by suturing the tissue together in a process called plication, thereby pushing the rectum back into its correct position. In some cases, the procedure is combined with a perineorrhaphy, which involves strengthening the perineal body—the tissue between the vagina and the anus—to provide additional support.
While the transvaginal approach is the most common, rectocele repair can also be approached through the anus (transanal) or via laparoscopic methods, often when other types of prolapse are being corrected simultaneously. The transvaginal repair is generally favored for its better anatomic results. The use of synthetic mesh or biological grafts to augment the repair is generally avoided for primary rectocele repair, as studies have not consistently shown improved outcomes over native tissue repair, and the use of mesh carries a risk of complications.
Maintaining Long-Term Correction
Achieving a successful long-term outcome after any rectocele treatment requires a commitment to specific behavioral modifications, regardless of whether the patient had a surgical repair or uses a pessary. A primary focus is avoiding any activities that increase chronic intra-abdominal pressure, which can strain the newly repaired or supported pelvic floor. This includes preventing chronic constipation, maintaining a high-fiber diet, and ensuring adequate fluid intake remains a lifelong habit.
Following surgery, there are typically restrictions on heavy lifting and strenuous exercise for a period of several weeks to allow the tissues to heal properly. In the long term, patients are advised to avoid heavy lifting and to manage their body weight, as obesity is a factor that contributes to pelvic floor stress. Continued attention to chronic conditions, such as a persistent cough due to smoking or allergies, is also important, as repetitive coughing places significant downward force on the pelvic support structures.
Continued adherence to a pelvic floor muscle strengthening routine provides ongoing support to the pelvic organs and helps prevent the recurrence of the prolapse. While surgical success rates are generally high, recurrence is a possibility, and maintaining a lifestyle that minimizes strain is the most effective strategy for ensuring the correction lasts.