A rectocele is a type of pelvic organ prolapse that occurs when the thin wall of tissue separating the rectum and the vagina weakens, allowing the rectum to bulge into the posterior wall of the vagina. This condition is sometimes called a posterior vaginal prolapse. While not life-threatening, a rectocele can significantly impact quality of life by causing symptoms like pressure, a vaginal bulge, or difficulty with bowel movements. Treatment options vary widely and are determined by the severity of the symptoms a patient experiences.
Initial Medical Assessment
Assessment begins with a thorough physical examination to determine the extent of the prolapse. This involves both a vaginal and rectal check, often while the patient is asked to strain, which makes the bulge more apparent. The degree of tissue descent is quantified using the standardized Pelvic Organ Prolapse Quantification (POP-Q) system.
The POP-Q system uses specific anatomical landmarks, with measurements taken from the hymen, to stage the rectocele. Measurement points Ap and Bp are used to gauge the severity of the bulge in the posterior compartment. Staging classifies the prolapse from minimal (Stage I) to most severe (Stage IV), which guides treatment discussion.
Imaging studies are sometimes used to confirm the diagnosis or evaluate concurrent issues, such as a hidden enterocele (small bowel prolapse). Defecography (X-ray or MRI) is often performed to visualize the rectum and surrounding structures while the patient attempts to empty their bowels. This functional imaging provides a dynamic view of how the rectocele affects rectal emptying and is helpful when symptoms involve obstructive defecation.
Non-Surgical Management Strategies
For individuals with mild symptoms, conservative, non-surgical management is the initial approach. Lifestyle modifications focus on managing bowel habits to prevent straining, a major factor contributing to rectocele development. This includes maintaining a high-fiber diet, ensuring adequate fluid intake, and using stool softeners to keep bowel movements regular and soft.
Pelvic floor muscle training (PFMT), commonly known as Kegel exercises, is a fundamental component of conservative care. These exercises strengthen the muscles that support the pelvic organs, which can improve mild symptoms and provide better support for the pelvic floor. A specialized physical therapist can provide tailored instruction to ensure the exercises are performed correctly, focusing on both the strength and coordination of the muscles.
A vaginal pessary is another non-surgical option; it is a removable silicone device inserted into the vagina. The pessary provides mechanical support to the prolapsed organs, holding the rectal tissue in a better position and relieving pressure. Pessaries require professional fitting and offer an effective, low-risk alternative for managing symptoms when surgery is deferred or avoided.
Surgical Repair Procedures
When non-surgical strategies fail or the rectocele is advanced, surgical repair becomes the definitive treatment option. The primary goal is to reinforce the rectovaginal septum (the supportive layer between the rectum and the vagina), pushing the rectal bulge back into its correct anatomical position. The most common technique is posterior colporrhaphy, a native tissue repair performed through a vaginal approach.
During a posterior colporrhaphy, an incision is made along the back wall of the vagina to expose the weakened fascia. The stretched connective tissue is brought together and secured with sutures, creating a stronger wall of support. This procedure reduces the herniation and prevents the rectum from bulging forward, addressing symptoms like obstructive defecation and vaginal pressure.
Surgeons may also perform a site-specific repair, focusing sutures on distinct defects within the fascia, rather than plicating the entire back wall. This technique is often combined with a perineorrhaphy, which tightens the perineal body (the muscular area between the vagina and anus) to provide additional support. The surgical approach is typically transvaginal, meaning no abdominal incisions are necessary, which allows for a quicker initial recovery.
The use of synthetic mesh or biological grafts to augment the repair is generally reserved for specific, complex cases. Current guidelines recommend against the routine use of mesh for a primary rectocele repair, as it does not consistently lead to better long-term outcomes compared to native tissue repair. Mesh also carries the risk of complications, such as erosion into the vaginal wall. However, a surgeon may consider using a graft material for extra durability in cases of recurrent rectocele where native tissue repair has failed multiple times.
Long-Term Recovery and Prevention
Following surgical repair, a structured recovery period is important to allow reinforced tissues to heal and maximize long-term success. Patients are advised to avoid heavy lifting (over 5 to 10 pounds) and strenuous activities for six to eight weeks. Refraining from sexual intercourse, douching, or using tampons is necessary during the initial four to six weeks to allow the vaginal incision to heal completely.
Preventing constipation and straining is paramount during recovery and for the rest of a patient’s life to avoid recurrence. This involves adhering to a high-fiber regimen and often using stool softeners or mild laxatives as recommended. Maintaining a healthy body weight also reduces chronic intra-abdominal pressure on the pelvic floor structures.
Long-term prevention centers on managing any condition that causes chronic downward pressure, such as a persistent cough or high-impact exercise. Continued adherence to pelvic floor muscle exercises helps maintain the strength and tone of the supportive muscles. Regular follow-up appointments allow the healthcare team to monitor the repair and address any potential issues early.