A rectocele is a type of pelvic organ prolapse that occurs when the supportive wall of tissue separating the rectum and the vagina weakens, allowing the front wall of the rectum to bulge into the back wall of the vagina. Many women with a rectocele experience a feeling of pelvic pressure or fullness, along with difficulty completing a bowel movement. Symptoms may also include the sensation that something is falling out of the vagina or the need to manually press on the vaginal wall to facilitate stool evacuation (splinting). Non-surgical management is the primary approach for mild to moderate cases, focusing on strengthening the pelvic floor and eliminating activities that increase downward pressure.
Lifestyle and Dietary Adjustments
The most immediate steps for managing a rectocele involve modifying diet and daily habits to prevent straining during bowel movements. Chronic straining is a significant factor in the progression of pelvic organ prolapse because it applies excessive downward pressure on the pelvic floor muscles and connective tissue. Achieving a soft, easily passed stool consistency is the first goal, accomplished primarily through dietary changes.
A high-fiber diet, aiming for 25 grams or more per day, helps to bulk and soften stool, reducing the effort needed for evacuation. Adequate hydration is equally important, as fiber absorbs water. Experts suggest consuming at least two to three liters of non-caffeinated, non-alcoholic fluids daily to keep the digestive tract moving smoothly.
Adjusting posture during defecation can also significantly reduce straining and pressure. Using a small footstool to elevate the knees above the hips mimics a squatting position, which naturally straightens the anorectal angle and allows for easier passage of stool. Activities that generate high intra-abdominal pressure, such as repetitive heavy lifting or a chronic cough, should be minimized to prevent further weakening of the pelvic support structures.
Pelvic Floor Physical Therapy
Specialized Pelvic Floor Muscle Training (PFMT), often referred to as Kegel exercises, is a foundational component of non-surgical rectocele treatment. These exercises focus on strengthening the levator ani muscles, which form the primary support structure for the pelvic organs. Strengthening these muscles provides better underlying support, which can reduce the symptoms of pressure and prolapse for many individuals.
Proper technique is paramount, as many people incorrectly bear down or engage their abdominal and buttock muscles instead of isolating the pelvic floor. A common recommendation involves holding a strong contraction for up to 10 seconds, followed by a full relaxation for 5 to 10 seconds, repeated in sets several times per day. Consulting a specialized pelvic floor physical therapist ensures the correct muscle groups are being activated and trained effectively.
Physical therapists also utilize tools like biofeedback to enhance the effectiveness of PFMT. Biofeedback employs specialized sensors, often internal probes or surface electrodes, to monitor the electrical activity of the pelvic floor muscles in real-time. This information is then displayed as a visual graph or auditory signal, giving the patient immediate feedback on the quality of their muscle contraction and relaxation. This objective feedback is invaluable for correctly identifying and isolating the internal pelvic muscles.
In some cases, the therapist may also incorporate electrical stimulation, which delivers mild electrical pulses to the pelvic nerves and muscle fibers. This stimulation helps to improve the nervous system’s connection to the muscles, increasing overall muscle strength and improving neuromotor control. Combining these therapeutic techniques significantly improves pelvic floor function, often leading to a reduction in the degree of prolapse and an improvement in symptoms.
Using Support Devices (Pessaries)
Another effective non-surgical option involves the use of a vaginal pessary, a removable medical device designed to provide mechanical support for the prolapsed organs. Pessaries are typically made of flexible silicone and come in numerous shapes and sizes, such as rings, cubes, or donut shapes. The device is inserted into the vagina and positioned to hold the rectum and other pelvic organs in their correct anatomical position, counteracting the bulge of the rectocele.
The function of a pessary is to alleviate the feeling of pressure and the sensation of the bulge, which improves quality of life. They are useful for women who wish to avoid surgery or whose symptoms are not resolved by physical therapy and lifestyle changes alone. A healthcare provider, such as a urogynecologist, must fit the pessary, as the correct size and type are essential for comfort and effectiveness. Regular follow-up appointments are necessary for cleaning the device and monitoring the vaginal tissue for irritation.
Determining the Need for Surgical Repair
While most mild to moderate rectoceles respond well to conservative measures, surgery becomes a consideration when symptoms are severe or when non-surgical treatments fail to provide adequate relief. The need for surgical repair is typically determined by two main factors: the degree of anatomical prolapse and the severity of the patient’s symptoms. Symptom severity is often measured by the impact on daily life, such as constant pain, debilitating pressure, or the inability to pass stool without consistently resorting to manual splinting.
Clinicians use standardized systems, such as the Pelvic Organ Prolapse Quantification (POP-Q) system, to objectively grade the extent of the rectocele relative to the hymen. Surgery is more likely to be recommended for advanced cases, which are generally classified as POP-Q Stage III or Stage IV. Stage III indicates that the most prominent part of the rectocele has descended more than one centimeter beyond the hymen. Stage IV represents a complete eversion where the prolapse is fully protruding outside the vaginal opening. Surgical intervention is reserved for situations where a thorough trial of diet modification, pelvic floor physical therapy, and pessary use has failed to alleviate these advanced symptoms.