What is a rectocele?
A rectocele is a bulging of the front wall of the rectum into the back of the vagina. The bulge, or herniation, occurs as a result of thinning and weakening of the band of tissue that separates the vagina from the rectum. This thinning has a number of causes, including:
- Advanced age.
- Multiple vaginal childbirths or trauma during childbirth (for example, the use of forceps or the tearing of tissue during delivery).
- Repeated surgeries in the area of the pelvic floor or rectum.
- Chronic straining during bowel movements due to long-term constipation.
Normal anatomy of rectum
Rectum with rectocele
What are symptoms of a rectocele?
Many women with a rectocele have no symptoms, and the condition is incidentally noted on physical examination. In general, if a rectocele is not causing symptoms or discomfort, it can be left alone.
When symptoms are present, they include:
- Difficulty having bowel movements.
- A sense of bulging or fullness in the vagina.
- Problems with sexual intercourse.
- Manually reducing the bulge in the vagina to have a bowel movement.
A rectocele should be treated only if symptoms interfere with a woman’s quality of life.
How is a rectocele repaired?
There are both non-surgical and surgical ways to treat a rectocele. In all cases, the patient should have a thorough physical exam and talk with her doctor before deciding on the best treatment.
What types of surgical repairs are available for a rectocele?
If non-surgical methods do not help control rectocele symptoms, surgery may be needed. Talking with a reconstructive surgeon who specializes in pelvic floor conditions can help women decide upon the best approach. In most cases, surgery is done under general anesthesia and takes approximately 1 hour.
There are a number of different surgical repair options, each of which takes its name from the path used by the surgeon to reach the rectocele.
- Transvaginal repair: The rectocele is reached through the vagina. This is the traditional approach to rectocele repair by gynecologists. It offers the chance to correct not only the rectocele but a relaxed perineum and widened vaginal opening. It also has the advantage of not disturbing any tissue in the rectal area.
- Transperineal repair: The rectocele is reached through the perineum. This method allows the surgical removal of hemorrhoids at the same time, if necessary. However, it usually requires the implanting of a mesh over the entire surgical area to provide added support following surgery.
- Transanal repair: The rectocele is reached through the anus. This method is preferred by many colorectal surgeons because it allows for correction of problems in the anal or rectal area, in addition to repairing the rectocele. Some studies also suggest that pain after surgery may be less with this method than with the transvaginal approach.
Other types of repairs include:
- Laparoscopic repair uses a laparoscope, a thin lighted tube that needs only a small opening to reach the area being repaired. Advantages to this method include clearer visibility of the affected area, quicker recovery time, less pain, and a shorter hospital stay. Disadvantages include difficulties with suturing, increased procedure time and expense, and extra time on the part of the surgeon to master laparoscopic techniques.
- Ventral-rectopexy involves the use of a polypropylene (flexible plastic) mesh that is stitched to the front of the rectum and attached to the back of the pelvis (the hip bone) using special types of tacks. The mesh pulls up the bowel and prevents it from sagging down into the vaginal wall. This operation may be performed using a laparoscope.
- Other types of mesh are made from the tissue surrounding a cow’s heart, or from pig skin and intestine. These materials closely resemble the type of tissue found along the wall of the vagina.
Risks / Benefits
What complications can occur after rectocele repair?
Risks of surgical rectocele repair include the following:
- Pain during sexual intercourse.
- Development of a fistula (an open channel) between the vagina and rectum.
- Recurrence of the rectocele.
Recovery and Outlook
What is the long-term outlook following rectocele repair?
The degree of success after rectocele repair depends on a number of factors, including:
- Type of symptoms present.
- Length of time the symptoms have been present.
- Surgical method and approach taken.
Studies show about 75% to 90% of patients have significant improvement but this level of satisfaction decreases over time.
What are non-surgical repairs for a rectocele?
Most symptoms of a rectocele can be kept under control without surgery. These methods include:
- Avoiding constipation by following a high-fiber diet (more than 25 grams of fiber per day) and drinking 6 to 8 10-ounce glasses of water per day.
- Avoiding straining during bowel movements and long periods of sitting on the toilet.
- Using stool softeners if needed.
- Following exercises designed to strengthen and retrain the muscles of the pelvic floor.
- Being fitted with a pessary, a device placed into the vagina to reduce the bulge.