Do you have an uncomfortable feeling that something is dropping down from your vagina? Do you feel a vaginal bulge? Do you have to press the back wall of your vagina to be able to pass stools?

If yes, you may be suffering from a rectocele. A rectocele is a condition in which the rectum bulges into the back wall of the vagina. It is akin to the hernia of the rectum into the vagina (‘recto’ meaning the rectum and ‘cele’ meaning hernia)

What is the cause of a rectocele?

A rectocele occurs because of thinning or weakness of the supporting tissue between the rectum and the vagina(called the rectovaginal septum) and reduced strength of the pelvic floor muscles. It can coexist with other types of prolapse: Often the rectovaginal septum is detached from the top (vault) of the vagina leading to co-existing enterocele. Prolapse of the posterior wall of the bladder into the vagina (called as cystocele) and prolapse of the top (vault) of the vagina (called as vault prolapse) can also be present simultaneously.

The weakness of the pelvic floor leading to rectocele most commonly results from injury sustained during childbirth as discussed in the overall article on prolapse. Additionally, chronic constipation and history of straining with bowel movements and non-relaxation of the pelvic floor muscle during defecation can also contribute to the development of a rectocele

What are the symptoms of rectocele?

Often a woman with rectocele may have no symptoms. Most common symptoms are

  • A feeling of bulge in the vagina or something dropping into the vagina.
  • Difficulty in evacuating bowels and the need to strain to evacuate stools: The patient may have to push on the back wall of the vagina to pass stools. Occasionally, the stool gets impacted in the herniation of the rectum into the vagina.
  • Urge to have multiple bowel movements
  • A dragging sensation in the pelvis and a lower backache
  • Rectal pain

Dyspareunia or pain with sexual intercourse and vaginal bleeding can also occur.

How is rectocele diagnosed?

Most commonly, a rectocele is found incidentally during a pelvic examination by the doctor. It is important to undergo a complete physical and pelvic examination to determine whether the symptoms are due to a rectocele alone or due to other co-existent problems. The urogynecologist will grade the severity of the rectocele during the pelvic examination

If the patient has non-relaxation of the pelvic floor muscles leading to constipation and contributing to the rectocele, surgical repair of the rectocele without biofeedback and physical therapy to teach her to coordinate her pelvic floor muscles better can lead to recurrence of the rectocele.

When the patient has co-existing constipation, it may be beneficial to undergo a defecogram to determine whether the non-relaxation of the pelvic floor muscles during defecation is contributing to both the formation of the rectocele and constipation. The test involves live x-ray imaging of a bowel movement after instillation of a contrast material into the rectum. The study assesses the rectocele size and its ability to empty.

How is a rectocele treated?

A rectocele should be treated only when it is associated with symptoms that are interfering with the quality of life. There are numerous non-surgical and surgical treatment options for rectocele.

Non-surgical management

Good bowel regimen: It is important to prevent constipation and straining to evacuate the bowel. It may be necessary to soften the stools so that significant straining with bowel movements is not required. This may be achieved by consuming a high fiber diet (consisting of 25-30 gms per day) and increasing water intake (typically 6 to 8 glasses per day). Stool softeners may also be used. It may also help to apply pressure to the back of the vagina to help move the bowels.

In patients with constipation and non-relaxation of the pelvic floor, performing rectocele repair without first doing a course of physiotherapy to teach the patient to relax the pelvic floor properly can lead to recurrence of rectocele.

Pelvic floor exercises (Kegel exercises) help to improve pelvic muscle tone. If you do not know how to exercise the right group of muscles, the physiotherapist will work with you to ensure that you learn to identify the right muscles.

Biofeedback: Patients who are diagnosed to have non-relaxing pelvic floor muscles or paradoxical contraction of the pelvic floor muscles may benefit from biofeedback. Biofeedback is a therapy in which a small pressure probe is placed in the vagina/anus and connected to a visual or sound display. It helps the patient to identify the correct muscles and learn to relax them and coordinate their activity better.

Vaginal estrogen therapy: Estrogen applied locally to the vagina helps reduce atrophy of the vaginal lining and helps to slow the progression of rectocele. In women with severe atrophy of the vaginal lining, a three month course of estrogen therapy to make the vagina healthier may be beneficial before performing any surgery.

Surgical management:

Surgery should be considered in patients in whom symptoms interfere with daily activities. In a woman who has opted for medical management initially, surgery may be considered if the non-surgical treatment options fail. Surgery is usually performed through the vaginal route. The detached rectovaginal septum is reattached to the apex and the wall between the vagina and the rectum is strengthened. The widened genital hiatus is reduced. The success rate of the surgery depends upon the severity of the problem and symptom duration. Repair of co-existing prolapse of other vaginal walls may have to be performed simultaneously. You can read more about vaginal surgery for prolapse here.

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