rectocele

Generality

The rectocele is the sliding of the rectum from its normal anatomical seat right into the vagina. This event is the result of a weakening of the pelvic floor. The resulting symptoms are numerous: from pelvic pain to difficult defecation. For a correct diagnosis, a pelvic exam is sufficient.

The therapy depends on the severity of the rectocele. The milder cases are treated with simple countermeasures, which avoid a worsening of the disorder. For the more serious patients, however, specific treatments are provided, sometimes even surgical.

Prevention, as always happens, is fundamental.

Short anatomical reference: the pelvic floor

To understand what happens in the rectocele, it is appropriate to make a brief anatomical review concerning the pelvic floor.

The pelvic floor is the set of muscles, ligaments and connective tissue placed at the base of the abdominal cavity, in the so-called pelvic area . These structures cover a fundamental and indispensable function: they serve to support and maintain in their positions the urethra, the bladder, the rectum and, in women, the uterus.

If the pelvic floor weakens and no longer offers the same support, disorders of a different nature, both physical and sexual, may appear.

THE POSITION OF THE RIGHT

The rectum is the terminal portion of the intestine. Approximately 13-15 cm long, the rectum connects the colon-sigma intestinal tract with the anus, and is surrounded by several muscles and ligaments of the pelvic floor. These structures are fundamental for the role, played by the rectum, of stool collection and evacuation.

uterus (anteriorly) and the vagina (inferiorly). To separate it from the vagina, there is a band of connective-fibrous tissue, called the rectum-vaginal septum .

What is the rectocele

The rectocele consists in the sliding (or prolapse) of a portion of the intestine rectum in the vagina. This slipping occurs due to a weakening, more or less severe, of the pelvic floor: in some cases, the rectovaginal septum can only loosen; in other cases, however, it can even tear itself apart.

Based on the extent of damage to the pelvic floor, three forms of rectocele can be distinguished:

1st grade rectocele, or mild . Characteristics: only a very small portion of rectum invades the vagina.
Rectocele of 2nd degree, or moderate . Characteristics: the portion of the rectum that invades the vagina is remarkable, and almost reaches the vaginal opening.
3rd grade rectocele, or grave . Characteristics: the rectum emerges from the vagina, due to the complete absence of support from the rectovaginal septum.

Epidemiology

The rectocele can arise at any age. However, adult women between the ages of 40 and 60 who have given birth several times or who have passed menopause are most affected. The explanation of this phenomenon will be discussed in the chapter on causes.

Unlike uterine prolapse and bladder prolapse (cystocele), which often occur in severe forms, the rectocele usually manifests itself slightly.

Causes of the rectocele

The possible causes of a rectocele are the following:

Vaginal delivery or with complications (for example, a long labor)
Large fetus
Constipation
Obesity
Lifting of heavy objects
Chronic constipation
Chronic bronchitis

How do these circumstances determine a rectocele?

PATHOPHYSIOLOGY

The occurrence of one of the aforementioned circumstances causes a traumatic stretching to the detriment of the pelvic floor. The muscles, ligaments and connective tissue that become weaker are affected.

Usually, the single event is not enough to cause a rectocele; the overlapping of several traumatic episodes, of the same type (for example, more vaginal parts) or of a different type (for example, obesity and chronic bronchitis) is instead decisive.

RISK FACTORS

Several risk factors associated with the onset of the rectocele have been identified.

The most important is certainly the high number of vaginal parts . According to some statistical data, in fact, women who have given birth several times vaginally are more prone to rectocele. Each part contributes to progressively weaken the pelvic floor, up to the tearing of some of its supporting structures. Further confirmation of the importance of the vaginal parts comes from the comparison with women undergoing cesarean delivery. The latter are less affected by rectocele.
The second factor, in terms of importance, is related to aging . Women, after menopause, produce less estrogen and this causes a weakening of the pelvic floor muscles. Estrogen deficiency also causes cystocele and uterine prolapse .
The third factor is related to previous surgery on the pelvic organs. If a woman has undergone such operations in the past, she has a weaker pelvic floor. Among the most favored pelvic organs, there is hysterectomy, which is the removal of the uterus.
The last factor is genetic . Although this is a rare circumstance, some women suffer from congenital diseases that alter the structure of collagen ( collagenopathies ). As a result, the pelvic floor becomes more loose and easily prone to lacerations.

NB: collagen is a fundamental protein of connective tissue.

Symptoms, signs and complications

The 1st grade rectocele (the most common form) is, in many cases, free of symptoms and noteworthy signs. In fact, it may happen that the patient does not even know she is affected.

However, when the protrusion of the rectum inside the vagina becomes more severe, the characteristic symptoms of the rectocele become evident. In similar situations, the patient complains:

Protrusion of a portion, more or less extended, of rectum from the vaginal opening (the dimensions depend on the severity of the rectal prolapse)
Difficulty going into the body ( obstructed defecation )
Sensation that the rectum, even after defecation, has not completely emptied
Sensation of pressure at the rectal level
Pain during sexual intercourse
Vaginal bleeding

WHEN TO REFER TO A SPECIALIST?

Small rectoceles do not require a specialist visit or even a specific treatment. However, it is good to keep in mind causes and risk factors, to avoid a possible worsening.

Conversely, a gynecological examination is recommended when the patient experiences difficulty in defecation and pain, such as to affect everyday life. This means, in fact, that the rectocele has degenerated from a mild to a more severe form, and needs due therapeutic attention.

COMPLICATIONS AND ASSOCIATED DISEASES

Figure: the deviation of the rectocele, as can be seen, is the reason why the obstacle to defecation is created. The connection between rectum and anus, in fact, is no longer linear. From the site: proctologia.biz

A rectocele, if underestimated, can get worse. It follows that the symptoms become more and more painful and the first complications emerge. The difficulties of defecation, for example, can be such as to require compression of the vaginal area ( manual evacuation ), to eliminate faeces, and constipation takes on the contours of a chronic disorder. Vaginal bleeding is increasingly common.

Moreover, the rectocele can be accompanied by the prolapses of other pelvic organs, such as bladder and uterus, since the triggering causes are the same. Therefore, the patient may suffer from cystocele or uterine prolapse .

Diagnosis

For a correct diagnosis of rectocele, a simple pelvic exam is sufficient. However, it may be useful to investigate some aspects, such as the severity of the disorder or the health of the pelvic floor. An evaluation questionnaire, a nuclear magnetic resonance, an ultrasound and defecography serve to enrich the initial diagnosis.

PELVIC EXAMINATION

The pelvic exam is useful for the gynecologist to understand if it is a rectocele or a prolapse of another pelvic organ. This check is more than exhaustive.

The specialist places the patient in a lying position and uses a speculum to examine the vaginal canal. During the examination, the sufferer is required to push, as when he goes to the body. With this operation, if it is rectocele, the rectal discharge from the vagina should be accentuated. In this way, the severity of the disease can be determined.

Another important assessment test is the control of the pelvic floor muscle strength. In this case, the patient is asked to contract the pelvic muscles, as if to block the flow of urine. If the test is negative, it means that the pelvic floor is weak.

ASSESSMENT QUESTIONNAIRE

Through an ad hoc questionnaire, the gynecologist investigates what emerged from the pelvic exam. The questions investigate how much the rectocele affects the quality of life of the patients. The information, which derives from it, helps during the therapeutic journey.

INSTRUMENTAL EXAMINATIONS

Ultrasound and nuclear magnetic resonance are two tests that are rarely performed. They serve to enrich the diagnostic framework with additional information, concerning:

The precise measure of the portion of the rectum that protrudes from the vagina
Prolapse of other pelvic organs

Instead, to assess the efficiency of intestinal emptying, the patient is subjected to a radiographic examination, called defecography .

What is defecography?

Defecography provides images, in real time, related to the defecation of the analyzed patient. It is a radiographic examination performed using a fluoroscope, useful when you encounter particular gastrointestinal disorders.

In preparation (about three hours before): a cleansing enema is performed to make more reliable what will be observed later.

The examination involves the rectal injection, using a catheter, of a barium-based contrast agent. The patient is then seated on a special toilet and the intestinal contractions, the moment of evacuation and the phase of emptying the rectum are observed. During these projections, the positions assumed by the intestine, in its anorectal tract, also emerge.

Defecography is an exhaustive but also invasive examination.

Therapy

The right therapy of a rectocele depends on the degree of severity with which it occurs and on the possible association with cystocele or uterine prolapse.

As mentioned above, mild grade rectoceles are asymptomatic and do not require special therapeutic treatment. Rectoceles of moderate-severe entity, on the other hand, require specific care: initially, the remedies are non-surgical; over time, however, surgery is essential.

TREATMENT OF 1 DEGREE RECTOCEL

It is very common that a rectocele, in its mildest form, goes unnoticed, due to the absence of specific symptoms. However, even if the gynecologist discovers their presence, during a routine examination, specific treatments are not provided.

The only recommended countermeasures are:

The constant practice of Kegel exercises, to reinforce the muscular tone of the pelvic floor
The control of obesity, as the excessive body weight, due to fatty deposits, stresses the musculature and the ligaments of the pelvic floor
Avoid lifting heavy objects

Sticking to these behaviors is essential to keep the situation stable. In the most fortunate cases, a regression of the rectocele may also occur.

NON-SURGICAL TREATMENT OF THE RECTOCEL OF THE 2ND AND 3N DEGREE

For moderate-severe rectoceles, two non-surgical remedies are provided: this is pessary and estrogen-based hormone therapy .

Non-surgical remedies	What is it and what is it for?
The pessary	It is a ring of rubber, or plastic, which must be inserted into the vagina. It serves to block the prolapse of the pelvic organs, which dominate the vagina. The specialist teaches the patient how to clean it and how to apply it. There are pessaries of different sizes, depending on the needs.
Estrogens	Menopause causes a reduction in the production of estrogens and their decline weakens the pelvic muscles. With the intake of estrogen, the pelvic floor muscles are strengthened in order to block the prolapse of the pelvic organs.

Pessary and estrogen are used to alleviate symptoms, but their use is temporary.

Often, in fact, similar solutions are used for a limited time, waiting for the ideal conditions for a surgical intervention, as these countermeasures have side effects. For example, prolonged use of the pessary causes an irritation of the internal cavity of the vagina.

Among non-surgical remedies, Kegel exercises and body weight control continue to provide valuable therapeutic support.

THE SURGICAL TREATMENT OF THE RECTOCEL

The reasons why the rectocele requires surgery are the following:

Unbearable pain, which negatively affects normal daily life
Clear discharge of the rectum from the vagina
Obvious defecation difficulties
Prolapse of other pelvic organs, such as bladder and uterus

The operation consists of a colorectal surgery operation. The procedure, which can be performed abdominally or vaginally, is as follows: the rectum is returned to its original position; after which the rectovaginal septum is closed and strengthened with a tissue transplant. The support, offered by this "patch", helps to support the rectum and not to do more protrude inside the vagina.

If the rectocele is also accompanied by a cystocele or a uterine prolapse, both disorders can be resolved with a single operation.

SURGERY AND PREGNANCY

If a woman with rectocele is still of childbearing age and wishes to have children, it is advisable to postpone the date of surgery at the end of the pregnancy. In the meantime, you can use the pessary.

Prognosis and prevention

The prognosis of the rectocele depends on the degree of severity of the disorder. The lighter the rectocele shape, the better the prognosis. However, it should not be forgotten that if the Kegel exercises are not practiced and the pathological condition is neglected, the chances of a worsening of the rectocele increase.

On the other hand, a different argument must be made when the rectocele is severe. In these situations, the containment of symptoms, by pessary and estrogen, is a temporary remedy, while the intervention becomes a necessity. However, like any surgical operation, even rectocele surgery is not without its complications. The rectovaginal septum, in fact, can break again, despite the reconstruction and its reinforcement. The prognosis, therefore, gets worse.