Understanding Rectocele: A Guide for Patients
What is a Rectocele?
A rectocele, also known as a posterior vaginal prolapse, is a type of pelvic organ prolapse. It is a bulge between the rectum and the posterior vaginal wall. The condition can happen when the tissue of the posterior vaginal wall weakens, causing a bulge or protrusion of the underlying rectum (or other pelvic organs) into the vaginal canal. The thin layer of connective tissue between the vaginal skin and the rectum is sometimes called the rectovaginal septum.
Patients with a rectocele may experience a bulge of vagina during bowel movements. This, and other symptoms, depend on the size of the prolapse. A small prolapse may present with no symptoms, while a large one can cause significant symptoms.
Studies show that rectoceles affect women at the average age of 60 and that up to 80% of women may have a rectocele at some point in their life.
What are the Risk Factors of a Rectocele?
There are multiple factors contributing to the development of a rectocele.
- Pregnancy and childbirth – Most women who have a rectocele have had at least one vaginal delivery. Along with age, childbirth is considered to be one of the highest risks. The more times a woman has given birth vaginally, the more likely she is to develop a rectocele. When a woman’s labor is excessively long or her baby is extra large, the stretching and straining can weaken the muscles of the pelvic floor as well as the rectal and vaginal walls.
- Chronic constipation – Just as with childbirth, constant straining and pressure in the lower abdominal region can increase a woman’s risk of a rectocele.
- Being overweight – Extra weight in the body can create constant pressure on the pelvic floor muscles and supporting tissues while sitting or standing. This chronic pressure can increase the risk of rectocele.
- Chronic cough – The straining and stretching that occurs from a cough can put added pressure on the muscles, weakening the posterior vaginal wall. The weakening can cause a rectocele. Treating a chronic cough is one of the best ways to prevent rectocele.
- Repetitive lifting and straining – The repeated stretching and strain can weaken the muscles of the pelvic floor, causing a rectocele.
Along with these common risk factors, there are other potential causes of a rectocele. Women going through menopause will experience changes in their body that can cause a prolapse. Aging is also a common cause of rectocele, as the muscle (known as levator ani muscles) and connective tissue tends to weaken over time.
Rectocele Symptoms
When you see a doctor for your rectocele symptoms, they will listen to you describe what you are experiencing and they will perform a physical examination which consists of a thorough examination of the organs in the pelvis and pelvic floor.
How is a Rectocele Diagnosed?
Many women also report feeling — or in some cases, seeing — a bulge in their vagina or pelvic area. This is caused by the prolapsing organ protruding within or outside of the vagina. It can also feel like sitting on a ball or an egg. When a bulge can be seen or felt, it is important to know that what is being seen or felt is the skin of the vagina. The organs themselves, bladder and bowel, are rarely visible at the vaginal opening as they are covered by the skin of the vagina.
Examination of the Pelvic Floor Muscles for Pelvic Organ Prolapse
The pelvic exam for rectocele is somewhat different than a “normal” pelvic exam where the doctor is examining the cervix (in the case of a Pap smear) as well as the uterus and tubes/ovaries. The pelvic exam for pelvic floor dysfunction, including rectocele, is an evaluation of the tissues of the vaginal walls, the pelvic floor muscles, the nerves supplying these tissue, and the function of all of these structures.
During the exam, the doctor will have the patient cough, strain, or bear down. This will enable them to evaluate the location and severity of any pelvic organ prolapse, including rectocele. The doctor will also ask the patient to contract the pelvic muscles in order to determine their strength.
Some doctors may also order a special x-ray called defecography, which gets an intricate look at the pelvic muscles during straining.
With these tests, doctors can determine if a patient has a rectocele and make suggestions regarding treatment for posterior vaginal wall prolapse.
How is a Rectocele Treated?
The usual treatment of a rectocele depends on its severity and the symptoms of the patient. Those without symptoms do not typically need any sort of treatment. However, in order to keep the body functioning properly and constipation at bay, it can be helpful for asymptomatic patients to eat a high fiber diet and drink 6 to 8 cups of water a day.
Overall, the basic treatment plan includes the avoidance of straining, even during a bowel movement. If a patient is unable to completely empty their bowels due to a lack of straining, they are advised to get up and try again later. Some patients may benefit from a ring that is inserted into the vagina, called a pessary. This ring can be used to support pelvic organs and keep the body running smoothly.
Other options for treatment include:
- Treating chronic cough
- Avoiding lifting heavy objects
- Not smoking
- Maintaining a healthy weight
- Kegel exercises
- Vaginal pessary
- Pelvic floor physical therapy
- Surgical repair
Many physicians will recommend lifestyle changes as a first attempt at healing. However, if these changes are not effective enough, the physician may recommend surgical repair.
Before surgical management, patients will meet with the surgeon to discuss personal issues such as overall health, age, medical history, future pregnancy potential, the specifics on the prolapse, desire for vaginal functions, and more. The information provided will help the surgeon determine the type of surgery that would be best for the patient.
Surgical options include both laparoscopic and vaginal approaches. Both options seek to eliminate the vaginal bulge in an effort to improve symtpoms. They may be done using the patient’s own tissue and absorbable stitches or they may involve the use of a mesh or graft in an attempt to make the rectocele repair procedure more durable.
Hospital stay largely depends on the duration and type of surgery as well as the patient’s other medical problems. Patients who have posterior vaginal prolapse repair usually go home from the hospital the same day or after a one night hospital stay.
Can Rectocele Be Prevented?
A posterior vaginal wall prolapse, or rectocele, is not something that can always be prevented. However, there are lifestyle changes that women can make to help decrease the likelihood of a symptomatic rectocele and other pelvic floor disorders.
These measures include:
- Regular Kegel exercise. Kegels help to strengthen the pelvic floor and provide support to the vaginal walls and connective tissues of the pelvis.
- Prevent constipation. Eat high-fiber foods, such as whole-grain cereals, fruits, vegetables, and beans.
- Use good lifting practices for heavy lifting, or avoid lifting altogether.
- Maintain a healthy weight.
What is the Prognosis after Rectocele Diagnosis?
Because rectocele is rarely dangerous, the prognosis is generally considered quite good. With a combination of diet and lifestyle changes along with physical therapy, coping techniqes, and possibly a surgical procedure, the chance that symptoms improve or go away completely is high.
An In-Depth Look at Treatment Options
Active Monitoring (Expectant Management)
Posterior vaginal prolapse is typically not serious or dangerous. This means rapid progression to invasive treatment options are not usually used or even necessary. The least invasive, and most common, treatment option is called expectant management. Also known as active monitoring, or watching and waiting, expectant management is essentially the option of waiting it out and keeping an eye on things. Many times patients with rectocele have no symptoms. For many, they are often only discovered during routine examinations. While asymptomatic patients may not be experiencing any discomfort, monitoring of the bulge and associated symptoms are warranted as the symptoms of rectocele and other pelvic organ prolapse can worsen over time. Through active monitoring of both symptomatic and asymptomatic vaginal prolapses, physicians are able to help patients decide when to intervene. As long as symptoms are minimal or non-existent, expectant management is a great treatment option for rectocele.
Lifestyle Changes
As there are multiple lifestyle issues that can cause a rectocele, making changes in these areas can help to treat the condition and prevent complications or an increase in symptoms. These changes should be made in conjunction with active monitoring to ensure optimal health.
Lifestyle changes include a regular, intentional focus on diet and exercise. Eating a diet that is high in fiber and drinking six to eight cups of water a day can help the body regulate to avoid constipation and other issues that can cause pressure and straining. A healthy diet and exercise can also help reduce the risk of weight gain, which can contribute to pelvic support defects.
Straining is a common cause of rectocele and can cause worsening of both symptoms and severity. In order to prevent a vaginal prolapse from becoming worse, it’s imperative that patients refrain from straining as much as possible. This means not straining during bowel movements, refraining from heavy lifting, and learning to use proper lifting techniques.
By eating a healthy diet that includes fiber and lots of water, exercising regularly, and avoiding activities that cause straining, those with rectoceles can reduce their risk factors and, often, prevent their symptoms and condition from worsening.
Treat Chronic Cough
Coughing is another factor that causes straining and should be reduced as much as possible. When women with a vaginal prolapse get a cough, they begin to put a lot of strain on their pelvic floor which can increase the severity of their posterior vaginal prolapse.
In order to reduce this strain, women should seek to determine the cause of their cough and attempt to treat it. While not always immediately effective, treatment for illness and cough can help to eliminate the cough faster than without. The quicker the cough ends, the better for the rectocele.
Kegels
Kegel exercises are a non-invasive type of exercise that helps strengthen their pelvic floor muscles. The muscles of the pelvic floor support the rectum, the bladder, the uterus, and more. As rectoceles can be caused by a weakening of these muscles, regularly performing kegel exercises can help to undo the damage to the area.
To engage in kegel exercises, women simply “hold their bladder” when they don’t actually have to urinate. When done regularly, this practice strengthens the muscles and can help to keep a rectocele from worsening.
Splinting
A bit more invasive than the previous methods of treatment, splinting can work to keep the vaginal muscles from protruding through the vaginal opening. Those with more serious prolapses may choose to engage in splinting while they are awaiting treatment, such as surgery.
When splinting, women will insert a tampon or their fingers into the vagina during bowel movements in order to hold the rectocele back and provide easier emptying of the rectum. This can be helpful for those who have a large bulge and have experienced constipation and other issues due to the difficulty they have during bowel movements.
Vaginal Pessary
A pessary is a ring that is inserted into the vagina in order to provide support for the vaginal walls and, by extension, the pelvic organs. For some women with symptoms, this can be a helpful and viable treatment option in order to avoid surgery. When the pessary is inserted, it reduces and/or elevates the prolapse, keeping in place and out of the way. Women with pessaries in place can often live without experiencing further symptoms, although the prolapse remains.
Rectocele Repair Surgery
When lifestyle changes and active monitoring do not provide sufficient treatment for a rectocele, physicians may recommend surgery. If surgery is not an option due to poor health, advanced age, or the patient not wanting the invasive treatment, a pessary can be used. However, for severe cases, surgery is often the optimal treatment.
The surgeon will work with the patient to determine the best surgical option, depending on a variety of factors including health, age, vaginal symptoms, physical exam, and patient goals.
Understanding Constipation
It’s important to understand constipation, as it is commonplace for women with a posterior vaginal prolapse.
What is Constipation?
Constipation is the condition of having difficult or infrequent bowel movements. Constipation can caused by rectocele and rectocele can be caused by constipation. Regardless of which came first, straining for bowel movements can cause the prolapse to protrude from the vaginal opening, making passing stools uncomfortable and difficult.
How to Avoid the Difficult Bowel Movement
Women with a rectocele can avoid constipation with a diet high in fiber, pelvic floor exercises such as kegels, and drinking a lot of fluids. Making sure to avoid heavy lifting is also helpful for preventing constipation.
How to Treat Constipation
The best way to treat chronic constipation is to prevent it with the dietary changes mentioned above. In some cases, passage of stool that is soft can be difficult simply due to the changes in normal anatomy caused by posterior vaginal prolapse. When this happens the use of a footstool (sometimes called a Squatty Potty) can be beneficial. Simply put, squatting changes the angle of the rectum allowing many patients to have a successful bowel movement more easily.
When to Call the Doctor
If the patient continues to experience constipation after treatment attempts, they should talk to their doctor. In these cases, stronger rectocele treatment options such as a pessary or rectocele repair may be necessary for constipation relief.