Caused by a Weakened Rectal Wall
Caused by a Weakened Rectal Wall
A rectocele is a bulge of the front wall of the rectum into the vagina. The rectal wall may become thinned and weak, and it may balloon out into the vagina when you push down to have a bowel movement. Most rectoceles occur in women where the front wall of the rectum is up against the back wall of the vagina. This area is called the rectovaginal septum and may be a weak area in the female anatomy. Although uncommon, men may also develop a rectocele.
A rectocele may be present without any other abnormalities. In some cases, a rectocele may be part of a more generalized weakness of pelvic support and may exist along with a cystocele, urethrocele, and enterocele, or with uterine or vaginal prolapse, rectal prolapse, and fecal or urinary incontinence.
The underlying cause of a rectocele is a weakening of the pelvic support structures and thinning of the rectovaginal septum. Certain factors may increase the risk of a woman developing a rectocele, including birth trauma – such as multiple, difficult or prolonged deliveries – or the use of forceps to assist in delivery, perineal tears, or an episiotomy into the rectum or anal sphincter muscles.
In addition, a history of constipation and straining with bowel movements, or hysterectomy may contribute to the development of a rectocele. Commonly, these problems develop with age but they may occasionally occur in younger women or in those that have not delivered children.
Many women have rectoceles, but only a small percentage of women have symptoms related to a rectocele. These symptoms may be primarily vaginal or rectal.
Vaginal symptoms include vaginal bulging, the sensation of a mass in the vagina, pain with intercourse or even something hanging out of the vagina that may become irritated.Vaginal bleeding is occasionally seen if the vaginal lining of the rectocele is irritated, but other sources of the bleeding should be checked by your doctor.
Rectal symptoms include constipation and/or particularly difficult evacuation with straining. Often this is associated with bulging in the vagina when straining to have a bowel movement. Some women find that pressing against the lower back wall of the vagina or along the rim of the vagina helps to empty the rectum. At times, there will be a rapid return of the urge to have a bowel movement after leaving the bathroom because stool that was trapped in the rectocele may return to the low rectum after standing up.
Most rectoceles can be identified on a routine office examination of the vagina and rectum. However, it may be difficult to assess their size and significance. A more accurate method of assessing a rectocele is an x-ray study called a defecagram. This study shows how large the rectocele is and if it empties with evacuation.
Rectoceles that are not causing symptoms do not need to be treated. In general, you should avoid constipation by eating a high fiber diet and drinking plenty of fluids.
If a rectocele causes significant symptoms, you should consult us. We must first decide whether your symptoms are caused entirely by the rectocele or whether there are multiple abnormalities present. If so, it may be best to address them all at once to give you the best chance for improvement. There are two approaches to treatment: medical and surgical.
The best first step is to begin a bowel management program. This includes a diet high in fiber and 6 to 8 glasses of fluids each day. Fiber acts like a sponge. It soaks up fluid so that less is removed as the stool travels around the colon. The stools will be larger, softer and easier to pass. You may wish to add a fiber supplement and/or a stool softener to this regimen to improve stool consistency. It is best to avoid active laxatives.
You should avoid prolonged straining. If you cannot completely empty, get up and try again later. Holding pressure with a finger to support the rectocele and encourage the stool to go in the correct direction is often helpful. This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina. Avoid placing a finger inside the anus to pull the stool out as this may cause harm. A pessary may be used to support the pelvic organs. A pessary is a ring that’s inserted into the vagina and must be individually fit to each woman.
If surgery is required to treat your rectocele, we’d be happy to refer you to a gynecologic specialist to handle the surgery.